1	Squamous Cell Carcinoma
2	"HPI:" HPI: 77y.o. AAM admitted for draining large lesion on plantar aspect of Lt foot. Lesion has been present for 1 yr after he had a cancerous lesion previously removed by radiation therapy. States this is in a new spot and has gotten larger over the course of a yr. states it is painful and he cant walk in shoes. It has been draining for 3wks. PMH/PSH: Prostate CA, Excision of Skin Lesion Med: Unknown Med. for Tx of Prostate CA All: NKDA SH: (-) Smoking, EtOH, Illicit Drugs
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8	Differentials Basal Cell Carcinoma Verrucous Carcinoma Keratocanthoma Eccrine Poroma Amelanotic melanoma Pyogenic Granuloma Ulcerative Lesion Reactive Epidermal Hyperplasia
9	Plan???
10	Biopsy Excisional Incisional Punch Shave Curettage Diagnostic, not curative
11	Incisional Biopsy This method was chosen because the lesion was too large to excise and a punch or shave was not felt to be proper. The medial margin was excised and normal tissue was also taken. The normal tissue was marked with undyed vicryl suture and the abnormal tissue was marked with prolene suture (is blue in color).
12	Diagnosis Squamous Cell Carcinoma
13	Squamous Cell Carcinoma 200,000 new per cases/yr Very rare in African Americans Mestastasis late, but uncommon (2%) >55y.o. 5% occurrence in leg and LE ~95% cure rate with proper excision
14	SCC Clark’s Level of Invasion Level I: Confined to epidermis, no metastasis, high (~100%) cure rate Level II: Invasion into papillary dermis past basement membrane (localized) Level III: Tumor fills papillary dermis and compresses reticular dermis Level IV: Invasion of reticular dermis (localized) Level V: Invasion of subcutaneous tissue ( direct extension)
15	SCC Breslow’s Depth of Invasion 0.75 mm (comparable to Clark Level II) > 0.75 - 1.5 mm (comparable to Clark Level III) > 1.5 - 4.0 mm (comparable to Clark Level IV) > 4.0 mm (comparable to Clark Level V)
16	American Joint Committee Cancer guidelines according to Tumor, Nodes, Metastasis (TNM) classification scheme: TX - Primary tumor cannot be assessed T0 - No evidence of primary tumor Tis - Carcinoma in situ T1 - Tumor less than 2 cm in greatest diameter T2 - Tumor 2-5 cm in greatest diameter T3 - Tumor greater than 5 cm in greatest diameter T4 - Tumor with deep invasion into cartilage, muscle, or bone
17	SCC Squamous epithelial proliferation Dermal infiltration Keratinization Cytologic atypia (nests of tumor cells)
18	"Treatment Options??????" Treatment Options??????
19	Treatment Options Amputation – TMA, LisFranc’s, Chopart’s, Syme’s, BKA Cryotherapy Radiation therapy 5-Fluorouracil Imiquimod
20	Considerations Treatment depends on size, shape, location, and rate of growth Recurrence is high Typically much larger than what appears on surface, therefore wide excision is necessary. High incidence of amputation/limb loss due to need for wide excision
21	Syme’s Amputation
22	Syme’s
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24	Why Syme’s The idea behind choosing the Syme’s was because this was recurrent Squamous Cell. Without very wide excision, this lesion would likely occur again. The hematology/oncology doctor on service agreed with the procedure and it was performed. TMA, LisFranc’s, and Chopart’s were not chosen because it felt they were not wide enough. BKA was not chose because it seemed to be too drastic
25	Summary Communication with other specialties and with patient is key!!! Biopsy unknown lesions Metastasis must be evaluated Must evaluate size and depth of lesion Wide Excision
26	Thank You