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2	Case History 48 y/o AAF STM on R Foot for 6yr Slow growing mass Difficulty with shoegear Non-painful No Hx of Trauma PMH – HTN No Hx of CA Soc Hx – THC abuse 25 pack yr tobacco
3	Physical Exam NVSI – Non-pulsatile mass Ortho – Mass effect causing deviation of digits 3 & 4 Semi-firm, non-fluctuant Non-septated Does not transilluminate Derm – HPK plantar 3^rd interspace No drainage, no ulcer upon debridement
4	Radiographs 10/29
5	X Ray – Radiologist Interpretation “3x4cm spherical soft tissue mass displacing the 4^th digit” Mass has thinned the mid-shaft of the middle and proximal phalanx No sign of calcification
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7	MRI – T2
8	MRI – T1
9	MRI –Radiologist Interpretation 3x3.5x3cm mass of heterogenous mixed signal Lateral subluxation of the 4^th and medial subluxation of the 3^rd MTPJ No associated abnormal marrow signal Associated mass effect upon the adjoining digits Encapsulated lesion No extension into surrounding soft tissues
10	"Epidermal Inclusion Cyst?" Epidermal Inclusion Cyst? Foreign Body Reaction? Hemangioma? Ganglion?
11	Development of the Plot Surgery cancelled because patient stopped taking anti-hypertensive meds : “I was smoking too much weed and didn’t want a bad reaction with the medication”
12	Needle Biopsy 2/17 Many degenerated squamous epithelial cells, RBC’s, few WBC’s and macrophages Negative for Malignant Cells Rescheduled for elective excision
13	Excision of Lesion
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15	Well encapsulated, not bound to surrounding soft tissue. Communicated with hyperkeratosis on plantar foot.
16	Pathology Epidermal Inclusion Cyst Foreign Body Granulomatous Reaction Mixed inflammatory infiltrate Foreign body giant cells Fibrosis
17	Pathology Continued . . . Malignant potential? Determined by . . . Cellular proliferation and tissue infiltration during acute foreign body reaction Fibrosis of the tissue capsule surrounding the FB Quiescence of the tissue reaction Direct contact with clonal preneoplastic cells No documented percentage for transformation.
18	Follow Up Patient missed 1^st post op visit F/U @ 3 weeks Suture removal Skin edges healed No hematoma / drainage Lost to long term follow up for 4.5 months Soft tissues remodeled Patient satisfied with outcome
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