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Transradial amputation
2%
26/1649
Cultures at 30-32° C with culture sensitive anti-mycobacterial agents
18%
293/1649
Rheumatologic consult for disease modifying antirhuematic drugs
5%
76/1649
Local fractionated radiation
38/1649
Wide local resection
73%
1201/1649
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The patient is presenting with biopsy-proven squamous cell carcinoma (SCC) which is best treated with wide local resection. Squamous cell carcinoma (SCC) is the second most common skin cancer, next to basal cell carcinoma, and frequently occurs in skin areas with high sun exposure. Lesion of the hand and upper extremity are less common than neck and face involvement. Actinic keratosis frequently precedes SCC and presents with scaly indurated skin. If there is suspicion of skin malignancy, a punch or shave biopsy should be performed. Once confirmed, wide excision of the lesion with 6 mm of margin and dissection to the subcutaneous fat is usually curative, as lesions are most often isolated to the skin. Askari et al. performed a retrospective review of 86 patients with SCC of the hand over a 20-year period. They reported an 88% and 57% 5- and 10-year survival, a 4% metastasis rate, and a 54% 10-year recurrence-free survival rate. They concluded that SCC of the hand is associated with relatively low metastatic rates, but high local recurrence rates which are associated with younger age, use of flap or skin graft closure, or history of transplantation. Ilyas et al. reviewed skin cancers of the hand and upper extremity. They reported that SCC can be treated with topical agents, wide excision, or Mohs surgery which has a local recurrence rate as low as 2.6%. Figure A is a clinical photograph depicting a left hand with SCC on the dorsum of the 1st webspace. Figure B is a histologic slide of SCC with keratin nodules with highly pleomorphic cells. Incorrect Answers: Answer 1: A transradial amputation is an extreme treatment option for malignancy with a low metastatic and relatively low local recurrence with wide local resection. Answer 2: Cultures at 30-32° followed by mycobacterial therapy would be a treatment option for mycobacterium marinum. However, the biopsy is not consistent with this diagnosis. Answer 3: Sarcoidosis is characterized by noncaseating granulomas, which are not present in the histologic slide. Answer 4: Radiation therapy is a treatment adjunct in some sarcomas and recurrent skin cancers. This is not necessary for a primary SCC lesion.
2.6
(5)
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