objectives squamous cell carcinoma of the footfoot. the patient denied any signifi-cant medical or...

AUGUST 2006 • PODIATRY MANAGEMENTwww.podiatrym.com 189

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Following this article, an answer sheet and full set of instructions are provided (p. 198).—Editor

Continuing

Medical Education

This is a case presentation with a discussion of epidemiology,

pathophysiology, signs and symptoms, differential diagnosis

and treatment.

ObjectivesAfter completion of this article, one should be able to:

1) Learn the etiologies of squamous cell carcinoma.2) Understand the development of squamous cell

carcinoma from a Marjolin’s ulcer.3) Understand the common causes of a Marjolin’s ulcer.4) Learn the stages of squamous cell carcinoma

based on differentiation.5) Understand the different clinical manifestation

of squamous cell carcinoma.6) Understand the imaging modalities available

for the assessment and diagnosis of squamous cellcarcinoma of the foot and ankle.

7) Learn the different techniques of biopsy availableand the need for biopsy of squamous cell carcinoma.

8) Understand the sentinal lymph node for squa-mous cell carcinoma and the need to biopsy after detection of the tumor.

9) Learn the different treatments available forsquamous cell carcinoma and the advantages and disadvantages of each.

10) Understand the different surgical techniquesfor plantar foot reconstruction after resection of asquamous cell carcinoma.

11) Understand the recurrence of squamous cell carcino-ma and the long-term follow-up needed for these patients.

12) Understand that chronic osteomyelitis can develop into squamous cell carcinoma.

13) Understand the common sites and the inci-dence of metastasis of squamous cell carcinoma.

the risk of metastases and recur-rence is high. A case presentation isfollowed by a thorough review ofliterature pertaining to SCC.

Case PresentationA 65 year old African-American

male with no significant medicalhistory was admitted to Graduate

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Squamous cell carcinoma (SCC)involving the distal lower ex-tremity, specifically the foot

and ankle, challenges the ability toambulate along with the overallhealth of the individual. Foot and

By Linnie Rabjohn, DPM, CorneliusDonohue, DPM, Richard Montilla,MD, and Frederick Lavan, MD.

ankle specialists must obtain agreater understanding about trans-formation of previously injuredskin into this form of malignancy,termed Marjolin’s ulcer. Currentlythere is not a defined standard ofcare relating to the biopsy of suspi-cious lesions and wounds. Whilethe incidence of SCC occurring onthe distal lower extremity is low,

Squamous Cell Carcinoma

of the Foot

C L I N I C A L P O D I A T R YC L I N I C A L P O D I A T R Y

decrease in segmental pressures oralteration in triphasic waveforms.

Initial SurgeryThe first surgery involved a de-

bridement of the area of the leftfoot with two separate soft tissuebiopsies collected. The two biop-sies, one central and one from thelesion perimeter, revealed an inva-sive, well to moderately-differenti-ated, keratinizing squamous cellcarcinoma extending to all bordersincluding the base of the biopsyspecimens. The intra-operative softtissue culture taken of the wound

grew pan-sensitive Staphylococcusaureus and Pseudomonas. The pa-tient was treated with a two-weekcourse of appropriate intravenousantibiotic.

Following the initial pathologyreport, an MRI of the left lower ex-tremity was performed. There wasincreased signal of the subcuta-neous area of the lesion and alsotissue deep to the flexors. No boneinfection was evident on MRI, andthe plantar fascia appeared normal.Six days after the initial surgical

procedures, a sentinel lymph nodebiopsy, wide excision of the lesionand a split-thickness skin graft wasperformed (Figure 1).

During the wide excision, partof the plantar fascia, as well as themuscle fascia of the first layer of in-trinsic musculature, was excisedand biopsied. The pathology reportfrom this second surgery showednegative sentinel lymph node re-sults of the left groin and negativeinvolvement of a pigmented nevialso located on the left lower ex-tremity. The flexor digitorum breviswas negative for SCC, and all bor-ders of the excised tissue were clearof SCC. A meshed full-thicknessskin graft was applied to the leftplantar foot following the excision.

The wound went on to heal un-eventfully (Figure 2).

Defining Squamous CellCarcinoma

Squamous Cell Carcinoma(SCC) is a malignant skin tumor ofkeratinocytes located in the epider-mis or appendages. This malignan-cy is the second most common skintumor following basal cell carcino-ma.1,2 SCC is linked to exposure toultraviolet light, its most commonetiology.3 The UVL (ultra-violetlight) acts as both a tumor promot-er and initiator by suppressing thetumor suppressor gene.5 For thisreason, the location of SCC typical-ly involves areas of sun-exposedskin, with only 2.4% occurring onthe foot.7 As latitude increases, sodoes the amount of UVL exposure;therefore, for every 8-10 degree in-


190 www.podiatrym.comPODIATRY MANAGEMENT • AUGUST 2006

Carcinoma...

Hospital from the hospitalwound care center with com-

plaint of a painful plantar lesionon his left foot. The patient relatedthat the lesion had been presentfor thirty-eight years but had in-creased in size and tenderness overthe past eight months. The lesionhad been treated as an ulcerationwith local wound care and oral an-tibiotics without improvementduring that time. He relates a his-tory of surgery in 1966 to have aforeign body removed from hisfoot.

The patient denied any signifi-cant medical or surgical history andrelated an unknown maternal fami-ly history but relayed that his fa-ther died of esophageal cancer. Hehas a pack-daily-for-twenty-yearshistory of smoking along withheavy alcohol use.

Physical examination revealed alesion on the plantar left foot de-scribed as a 5 cm. by 6 cm. circularlesion with blackened borders andcentro-medial herniating, peduncu-lating mass appearing fibro-granu-lar. There was no sign of cellulitis,purulence, or tracking to osseousstructures at that time. The dorsalispedis and posterior tibial pedalpulses were normal and symmetri-cal, bilaterally.

Admission labs demonstratedno leukocytosis, and all other ini-tial lab values were within normallimits. Radiographs of the left lowerextremity were unremarkable andnegative for osteomyelitis. Vascularstudies revealed ABI of 1.19 and no

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Figure 2: Squamous cell carcinoma three months after full exci-sion and placement of skin graft.

Figure 1: Squamous cell carcinoma following excisionand placement of full-thickness skin graft to site.

Squamous CellCarcinoma (SCC) is a

malignant skin tumor ofkeratinocytes located in

the epidermis orappendages.


concept that damaged tissue mayincur vascular compromises, whichmay lead to nutritional deficits, cre-ating an environment suitable fordevelopment of an ulcer. Both thesurrounding vascular and lymphat-ic channels are compromised,which may lead to a decrease in

surveillance ofcellular muta-tions occurring atthe site.9 Inessence, there isan area of whichthe immune sys-tem is unaware.

Treves andPacks theorizedin 1930 that ep-ithelium for amultitude of rea-

sons may become dry, thin, anddelicate, allowing even slight trau-ma to cause destruction.11,14 As thisarea is regenerating, neoplasticchanges may occur due to the lossof the tissue’s normal characteris-tics. The exact cause of cellular mu-tation remains unclear but may bethe result of chronic irritation andadaptation, or the release of toxinsfrom the damaged tissue.9,15

Ribbet’s theory associates themisplaced and inferior epitheliumto the chronic irritation and break-down of epithelium.11 The durationbetween the initial alteration ofskin components to the develop-ment of malignancy varies depen-dent on the type of alteration andpossibly is associated with thehost’s systemic factors. A burn scarbecomes an isolated area in regardsto immunology due to the oblitera-tion of surrounding lymphaticchannels.9 This isolation causes thesurveillance mechanism for cellular

crease in latitude, the incidence ofSCC doubles.3 The highest inci-dence of SCC occurs in countrieswith high sun exposure.4

There exists a strong link be-tween immuno-compromised pa-tients and the de-velopment ofSCC. Patients re-ceiving immuno-suppressive thera-py for organtransplant havean occurrencerate 65-250 timesmore than thegeneral popula-tion.4 Renal trans-plant patientshave the highest occurrence.6 Re-search has shown that cyclosporinein combination with other medica-tions exhibits a higher likelihoodfor development.7 Studies are need-ed to determine any links betweenthe more recent immunosuppres-sive agents and subsequent in-creased incidence of SCC.

Marjolin’s UlcerA subset of SCC arises from pre-

viously injured areas of skin and isreferred to as Marjolin’s ulcer, themajority of which are located inthe lower extremity. Marjolin’sulcer is a term used to describe ma-lignancy involving a post-traumaticscar and frequently has been pri-marily associated with develop-ment with a burn scar.8-11 Currently,the term has broadened to includemalignancy involving any previ-ously degenerated or compromisedchronic cutaneous alteration. Themajority of Marjolin’s ulcers,around 60%, are located on thelower extremity. It is imperativethat clinicians be aware of the ca-pacity to develop SCC from chronicneuropathic wounds, venous stasis,sinus tracts, osteomyelitis, decubi-tus ulcerations, warts, burns, or anypreviously injured skin.9-13,33-4

The exact mechanism forpathogenesis of SCC within com-promised skin has yet to be deter-mined. The three main theories onthe development of Marjolin’s ul-cers have been cited in literatureand built upon since their construc-tion.11 Virchow’s theory reflects the

Carcinoma... mutations to becomeless effective and efficient.In turn, the tumor may growto very large sizes before detec-tion by the body’s immune system.The lag period between develop-ment of malignancy and the age attime of burn is thought to be in-versely proportional.11

SCC arising from a Marjolin’sulcer initiated from a pressurewound can be more aggressive thancarcinomas associated with otherchronic wounds.16 There appears tobe an increased metastatic rate withpressure, ulcer-related SCC and in-creased mortality. An atypical cellu-lar occurrence within the wound-healing process could be responsiblefor the malignant transformation.

Clinical ManifestationsWith focus on the lower ex-

tremity, certain features shouldtrigger the physician into a widerdifferential diagnosis, to includeSCC, based on etiology, physicalappearance, and morphology ofchronic wounds. While Marjolin’sulcer is associated with previousburns, repeated trauma, radiothera-py, and diabetes mellitus, lack ofetiology also raises concern. As thephysician follows the course of achronic wound, physical morpho-logic change should be assessed.

Marjolin’s ulcer is associatedwith two main physical descrip-tions.8,9 The first is a shallow, well-defined ulcer with nodular eleva-tions at the periphery. The SCCcomponent is typically located atthe margins in this form. The sec-ond is an aggressively growing exo-phytic tumor with papillary granu-lations.10 This may also have the ap-


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Currently there isnot a defined standard

of care relating to the biopsy of

suspicious lesions andwounds.

TABLE 1SQUAMOUS CELL

CARCINOMA STAGESStage Percentage based on number of differentiated cells

I >75% well differentiatedII 50-75% well differentiatedIII 25-50% differentiatedIV <25% differentiated

Biopsy ProtocolTo date there exists no protocol

defining requirements for the needof biopsying chronic wounds to de-termine the presence of malignan-cy. There is literature to supportroutinely biopsying all wounds, de-termining the need for biopsybased on length of time the woundhas been present, and only biopsy-ing those wounds that appear sus-picious. Suspicious is a vague term

for the description of the appear-ance of a wound and therefore canbe very misleading. On the otherend of the spectrum, biopsying allwounds is neither efficient norcost-effective. So then how does aclinician define a protocol for biop-sying wounds? There is a need toclosely follow chronic ulcers and arecognition that changes withinthe ulcer do warrant baseline and

repeat biopsies. The indications forbiopsies have been defined in tabletwo. Although not inclusive, theydo provide some guidelines forbiopsy.

Sentinel Node BiopsySentinel node biopsy allows for

mapping and identification of thelymph node that drains the site ofprimary malignancy.2 The sentinellymph node (SNL) is the first nodein the lymphatic channel to receivelymph from a tumor site. Concern-ing the lower extremity, it generallywould be considered either thepopliteal or inguinal node. If theSNL is found to be free of cancer,then no further dissection of thelymph node is needed. The clini-cian should continue to closelymonitor the lymph node for anychange.

Imaging Modalities of SCCSquamous cell carcinoma invad-

ing bone by metastasis through softtissue may be visualized by plainfilm radiography. Plain filmsshould be ordered for any patientpresenting with either a previouslydiagnosed SCC of the lower extrem-ity or for those whose diagnosis hasyet to be confirmed (Figure 3). AnSCC involving the lower extremity,especially the foot, warrants plainfilms due to the limited soft tissueenvelope surrounding the bonestructures. If the SCC presents inthe form of Marjolin’s ulcer, thereshould also be concern about thepresence of osteomyelitis.

Metastatic lesions of the boneare characterized by the presence ofdiffuse demineralization and exten-sive destruction.20 Note that there isdifficulty in the distinction be-tween necrotic and metastatic boneby radiograph alone. Plain filmsmay also mislead one to the as-sumption that bone is not involvedwith an absence of osseouschanges, when, in fact, the perios-teum may have been invaded.10 Ametastatic development withinbone complicates both the primarytreatment of the cancerous lesion,but also the ability to save a limb.13

The clinical value of MRI forSCC lies in its non-invasive capaci-ty and the ability for high resolu-tion definition of soft tissues.23 MRI



Carcinoma...

pearance of a dermatitis-likeplaque.18 Most skin pathologies

have a preferential area of involve-ment; therefore, wounds occurringat unusual locations also warrantsuspicion.

With subungual or digital in-volvement, physical symptoms ofthe tumor may lead to misdiagno-sis of nail pathology, such as ony-chomycosis or paronychia to softtissue masses such as pyogranulo-ma or subungual exostosis. 19,20

Bone involvement of the distalphalanx should be consideredhigh due to the very limited softtissue envelope of the digit. Forthis reason, proximal amputation,either partial or full digit, is adefinitive cure with little post-op-erative ambulatory modificationsfor the patient.

Staging of SCCStaging of SCC is based on a

gradient determined by the per-centage of differentiated cells pre-sent within a biopsy of the tumor.

The staging should include SCCborders assessing the boundary ofthe tumor.6 Prognosis, aggressive-ness, and metastatic potential wors-ens with each degree of differentia-tion.5 Different fields of the tumormay exhibit varied differentiation,and thus grading is based on theleast-differentiated portion.

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TABLE 2INDICATIONS FOR BIOPSY OF A

CHRONIC WOUND

Chronic wound refractory to healing by standard wound care

Wounds with increasing size despite appropriate treatment

Malodorous or painful wounds

Wounds with excess granulation tissue that exceeds beyond margins

Wounds with irregular base or margins

Wounds with a change in drainage, excess bleeding, or exophytic growth

Dermatitis unaffected by anti-fungal or steroid creams18

Warts unresponsive to therapy5

Wounds whose etiology can not be linked to neuropathy, pressure,vascularity, or an underlying systemic disease

Marjolin’s ulcer is a term used to describemalignancy involving a post-traumatic scar

and frequently has beenprimarily associatedwith development with a burn scar.


Carcinoma...

is an inferior modality for thedelineation of bones involved inSCC when compared to CT scan-ning; however, the ability to clearlydefine soft tissue anatomy makes ita powerful tool for the imaging ofSCC. MRI allows for the definingvisualization of the tumor margins,including depth, and its anatomicrelationship to the surrounding softtissues.23,24 Cellular water content isthe distinguishing factor that al-lows for the differentiation betweennormal soft tissues and those af-flicted with SCC. On T1 weightedimages, SCC and metastatic lesionswill appear hypo-intense (Figures 4and 5).24

Ultrasound may be used for a“real-time” examination of soft tis-sue close to the skin surface. Al-though to date there has been lim-ited application of ultrasound for

the lower extremity, its use is be-coming more recognized. With useof high frequency ultrasound, highresolution and magnification ofsoft tissue structures can beachieved.25 The epidermal band andunderlying dermis are consideredhyper-reflective, allowing for thedistinction between a skin tumorappearing as a homogenously echo-poor area. Tumor borders may bedefined; however, these are easilymisinterpreted. Determination forthe type of skin tumor to date isnot available with ultrasound.

SCC and OsteomyelitisSCC is the most common ma-

lignancy arising from sites ofchronic osteomyelitis. Chronic os-teomyelitis is associated with sinustracts formed within the soft tissuesurrounding affected bone. Clinical


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Figure 5: STIR sagittal MRI image with marker evident at site of SCC. The ap-parent hypointense signal plantarly at the area of subcutaneous tissue may beconfused with cellulitis, but is in fact the SCC.

Figure 3: Plain lateral radiograph showing soft tissue irregularity on the plan-tar foot. There is no evidence of bone involvement with intact plantar corticesseen.

Figure 4: T1 weighted sagittal MRI image with round marker shown plantarlyat the site of SCC. The apparent decrease in signal is seen plantarly within thesubcutaneous tissue. It also shows an intact plantar fascia and no evidence ofbone involvement.

Sentinel node biopsyallows for mapping and

identification of thelymph node that drains

the site of primarymalignancy.

for patients who are unstable forsurgery. Complications include hy-pertrophic scarring and post-in-flammatory pigment changes.

Intra-lesional injections of in-terferon alpha-2b have been shownto be efficacious in patients withSCC.26 The interferon appears to en-hance natural killer cells’ cytotoxic-ity against neoplastic cells. The in-jections are done over a three tofive-week period, and both clinicaland histological improvement is

seen around eight to sixteen weeks.A higher individual or total dosemay be needed for eradication oflarger or more aggressive tumors.

Wide excision of the SCC is acommon surgical option for treat-ment, and is considered, by some,the treatment of choice for verru-cous carcinoma.5 This type of exci-sion involves an incision deepenedthrough the subcutaneous fat forsuperficial SCC with recommendedmargins of at least 4 mm. with 6mm. being standard in high-risk tu-mors. For SCC that invades thedeeper structures of the lower ex-tremity, excision may involve the

resection of muscle and bone.Frozen sections may be reviewedintra-operatively; however, they donot have the highest accuracy.

Moh’s micrographic surgery is aform of wide excision that is associ-ated with the lowest chance of re-occurrence and the highest curerate (99%) of any treatment modal-ity, except amputation.2,5,6 For thisreason. it is considered the treat-ment of choice for high-risk and re-current SCC.2,4,15 Horizontal sectionsof excised tumor tissue are reviewedintra-operatively for histologic fea-tures of SCC.6 This allows for obser-vance of the entire lesion, includ-ing all lateral and deep margins.1

Application to conserve all normaltissue is a principle important forlimb salvage.

Limb salvage is a principle con-cept in the evaluation of SCC in-volving the lower extremity. Thereare limitations to this principle thatare important to recognize thatmandate amputation. Choice ofamputation may be based on thetumor grade or size. Those that arehigh risk and involve muscle andbone to which adequate excisioninvolves loss of function of thelimb warrant amputation.19,22 Referto table three for a list constructedby Fleming concerning appropriatereasoning for amputation.9

Plantar Foot ReconstructionSCC involving the plantar as-

pect of the foot poses a complicatedsituation for reconstruction. Ade-quate reconstruction following re-section of the malignancy focuseson providing an adequate contour,durable skin, protective sensation,and resistance to shearing forces.22

Those properties allow for uninhib-ited ambulation. While each pa-tient must be evaluated individual-ly and a customized reconstructiveplan formulated, certain principlesremain for all patients. The soft tis-sue envelope of the foot and ankleis limited. Any compromise of thissoft tissue could jeopardize the in-tegrity of the interactions of thesmall bones of the foot, along withthe articulations of the small joints.

The plantar aspect of the footmay be divided into three distinctzones. Each zone is comprised ofspecific properties unique to this re-



Carcinoma...

and radiographic signs thatarouse suspicion of a malignant

transformation include: increasedpain with foul or bloody dischargefrom a sinus tract, an enlargingmass around the sinus tract, and/orprogressive osseous destruction.17,29

TreatmentCure rates have been estimated

at around 90% for SCC treated withthe available modalities.20 As thereare many documented treatmentsfor SCC, each case must be ad-dressed on an individual basis, fac-toring in the location and presenceof underlying systemic diseases ofthe patient. Curettage of the tumor,followed by electro-cauterization ofthe base, is indicated for smaller le-sions occurring on sun-exposedareas.35 This modality is less effec-tive for those lesions that have in-vaded subcutaneous fat or are re-current.1 Re-occurrence after curet-tage of a lesion usually occurs atthe margins, due to a lack of aggres-siveness.6

Cryologic surgery, with use ofliquid nitrogen, lowers the temper-ature of the tumor cells to tumorci-dal levels.1 To be effective, the tem-perature range must be around 50degrees Celsius below zero, andshould involve at least two freeze-thaw cycles.5 Indications includeSCC in situ and those lesions thatare less than one cm in diameterand on sun-exposed areas. The mar-gin of the periwound normal skinshould also be frozen to ensureeradication. This modality is ideal

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Squamous cellcarcinoma invadingbone by metastasis

through soft tissue maybe visualized by plain

film radiography.

TABLE 3REASONS TO CONSIDER AMPUTATION

AFTER DIAGNOSIS OF SCC

Hemorrhage due to the erosion of an ulcer into a large vessel

Cancer that has invaded so deep that excision is impossible

Involvement of a large joint, such as the ankle or knee

Large areas of necrotic bone exposed

Systemic toxemia caused by uncontrollable infection of the ulcer

Local excision would result in a non-functional limb


foot for donation, and therefore thedeficit must be small enough toallow coverage. Donor site prepara-tion requires multiple debride-ments to provide skin free of hyper-keratotic tissue. Return of sensationis probable if underlying innerva-tion has not been destroyed. Biop-sies of the area post-application andi n c o r p o r a t i o nshow histological-ly similar compo-nents to normalplantar skin.

For coverageof areas around 4-5 cm., a free flapreconst ruc t ionmay be used.28

The gracilis, latis-simus dorsi, rec-tus abdominus,and serratus anterior may be uti-lized for these small or large de-fects.32 For involvement of deepertissues, such as muscle, bone, circu-lation, or innervation, amputationat the following levels is a consider-ation. A LisFranc’s disarticulationoccurs at the tarso-metarsal level. Ahigher occurrence of adductovarusmay occur with this disarticulationrelated to the resection of majortendons.

A concern with muscle flaps in-volves the maintaining of the con-

tour of the plan-tar foot. Theseflaps may bebulky. Thischange in con-tour may lead tocompensation ofgait and requirefurther revisionalsurgeries.

MetastasisWith a con-

firmed SCC of thelower extremity,steps must betaken to deter-mine the pres-ence and poten-tial of metastasis.

SCC has been conceived as havinga relatively low rate of metastasis ataround 4%.21 Those that involvethe lower extremity, however, havea higher rate at around 30%.10,15

Tumor size and depth have beenfound to influence the metastatic

gion designed for its function inambulation. The first zone is de-scribed as distal to the proximalone-third metatarsal shafts. SimpleV-Y skin flaps allow for advance-ment of the plantar skin proximallyto cover deficits as large as 4-5 cm.Neurovascular flaps involve the lat-eral sub-hallux skin innervated bythe deep peroneal for coverage of 2-3 cm. Digital skin flaps with intactplantar digital vessels sacrifice thedigit allowing for coverage of a 3cm. area. The forefoot may be sacri-ficed and the patient still able toambulate. Amputation may beneeded if salvage is not conceivableand can be done at the trans-metatarsal level. This remains func-tional; however, an Achilles tendonlengthening will augment the am-putation by preventing adducto-varus from developing.

The plantar midfoot comprisesthe medial non-weight bearing sur-face area and the lateral weight-bearing structures. Split-thicknessskin grafts (STSG) are adequate ifthe deep structures of the non-weight-bearing transverse area ofthe arch are intact.28 Skin graftsmay not be placed directly over pe-riosteum or tendons lacking sheathor paratenon. Studies have shownthat STSG on theweight -bear ingbecome unstableover time, requir-ing revision inroughly half thecases.28 Careshould also betaken to avoidcovering a residu-al tumor that mayhave gone unde-tected.

Glabrous skingrafts are those inwhich the donorsite is the plantaraspect of thefoot.31 The sole ofthe foot has skinqualities that allow one to sense po-sition and protect against environ-ment and shear forces. If unable toreplace plantar tissue with like tis-sue, long-term sequelae regardingambulation may occur. Surgicaltechnique involves the sole of the

Carcinoma... potential of SCC. Le-sions greater than 2 cm indiameter are three times morelikely to metastasize than small-er counterparts.2 The risk of metas-tasis is directly related to the depthof the tumor. Deeper lesions, whichinvade the reticular dermis or un-derlying fat, are more likely to

metastasize.2,15 Le-sions less than 2mm. in depthhave virtually norisk, those 2-6mm. in depthhave a low risk,while those thatare greater than 6mm. are charac-terized with thegreatest risk.21 Lo-cation and etiolo-

gy of the SCC must also be consid-ered in determination of metastaticpotential. SCC occurring on sun-ex-posed areas of the skin is less likelyto metastasize as those related todegenerative or inflammatory pro-cesses, such as a Marjolin’s ulcer.5

SCC with perineural involvementshows an increased likelihood oflymph node involvement. Recur-rent SCC lesions are also more like-ly to metastasize.

If metastasizing, 85% will occuraround the regional lymph nodeswhereas the other 15% will involvedistant viscera.2,5,10 Dissection andbiopsy of regional lymph nodesthrough various techniques bringsup factors influencing the need andthe technique used to determinemetastasis of SCC. With SCC of thelower extremity, the lymph nodesmost regional to this area, thepopliteal and inguinal, should clin-ically be monitored closely. Lymphnode dissection/biopsy in a clinical-ly lymph node-positive patient isgenerally accepted as standard ofcare to rule out metastasis to theseregions. The protocol is vaguer inpatients who are lymph node-nega-tive by exam. Literature varies onthis subject, some recommendingthat prophylactic dissection shouldoccur only in grade 2 or 3 SCC le-sions.22

RecurrenceNot withstanding the choice of

treatment modality, recurrence ofContinued on page 196

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Moh’s micrographicsurgery is a form of wide

excision that isassociated with thelowest chance of re-occurrence and the

highest cure rate (99%)of any treatmentmodality, except

amputation.

With a confirmed SCC ofthe lower extremity,

steps must be taken todetermine the presence

and potential ofmetastasis.

mez B, Numanoglu A: Reconstructionof the weight-bearing surface of thefoot with non-neurosensory free flaps.Plast Reconstr Surg 111:2231, 2002.

28 Uroske T, Colen L: Soft tissuereconstruction for the heel and plan-tar foot. Foot Ankle Clin N Am 6:801,2001.

29 Ziets R, Evanski P, Lusskin R,Lee M: Squamous cell carcinoma com-plicating chronic osteomyelitis in atoe: a case report and review of theliterature. Foot and Ankle 12:178,1991.

30 Biersack HJ: Nuclear Medicinein Clinical Oncology. New York,Springer-Verlag,1986.

31 Banis J: Glabrous skin grafts forplantar defects. Foot Ankle Clin J Am6:827, 2001.

32 Langstein H, Chang D, MillerM, Evans G, Reece G, Kroll S, Robb G:Limb salvage for soft-tissue malignan-cies of the foot: an evaluation of free-tissue transfer. Plast Reconstr Surg109:152, 2001.

33 Imitiaz K, Khaleeli A: Squamouscell carcinoma developing in necro-biosis lipoidica. Diabet Med 18:325,2001.

34 Miller S, Brandes B, MahmarianR, Durham J: Verrucous carcinoma ofthe foot: A review and report of twocases. JFAS 40:225, 2001.

35 Whelan C, Deckers P: Electroco-agulation for skin cancer. Cancer47:2280, 1981.

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SCC is a threat that can notbe underestimated. The prognos-

tic factor that appears most signifi-cant for the reoccurrence of SCC isthe histologic grading of thetumor.5,10,22 Grade II tumors aremoderately differentiated and havea predilection of recurrence withrapid, usually fatal spread to lymphnodes. Grade I SCC typically willnot recur if adequate primary treat-ment is chosen.

For this reason, patients whohave been diagnosed and treatedwith SCC of the lower extremityshould be followed throughouttheir lifetime by a foot and anklespecialist. Recurrence of a SCC canbe as damaging, if not more so,than the original tumor. Patientsshould be monitored for any signsof metastasis. Those who have un-dergone a reconstructive procedurewill need assessment of the graftsand/or flaps for the duration oftheir lifetime. ■

Bibliography1 Drake L: Guidelines of care for

cutaneous squamous cell carcinoma. JAm Acad Dermatol 28:628, 1993.

2 Ozcelik D, Tatlidede S, Haciker-im S, Ugurlu K, Atay M: The use ofsentinal lymph node biopsy in squa-mous cell carcinoma of the foot: acase report. JFAS 43:60, 2004.

3 Johnson T, Rowe D, nelson B,Swanson N: Squamous cell carcinomaof the skin (excluding lip and oralmucosa). J Am Acad Dermatol 26:467,1992.

4 Euvrard S, Kanitakis J, Claudy A:Skin cancers after organ transplanta-tion. N Engl J Med 348:1681, 2003.

5 Cancer: Principles and practiceof oncology. Philadelphia, LippincottWilliams and Wilkins, 1993.

6 Haskell CM: Cancer treatment.Philadelphia, W.B. Saunders Compa-ny, 2001.

7 Price ML, Tidman MJ, Ogg CS,Macdonald DM: Skin cancer and cy-closporine therapy. N Engl J Med313:1420, 1985.

8 Konigova R, Rychterova V: Mar-jolin’s ulcer. Acta Chirurgiae Plasticae42:91, 2000.

9 Fleming M, Hunt J, Purdue G,Sandstad J: Marjolin’s ulcer: a reviewand reevaluation of a difficult prob-lem. J Burn Care Rehabil 11:460,1990.

10 Sabin S, Goldstein G, RosenthalH, Haynes K: Aggressive squamous cell

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ncarcinoma originating as a Marjolin’sulcer. Dermatol Surg 30:229, 2004.

11 Novick M, Gard D, Hardy S,Spira M: Burn scar carcinoma: a re-view and analysis of 46 cases. J Trau-ma 17:809, 1977.

12 Holgado R, Ward S, SuryaprasadS: Squamous cell carcinoma of thehallux. J Am Podiatr Med Assoc90:309, 2000.

13 Smith J, Mello L, Nogueira N,Meohas W, Pinto L, Campos V, Barcel-los M, Fiod N, Rezende J, Cabral C:Malignancy in chronic ulcers andscars of the leg (Marjolin’s ulcer): astudy of 21 patients. Skeletal Radiol30:331, 2001.

14 Treves N, Pack GT: The develop-ment of cancer in burn scars. Surg Gy-necol Obstet 51:749, 1930.

15 Kwa R, Campana K, Moy R: Bi-ology of cutaneous squamous cell car-cinoma. J Am Acad Dermatol 26:1,1992.

16 Stankard C, Cruse C, Wells K,Karl R: Chronic pressure ulcer carcino-mas. Ann Plast Surg 30:275, 1993.

17 Saglik Y, Arikan M, Altay M,Yildiz Y: Squamous cell carcinomaarising in chronic osteomyelitis. Inter-national Orthopedics 25:389, 2001.

18 Barnett C, Barnett J, Schwartz R:Dermatitis-like squamous cell carcino-ma. Dermatol Surg 30:334, 2004.

19 Peterson A, Layton E, Joseph A:Squamous cell carcinoma of the nailunit with evidence of bony involve-ment: a multidisciplinary approach toresection and reconstruction. Derma-tol Surg 30:218, 2004.

20 Nasca M, Innocenzi D, MicaliG: Subungual squamous cell carcino-ma of the toe: report on three cases.Dermatol Surg 30:345, 2004.

21 Breuninger H, Black B, RassnerG: Microstaging of squamous cell car-cinomas. Am J Clin Pathol 94:624,1990.

22 Lifesco R, Bull C: Squamous cellcarcinoma of the extremities. Cancer55:2862, 1985.

23 Ono I, Kaneko F: Magnetic Res-onance Imaging for diagnosing skintumors. Clin Dermatol 13:393, 1995.

24 Rajeswari M, Jain A, Sharma A,Singh D, Jagannathan N, Sharma U,Degonkar M: Evaluation of skin tu-mors by magnetic resonance imaging.Lab Invest 83:1279, 2003.

25 Ruocco E, Argenziano G, Pella-cani G, Seidenari S: Noninvasive imag-ing of skin tumors. Dermatol Surg30:302, 2004.

26 Kim K, Yavel R, Gross V, BrodyN: Intralesional interferon alpha-2b inthe treatment of basal cell carcinomaand squamous cell carcinoma: revist-ed. Dermatol Surg 30:116, 2004.

27 Sonmez A, Bayramicli M, Son-

D r . L i n n i eRabjohn i s at h i r d y e a rre s ident a tThe GraduateHospital Footand Ank l eSurgical Pro-g r a m i nPhiladelphia,Pennsylvania.

Dr. CorneliusDonohue is anattending physi-cian in podiatricsurgery at TheGraduate Hospi-tal in Philadel-phia, PA and aFellow of theAmerican Pro-fessional Wound

Care Association.Dr. Richard Montilla is an attend-

ing physician in plastic surgery atThe Graduate Hospital in Philadel-phia, PA.

Dr. Frederick Lavan is a residentat The Graduate Hospital GeneralSurgery Program in Philadelphia, PA.


of osseous invasion of thetumorB) To determine the presenceof osteomyelitis in cases ofMarjolin’s ulcerC) To determine the amountof soft tissue involvement ofthe tumorD) Both a and b

6) Which of the following modali-ties allows for the best soft tissuedefinition in regards to a squa-mous cell carcinoma of the footand ankle:

A) Computerized tomographyB) Plain film radiographyC) UltrasoundD) Magnetic resonance imag-ing

7) Which of the following condi-tions warrants biopsy of the softtissue:

A) Warts that are unresponsiveto therapyB) Wounds with excessivegranulation tissue beyond thewound marginsC) Wounds with increasingsize despite appropriate treat-mentD) All of the above

8) What is the appropriate defini-tion of a sentinal lymph node:

A) The closest geographiclymph node to the area of thesquamous cell carcinomaB) The largest lymph node inthe lymphatic systemC) The lymph node that drainsthe site of the primary lesionD) This lymph node is alwaysthe inguinal lymph node re-gardless of the area of theSCC

9) Which of the following is theestimated cure rate for SCC iftreated by available modalities:

A) 20%B) 50%C) 75%D) 90%

10) In regards to staging of a SCCtumor, which of the following iscorrect:

A) prognosis improves as the

1) Which of the following best de-scribes a squamous cell carcinoma:

A) Benign tumor that involvesthe keratinocytes of the epi-dermisB) Benign tumor that involvesthe hypodermis of the skinC) Malignant tumor that in-volves the keratinocytes of theepidermisD) Malignant tumor that in-volves the hypodermis of theskin

2) Which of the following hasbeen cited to cause a Marjolin’sulceration:

A) WartsB) Venous stasisC) Chronic sinus tractsD) All of the above

3) Which of the following is notassociated with the staging ofsquamous cell carcinoma:

A) Percentage of differentiat-ed cellsB) Prognosis, aggressiveness,and metastatic potential wors-ens with each degree of differ-entiationC) Prognosis, aggressiveness,and metastatic potential getsbetter with each degree of dif-ferentiationD) Both a and c.

4) Which of the following state-ments is correct:

A) Lower extremity squamouscell carcinoma has a higherrate of metastasis when com-pared to the average rate ofmetastasisB) The rate of metastasis isindependent of size anddepthC) The rate of metastasis is in-dependent of the location ofthe tumorD) The rate of metastasis is in-dependent of the presence ofa recurrent SCC

5) Plain film radiographs of thefoot and ankle are indicated in pa-tients suspected of squamous cellcarcinoma for which of the fol-lowing reasons:

A) To determine the presence

percentage of differentiatedcells increasesB) prognosis worsens as thepercentage of differentiatedcells decreasesC) metastatic potential be-comes greater as the percent-age of differentiated cells in-creasesD) both a and c

11) Which of the following is trueregarding grading of a SCC:

A) the determination of thegrade is based upon the mostdifferentiated portionB) the determination of thegrade is based upon the leastdifferentiated portionC) the determination of thegrade of the tumor does notinvolve the differentiation ofcellsD) none of the above

12) Which of the followingwounds should be biopsied to de-termine if there is a presence ofSCC:

A) chronic wound that doesnot appear to be healing suc-cessfully with wound careB) wounds with excess granu-lation that go beyond themargin of the woundC) wounds with irregular bor-ders and/or marginsD) all of the above

13) Concerning SCC of the lowerextremity, which of the followinglymph nodes are generally consid-ered possible sentinal nodes:

A) poplitealB) inguinalC) both a and bD) neither a nor b

14) Which of the following imag-ing modalities is best for deter-mining soft tissue AND bone in-volvement for SCC:

A) Plain radiographB) Tec-99 bone scanC) CT scanD) MRI

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198 PODIATRY MANAGEMENT

15) Which of the following statements is true:A) SCC is the least common malignancy to arisefrom chronic osteomyelitisB) SCC is the most common malignancy to arisefrom chronic osteomyelitisC) SCC never involves the bone so therefore hasno association with osteomyelitisD) Both a and c

16) Which of the following is true regarding cry-ologic surgery for SCC:

A) The tumor only needs to be frozen one timein order for tumor cells to be killedB) Freezing of the tumor cells requires a temper-ature of at least 100 degrees below zero (Cel-sius)C) Care should be taken not to freeze any of thenormal tissue immediately surrounding thewoundD) This type of treatment could lead to hyper-trophic scarring

17) What type of treatment for SCC has shown thehighest cure rate (99%) and the lowest chance ofreoccurrence:

A) Cryologic therapyB) Wide excisionC) Interferon injectionsD) Moh’s micrographic surgery

18) Which of the following warrants considerationfor an amputation regarding SCC of the lower ex-tremity:

A) Involvement of a large jointB) Tumor that has invaded so deep that excisionwould cause loss of functionC) Large areas of necrotic boneD) All of the above

19) Which of the following is true regardingmetastatic potential for SCC:

A) SCC has a relatively low rate of metastasisB) SCC involving the lower extremity has in-creased occurrence of metastasisC) SCC involving the lower extremity has de-creased occurrence of metastasisD) Both a and b

20) What is the most significant factor when deter-mining the prognosis of recurrence after treatmentof SCC:

A) Size of the tumorB) Depth of the tumorC) Histologic grading of the tumorD) Color of the tumor

E X A M I N A T I O N

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See answer sheet on page 199.

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LESSON EVALUATION

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EXAM #6/06Squamous Cell Carcinoma

of the Foot(Rabjohn, Donohue, Montilla, and Lavan)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

objectives squamous cell carcinoma of the footfoot. the patient denied any signifi-cant medical or...

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