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FASXXX10.1177/1938640015569766Foot & Ankle SpecialistFoot & Ankle Specialist

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〈 Case Report 〉 Squamous Cell Carcinoma With Chronic Osteomyelitis

Spencer J. Monaco, DPM, Kyle Pearson, DPM, and Dane K. Wukich, MD

A Case Report

Abstract: Squamous cell carcinoma is one of the most common human malignancies; however, it is uncommon in the lower extremity. These lesions require prompt surgical attention and a delay in diagnosis can be harmful to the patient. We present a case report of squamous cell carcinoma with chronic osteomyelitis in a patient without diabetes. Definitive treatment included a transtibial amputation and metastatic workup was negative for active malignancy. Surgeons who treat chronic wounds should be cognizant of the potential for malignant degeneration. Levels of Evidence: Therapeutic, Level IV: Case report Keywords: amputation and limb salvage; diagnostic and therapeutic techniques; nonhealing ulcer; wound care; osteomyelitis; bone

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quamous cell carcinoma (SCC) is divided into 2 categories: ulcerative and papillary. Classic or ulcerative SCC is characterized by an area of chronic ulceration unresponsive to topical treatments with a firm slightly

raised tissue with hypertrophic borders.1 SCC is the second most common skin tumor following basal cell carcinoma.2 Marjolin3 first described malignant change with chronic draining wounds in 1828. The purpose of this report is to present a case of squamous cell carcinoma presenting as chronic osteomyelitis with an overlying ulceration.

Case Report



including infections disease and plastic surgery. He completed a long-term course of intravenous antibiotics, several incision and drainage procedures, and a partial calcanectomy for biopsy proven osteomyelitis. During this 10-year period, the patient remained highly functional using crutches for gait assistance. He had a past medical history significant for basal and squamous cell carcinoma on his thorax secondary to sun exposure; however, there was no history of lower

A 60-year-old man presented with a SCC [squamous cell carcinoma] is nonhealing wound on the second most common skin tumor the posterior aspect of his left heel/ankle. The following basal cell carcinoma.” patient sustained an open tibia fracture after being involved in a extremity malignancy. His family history motorcycle accident in 1971 resulting in was negative for cancer, and he denied multiple reconstructive surgeries, any tobacco or alcohol use. On review including an intramedullary tibial nail of systems he denied fevers, chills, night and a local rotational skin flap. sweats, or any recent change in weight Approximately 10 years before he or appetite. The foot ulceration was presented to our clinic, the patient painful and he regularly used opioids for developed a left heel wound, which analgesia. would intermittently heal and reulcerate. Physical examination revealed a He had been treated by several other relatively healthy male in no acute physicians prior to presentation,

DOI: 10.1177/1938640015569766. From the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Address correspondence to: Spencer J. Monaco, DPM, Podiatric Residency Program, University of Pittsburgh Medical Center, Pittsburgh, PA 15219; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)

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Figure 1.

Figure 2.

Clinical photograph.

Lateral hindfoot/ankle radiograph.

distress. His focused lower extremity examination revealed palpable pulses on the contralateral foot. Pulses were unable to be obtained on the left foot, however; the posterior tibial and dorsalis pedis artery were audible with a handheld Doppler. There was severe left lower extremity lymphedema up to the level of the tibial tuberosity. He was intact neurologically in the bilateral lower extremities with vibratory sensation, monofilament exam, and Achilles deep tendon reflexes on the right. His left Achilles reflex was absent from the trauma and reconstructive surgery. There was a full thickness, poorly defined, fungating, ulceration encompassing the entire posterior and medial aspect of the heel/ankle with a mixed fibrous/necrotic base (Figure 1). The ulceration probed to bone however, no purulence was identified. The deep wound cultures obtained from another facility were positive for pseudomonas and enterobacter. His peripheral white blood cell count was 14 000/µL, erythrocyte sedimentation rate was 29 mm/h, and C-reactive protein level was 2.4 mg/L. Radiological examination revealed severe cortical destruction (Figure 2).

Surgical Procedure The patient underwent and failed multiple attempts of limb salvage by reconstructive plastic and orthopaedic

Figure 3. Anteroposterior tibia/fibula radiograph. Arthrodesis of the tibia and fibula was performed as described by Ertl.

surgeons. During his first visit at our clinic, transtibial amputation was recommended and the patient declined. Additional debridement was carried out with utilization of surgical debridement and application of allograft skin substitute without success, and ultimately the patient requested a transtibial amputation. A biopsy was not obtained during this procedure secondary to failure to recognize the patient did not have a previous biopsy already taken. A staged transtibial amputation was performed by the senior author,

performing a guillotine amputation initially (Figure 3). The specimen pathologically demonstrated a deeply invasive, moderately differentiated keratinizing squamous cell carcinoma approximately 20 cm in size (Figure 4). The proximal skin and bone margins were clear from any carcinoma. After the definitive transtibial amputation had healed, he was referred to the Hematology/Oncology Service. The metastatic workup included a positron emission tomography/computed tomography of the neck, chest, abdomen, and pelvis, which was negative for malignancy. At the time of most recent follow-up (10 months) the patient is ambulating 2 miles per day with his prosthesis.

Discussion Potter et al1 retrospectively reviewed 12 patients with SCC of the foot with a mean follow-up of 43 months.1 The patients were reviewed for disease, treatment, and functional and oncologic outcomes. Eight (68%) out of the 12 patients had and identified risk factor for the development of SCC. Two-thirds of the patients (8 of 12 patients) had inappropriate or inadequate procedures performed, and 4 of those patients required more aggressive procedures. The definitive procedures included 4 wide excisions, 4 partial or complete toe excisions, 3 partial foot amputations, and 1 transtibial amputation. In 2004, Altay et al4 reported on 7 patients with chronic osteomyelitis of the foot and SCC, and the treatment included 4 transtibial amputations, 2 Syme’s amputations, and 1 wide debridement with limb salvage and preservation of the foot. A recent study by Chiao et al5 reported on a diabetic patient with a symptomatic plantar lesion of 2 years’ duration that did not respond to local wound care. Surgical debridement was performed. The patient did not respond to the debridement so a biopsy was then performed which revealed an invasive SCC with osteomyelitis. The definitive procedure performed was a forefoot amputation. In our case report,

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Figure 4. H&E stain revealing infilitrating squamous cell carinoma.

treatment. Ulceration with an atypical presentation and a long duration should raise clinical suspicion and a biopsy should be performed to exclude underlying malignancy. Ideally, the definitive procedure should be performed by the surgeon who obtained the biopsy.

References 1.  Potter BK, Pitcher DJ, Adams SC, Temple TH. Squamous cell carcinoma of the foot. Foot Ankle Int. 2009;30:517-523.

the patient did not have diabetes but did have a preexisting traumatic event. Mankin et al6 performed a study in 1982 to evaluate the hazards of 329 biopsies of primarily malignant musculoskeletal tumors, including bone and soft tissue. The results demonstrated troubling rates of errors in diagnosis and technique, resulting in complications and poor patient care. The same group of investigators replicated this study 10 years later and found similar results. In our case report, multiple procedures were performed at an outside facility prior to the Hematoxylin and eosin stain diagnosis of SCC. Histopathology was unable to be obtained from previous surgeries and we cannot definitively state

when this neoplasm developed. In retrospect, we failed to recognize the patient did not have the ulceration biopsied previously. A biopsy should have been obtained during our index procedure. Currently, the patient in this case report is 10 months status after below-the-knee amputation and his recent positron emission tomography and computed tomography scans did not show any reoccurrence or metastasis.

Conclusion Squamous cell carcinoma is a rare lesion found in the lower extremity.7 SCC can have devastating implications when there is a delay in diagnosis and

2.  Guidelines of care for cutaneous squamous cell carcinoma. Committee on Guidelines of Care. Task Force on Cutaneous Squamous Cell Carcinoma. J Am Acad Dermatol. 1993;28:628-631. 3.  Marjolin JN. Ulcère. Dictionnaire de Médecine. 1828;21:31-50. 4.  Altay M, Arikan M, Yildiz Y, Saglik Y. Squamous cell carcinoma arising in chronic osteomyelitis in foot and ankle. Foot Ankle Int. 2004;25:805-809. 5.  Chiao HY, Chang SC, Wang CH, Tzeng YS, Chen SG. Squamous cell carcinoma arising in a diabetic foot ulcer. Diabetes Res Clin Pract. 2014;104:e54-e56. 6.  Mankin HJ, Lange TA, Spainer SS. The hazards of biopsy in patients with malignant primary bone and soft tissue tumors. J Bone Joint Surg Am. 1982;64:1121-1127. 7.  Galinski AW, Williams JE Jr, Geduldig SB. Squamous cell carcinoma: a review of the literature and case report. J Am Podiatry Assoc. 1981;71:505-508.

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Squamous Cell Carcinoma With Chronic Osteomyelitis: A Case Report.

Squamous cell carcinoma is one of the most common human malignancies; however, it is uncommon in the lower extremity. These lesions require prompt sur...
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