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Cutaneous tumors

A painful skin lesion next to the toenail

Case Identification
Case ID Number: 
20110215TN
Benign/Malignant: 
Malignant
Clinical case information
Case presentation: 

The patient has a painful skin lesion on the dorsolateral surface of the left second toe, adjacent to the base of the left second toenail. The lesion does not have any visible pigmentation. It has a raised, red, scaly appearance with the overlying skin coming off in small flakes. It has been present at least one year, with slow growth.

Differential Diagnosis: 
Both benign and malignant lesions must be considered

A subcutaneous tumor on the foot that has come back rapidly after surgery

Case Identification
Case ID Number: 
20121212ST
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 22 year old woman had a subcutaneous tumor removed from the top of her big toe 6 months ago. The tumor has already started to come back. A photo from before the surgery is shown.

Radiological findings:: 
A nonspecific, subcutaneous lesion is seen dorsal to the toe
Laboratory results:: 
The patient has no findings consistent with rheumatoid arthritis.
Differential Diagnosis: 
This is a tumor that podiatrists, orthopedic surgeons who treat foot and ankle conditions, and hand surgeons will see relatively frequently . Dermatologists and primary care MD's may also encounter this lesion. Students and practitioners of surgery of the foot should be aware of this lesion and include it in their differential when encountering skin and subcutaneous tumors in the foot.
Further Work Up Needed:: 
What is the best next step in managing this particular patient?
Pathology results:: 
The excision shows large areas of geographic necrobiosis with surrounding palisaded histiocytic inflammation and fibrosis. The areas of necrobiosis have a somewhat basophilic tint and are shown to contain degenerated collagen as well as mucin, highlighted on trichrome and Alcian blue stains respectively. The differential diagnosis for palisaded histiocytic inflammation in the deep soft tissues primarily includes rheumatoid nodule and subcutaneous granuloma annulare. Rheumatoid nodules are often seen in older patients in conjunction with a clinical diagnosis of rheumatoid arthritis. In addition, mucin deposition within the lesions is unusual, although it has been reported. Subcutaneous granuloma annulare is more common in children and young adults, and the areas of necrobiosis show more basophilia and often show mucin deposition. Unfortunately, there can be histologic overlap between these two diagnoses. In a young patient in the absence of coexisting rheumatoid arthritis and given the somewhat basophilic necrobiosis with positive mucin deposition, the findings are most consistent with subcutaneous granuloma annulare. However, if the patient has a known history of rheumatoid arthritis and the lesion is adjacent to an affected joint, these findings are best interpreted as rheumatoid nodule.
Treatment Options:: 
This lesion may require biopsy for conclusive diagnosis, but surgical excision is not needed and other treatments are better suited. Surgical treatment is frequently followed by recurrence. See the associated page on this site for complete information on this tumor.
Special Features of this Case:: 
The patient is a very pleasant 22-year-old woman who presents approximately 6 months after having had surgical treatment of a mass in the left great toe. She shows us a picture of multiple subcutaneous masses, adjacent to each other, on the dorsum of the left great toe, which blanch slightly with flexion of the toe, each may be six or 7 mm and roughly round, apparently projecting from the skin surface by a few millimeters. Overlying skin otherwise normal. These had gradually grown and increased in size over a period of two years.

Collagenous fibroma (desmoplastic fibroblastoma)

Collagenous fibroma (desmoplastic fibroblastoma) is a rare, benign subcutaneous soft tissue tumor that affects mostly men in their 50s to 70s, predominantly on the upper and lower extremities.
Men are affected by this tumor 4 times more frequently than women. The age range is wide, withe the peak age at diagnosis being in the 50s, 60s, and 70s.
Patient presents with a slowly growing painless mass in the subcuticular tissues a peripheral site, most commonly the upper or lower extremities, which may involve skeletal muscle. The size may be from one to several centimeters, with masses as large as 20 cm possible.X-ray findings are normal.
Complete surgical removal is curative.

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Ouch! A tumor in the heel that hurts so much she can't put it down.

Case Identification
Case ID Number: 
20121213TH
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

A year old woman has an exquisitely painful area on her heel. The are has become so painful she must walk on her toes. It is extremely sensitive to cold, as well as any pressure.

Radiological findings:: 
There is a small mass in the subcutaneous tissues of the heel, generally isointense on T1 and moderately bright on T2. There is a plantar mass, which is approximately 2 x 2 x 1 cm, nearly subcutaneous in the plantar surface of the left foot, just at the border where the subcutaneous tissue meets the plantar fat pad.
Special Features of this Case:: 
When a subcutaneous mass causes very severe local pain and cold sensitivity, this diagnosis should be considered. See the page on glomus tumor on this site.
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