An unusual presentation of squamous cell carcinoma
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1731 (Published 15 April 2015) Cite this as: BMJ 2015;350:h1731
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Thanks for your comments.
We agree that in a smaller lesion with a functioning finger, with intact bone and joint, excision with a safe margin would be the preferred option. Primary amputation would be considered excessive and would not be considered in the above scenario.
The reported patient presented late with extensive soft tissue changes with functionless stiff finger discharging pus with imaging showing destroyed bone and joint. This was discussed in the cancer MDT. Given the clinical and radiological findings primary amputation was considered rather than two stage.
We agree incision biopsy followed by amputation is an available option.
Regarding the level of amputation, as it was potentially infected with skin changes to proximal phalangeal level it was decided to disarticulate at MCP level to achieve primary healing. Gap between fingers does cause functional disability. Following discussions, it was decided that " closing the gap" procedure would be considered at a later date if patient wishes.
Ray resection with deep transverse metacarpal ligament repair, Ray centralisation, Ray transposition are the available options for central digit amputations whereas Ray amputation on its own for index and little ray provides a cosmetically acceptable three finger hand.
R. Swaminathan
L. Abdeh
Competing interests: No competing interests
Cutaneous squamous cell carcinomas on extremities are not uncommonly encountered and managed by plastic surgery units in the UK. Clinicians assessing chronic ulcerating lesions anywhere on the body should have a high clinical suspicion of malignancy. Initial management should be guided by tissue diagnosis and discussion in a skin cancer Multidisciplinary Team for definitive treatment planning. Patients should be fully assessed for evidence of further local, regional and systemic disease and should be followed up in accordance with guidelines such as those issued by the British Association of Dermatologists (BAD) for SCCs (www.BAD.org.uk).
Primary amputation to the level of the MCPJ for diagnostic purposes might be considered to be excessive in a chronic non-progressive lesion. The BAD guidelines for SCC advocate margins of 6mm or more for tumours, such as this, which are greater than 2 cm in diameter or which extend into the subcutaneous tissue, and if space permits, 1cm margins might provide adequate assurance of removal. Excising the ring finger's proximal phalanx to the level of the MCPJ without amputating the ray impairs hand function, particularly through the obliteration of the webspaces, which help grip. Preservation of proximal phalanx's length even in the absence of flexor tendon attachment still keeps some hand function through the action of the intrinsic muscles. Soft tissue cover might be a consideration requiring further reconstruction once margins have been established to be clear. As details of the extent of the tumour's spread and different imaging modalities employed are unavailable, the appropriateness of this level of amputation is unclear.
In summary, chronic ulcerating lesions in the fingers are not rare and should primarily be managed with tissue biopsies in the context of MDT discussion to establish the need for further intervention.
Competing interests: No competing interests
What is unusual about this presentation? !!
Squamous cell carcinoma of the skin is not unusual and its septic complication is a frequent occurrence particularly when it is located in the peripheral parts like the limbs or anal region.
Cutaneous ulcers with or without a septic look that are unresponsive to routine management lines should prompt the index of suspicion for malignancy and little time wasted before ulcer edge biopsy is done.
Virtually any of the cutaneous cancers can be complicated with exogenous sepsis if location and attrition factors predispose
Competing interests: No competing interests
Re: An unusual presentation of squamous cell carcinoma
With regards to why we believe this presentation was unusual, it is explained by the following:
This patient presented late and the disease was quite advanced by then. The initial presentation mimicked a chronic infection, as there was purulent discharge from the finger. Although we do agree that neoplasia should be considered in any atypical soft tissue infection, the diagnosis of aggressive neoplasia did not arise based on initial clinical assessment.
X-ray changes in bone in malignant aggressive lesion is usually permeative with wide zone of transition, but the x-ray images in this case revealed bony changes with narrow zone of transition, which is seen in benign or less aggressive neoplasia.
Whilst we also agree that squamous cell carcinomas of the skin are not uncommon, their presentation in the fingers is uncommon (1, 2).
Thank you for your comments
R. Swaminathan, Consultant Trauma and Orthopaedics
L. Abdeh, SHO
References:
1) Albom, A. J. (1975). "Squamous-cell carcinoma of the finger and nail bed: a review of the literature and treatment by the Mohs' surgical technique." J Dermatol Surg 1(2): 43-48.
2) Tomsick, R. S. and H. Menn (1984). "Squamous cell carcinoma of the fingers treated with chemosurgery." South Med J 77(9): 1124-1126.
Competing interests: No competing interests