Subungual Squamous Cell Carcinoma Research Articles

Onychocytic Matricoma: A Clinical, Dermoscopic, and Pathological Analysis of 14 Cases.

Onychocytic matricoma (OCM) is a benign neoplasm of the nail matrix. Only 18 cases of this tumor have been reported in the literature to date. We retrospectively analyzed the clinical features of 14 patients with OCM. The most common clinical feature was longitudinal xanthopachyonychia (n = 9), followed by longitudinal leukopachyonychia (=3) and longitudinal pachymelanonychia (n = 2). The most common clinical findings identified following dermoscopy and analysis at high magnification of classical photographs were free-edge thickening of the nail plate without pitting (n = 14), longitudinal ridging (n = 7), round white clods (n = 7), white dots (n = 7), and filiform hemorrhages (n = 7), followed by oval and linear white clods (n = 5), fuzzy lateral border (n = 5), and red-purple blood clods (n = 3). Nail clipping histopathology showed a thickened nail plate with multiple, small, round-to-oval spaces. The tumor expressed immunopositivity for LEF-1. Dermoscopy of the nail plate and nail clipping histology provides useful information with regards to the differential diagnosis with subungual squamous cell carcinoma and nail melanoma. Ex vivo-in vivo correlation facilitates a better dermoscopic assessment of this unique underrecognized disease. However, the differential diagnosis between OCM and onychocytic carcinoma requires biopsy of the tumor. LEF-1 as an onychogenic marker can be used to resolve the differential diagnosis between OCM and subungual longitudinal acanthoma/seborrheic keratosis.

Subungual squamous cell carcinoma leading to arm amputation

Subungual squamous cell carcinoma leading to arm amputation

First dorsal metacarpal artery flap in soft tissue reconstruction of recurrent thumb squamous cell carcinoma

Background. Subungual squamous cell carcinoma (SCC) of thumb is a rare disease. However, it is the most common malignancy affecting the nail bed. Early recognition is crucial and important for prompt diagnosis and effective treatment. Often this tumour needs to be treated surgically with wide local resection, which results in a defect in the thumb. If not handled appropriately, such defects render restriction in functionality of the involved thumb as well as a poor aesthetic outcome. In the worst-case scenario, it may result in a poor function of involved hand. Thus, reconstruction of the involved thumb is necessary. The main aim of reconstruction is to regain the hands' function and preserved the thumbs' sensation. Secondarily, to have an aesthetically pleasing hand. Our hands carry out delegate job and important duty for daily function. Especially, the thumb working together with the other fingers to carry out the hand function as one unit. Loss of thumb function affects the whole performance of the hand. Case descriptions. We report a case of recurrent subungual squamous cell carcinoma of thumb, which had wide local resection and subsequently underwent soft tissue coverage with an islanded first dorsal metacarpal artery (FDMA) perforator flap. One month after surgery, the patient was able to regain a good functional outcome of the hand. In this report, we discussed the procedures that had been done. Conclusion. The patient regained full functional hand after reconstruction with preserved sensation over distal thumb. The aesthetic outcome is satisfactory. The FDMA perforator flap is a very pliable and robust flap for reconstruction of distal thumb defect.

Subungual squamous cell carcinoma with metastasis to the femur, multiple lymph nodes, adrenal glands, and lungs

Subungual squamous cell carcinoma with metastasis to the femur, multiple lymph nodes, adrenal glands, and lungs

34216 Subungal squamous cell carcinoma presenting as longitudinal melanonychia

An 85-year-old African American woman with erosive lichen planus, diabetes, and rheumatoid arthritis presented for evaluation of linear melanonychia of the right first fingernail. The lesion had been present for multiple years, slowly increasing in size, darkening, and becoming painful. Upon evaluation, the patient had a 4 x 2 mm pigmented macular lesion at the proximal nail fold with a 3-mm-wide pigmented streak extending to the end of the nail plate. No nail deformity, bleeding, or drainage was noted. Excisional biopsy of the nail matrix with 1mm margins was performed, yielding a 5 x 3 mm defect at the proximal nail fold. Histopathology revealed high-grade squamous intraepithelial lesions involving the epidermis and nail bed. Stain for Melan-A was positive in dendritic melanocytes and less than 1% of epithelial cells. Stain for p16 showed strong confluent staining with more than 90% of dysplastic epithelium. Positive p16 staining is consistent with HPV-associated squamous cell carcinoma (SCC). The diagnosis of subungual SCC was made and the lesion was further excised with Mohs micrographic surgery approximately 2 months later. A total of 2 stages and 4 tissue sections were required to obtain clear margins. The postsurgical defect was 23 x 21 mm and repaired using a rotation flap. This case of a rare malignant subungual tumor, SCC of the nail bed, is especially unique due to its presentation. The presence of a darkly pigmented streak is more typical of subungual melanoma. Awareness of various presentations of SCC of the nail bed, often called the “great mimicker,” is important as it is frequently misdiagnosed.

Radiographic features of subungual keratoacanthomas in dogs

Subungual keratoacanthoma (SK) is a digital neoplasm that has rarely been reported in dogs and carries an excellent prognosis following surgical removal. Radiographic features of canine SK have only been briefly discussed in two prior case reports. Both articles described extensive distal phalangeal osteolysis, a feature more commonly associated with malignant digital neoplasms (e.g., subungual squamous cell carcinoma (SCC) or melanoma). This retrospective case series aimed to further characterize radiographic findings of histologically confirmed canine SK. Seven dogs met the inclusion criteria, with a total of seven affected digits. All seven digits (100%) had osteolysis of the distal phalanx's ungual process and crest, as well as regional soft tissue swelling. Osteolysis of the ungual process was severe in all cases, with complete destruction in six of seven digits (86%). Partial ungual crest geographic and expansile osteolysis was noted in four of seven digits (57%), while two digits (28%) had complete ungual crest destruction. Seven of seven digits (100%) had a radiographically thickened claw, and two of seven digits (28%) had associated lysis of the distal aspect of the middle phalanx. Based on these findings, an osteolytic subungual mass should not be considered pathognomonic for malignant neoplasia. Observing the imaging features previously described should prompt veterinarians to consider SK as a differential diagnosis.

Pleomorphic Onychomatricoma: A Mimicker of Malignancy.

Pleomorphic onychomatricoma is a rare condition mimicking malignant neoplasms. Given its rarity, the diagnostic and prognostic criteria of this condition are not well established. The aim of this study was to characterize a series of 6 cases of pleomorphic onychomatricoma. In 3 cases the submitting clinical diagnosis was subungual squamous cell carcinoma. For all 6 cases, nail clipping showed typical features of onychomatricoma as a free-edge thickening and pitting of the nail plate with an additional feature of projecting line pattern. Pleomorphic onychomatricoma was diagnosed based on moderate-severe cytological atypia, yet degenerative-appearing with multinucleation or smudged chromatin, no mitotic activity or necrosis, and a Ki67 proliferative index inferior to 5% overall. Other finding s included epithelioid multinucleated cells with deeply eosinophilic cytoplasm mimicking epithelioid malignant cells, overexpression of Ki67 and p53 on atypical cells and diffuse expression of p16. This study describes additional criteria in pleomorphic onychomatricoma, permitting a wider recognition in order to avoid inappropriate treatment.

Subungual squamous cell carcinoma in situ presenting as longitudinal melanonychia

Subungual squamous cell carcinoma in situ presenting as longitudinal melanonychia

A Case of Subungual Squamous Cell Carcinoma with Dermal Myiasis

A Case of Subungual Squamous Cell Carcinoma with Dermal Myiasis

Intraoperative dermoscopy features of subungual squamous cell carcinoma: a study of 53 cases.

Subungual squamous cell carcinoma (SU-SCC) is the most common malignant tumour of the nail unit. Intraoperative nail dermoscopy has been described only for pigmented tumours, onychomatricoma and glomus tumours. To establish a description of intraoperative dermoscopic features of SU-SCC. A single-centre retrospective cohort of 53 SU-SCC cases over a 5-year period was reviewed by six examiners who individually scored 31 intraoperative dermoscopic features as present or absent. For each feature, the frequency and interobserver agreement was evaluated, then the data were compared and a consensus was reached. No feature had perfect or substantial interobserver agreement. Regarding anatomy and architecture, most tumours involved both the nail bed and nail matrix (n=34, 64.2%) and had nonparallel lateral side edges (n=36, 67.9%). Regarding vascular features, several different patterns were found: dotted vessels (n=49, 92.5%), irregular vessels (n=47, 88.7%), curved vessels (n=46, 86.8%), sagittal vessels (n=45, 84.9%), milky-red areas (n=42, 79.2%), linear and regular vessels (n=30, 56.6%), coiled and hairpin vessels (n=23, 43.4%), and arborizing vessels (n=16, 30.2%). Pigmented dermoscopy structures included dotted purpura, grey granulation and splinter haemorrhages, which were found in 49 (20.8%), 9 (17%) and 9 (17%) cases, respectively. Other dermoscopic signs were pink background, translucent structureless area, whitish scaly areas, distal plug, yellowish scales and dots, and 'digitiform' proximal edge, which were found in 49 (84.9%), 49 (84.9%), 43 (81.1%), 37 (69.8%), 28 (52.8%) and 22 (41.5%) cases, respectively. Analysis of this first large series of SU-SCC studied by intraoperative dermoscopy suggests that it gives useful information to better approach the diagnosis and to target biopsies.

Subungual Squamous Cell Carcinoma in a Patient with Psoriasis.

Subungual squamous cell carcinoma (SCC) is often misdiagnosed as a benign condition so most cases are invasive by the time of diagnosis; nail elevation and biopsy are recommended in all suspicious cases.Although psoriasis is not an independent risk factor for subungual SCC, the cyclosporine and PUVA used to treat psoriasis are risk factors for cutaneous SCC.The aetiology for subungual SCC is still unclear, but it should be suspected in patients with psoriasis and a suspicious presentation.

Acremonium nail bed mycetoma masquerading as subungual squamous cell carcinoma

Acremonium is a large fungal genus that is comprised of approximately 150 species, found ubiquitously in nature. Although the majority are recognized as being saprophytes in soil and pathogens of plants, several species are emerging as causative agents of a variety of human infections, including mycetomas. Herein, we present a young man that was referred to our department with a painful subungual mass that developed following traumatic inoculation of Acremonium spp. In recent years, the role of Acremonium spp. has been increasingly recognized in localized infections, such as mycetoma, in humans. Other locally invasive as well as disseminated infections are also described. Optimal treatment of Acremonium spp. mycetoma is not well defined owing to the rarity of cases, thus posing a therapeutic challenge.

Phalangeal and metatarsal bone destruction by subungual squamous cell carcinoma complicated by Peptostreptococcus sp. infection in a dog – importance of histopathological diagnosis.

The present article reports the case and complications of a canine with a subungual squamous cell carcinoma infected with Peptostreptococcus sp. whose initial diagnosis was erroneously considered as osteomyelitis, highlighting the importance of histopathological evaluation in digital lesions. A six-year-old female Rottweiler dog presented radiographic right metatarsal bone lysis after amputation of digit II phalanges due to a nonhealing ulcerated lesion. Amputated phalanges were fixed in formalin, but no histopathological evaluation was performed on that occasion. Osteomyelitis was suspected and clindamycin was prescribed. Bone lysis progressed up to tarsal bones even under antibiotic therapy, and due to its progression and severity, limb amputation was performed. Microbiological and histopathological evaluation of the limb respectively revealed Peptostreptococcus sp. and squamous cell carcinoma, the last one invading metatarsal bone, the same diagnosis later found in previously amputated phalanges. As shown on histopathological results, subungual squamous cell carcinoma advanced adjacent tissues and Peptostreptococcus sp. was considered an opportunistic agent. The patient recovered well and was healthy, with no evidence of metastasis a year and a half after amputation. The present case demonstrates the importance of histopathological evaluation to elucidate bone lesions and avoid complications, especially when digits are concerned.

Subungual Squamous Cell Carcinoma of the Thumb Treated by "Function Sparing Approach" Using Contact Radiotherapy (Brachytherapy)

Subungual Squamous Cell Carcinoma of the Thumb Treated by "Function Sparing Approach" Using Contact Radiotherapy (Brachytherapy)

A SINGULAR CLUBBED DIGIT INDICATING SARCOIDOSIS

SESSION TITLE: Signs and Symptoms of Chest Disease SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: First described by Hippocrates, digital clubbing is a classic physical exam finding associated primarily with pulmonary disease. Clubbing also has well established associations with suppurative lung infection, bronchogenic carcinoma, bronchiectasis, pleural tumors, idiopathic pulmonary fibrosis, cirrhosis, endocarditis, and cyanotic heart disease among others.[1-3] However, isolated clubbing of a solitary digit most often is related to a neoplastic condition such as osteoid osteoma or enchondroma. We report the rare case of a patient presenting with classic findings of sarcoidosis whose heralding symptom was isolated digital clubbing of a single finger. CASE PRESENTATION: A 47 year-old man was referred to our clinic with worsening dyspnea on exertion, fatigue and intermittent dry cough. His vital signs were normal: temperature 36.4°c, respirations 14/min, pulse 66/min, blood pressure 131/82 mmHg and SpO2 97% on room air. His examination was unremarkable apart from prominent digital clubbing of a solitary finger; all other fingers and toes were normal (Fig 1). He was a nonsmoker without history of prior hand injury. There was no family history of rheumatologic or pulmonary disease. Hand x-ray (Fig. 2) revealed moth-eaten appearance with acroosteolysis of the distal phalanx, but no other regions of boney destruction. Chest x-ray (Fig 3) showed bilateral bulky hilar lymphadenopathy along with reticular and nodular opacities within the lungs. Bone biopsy from the distal phalanx (Fig. 4) demonstrated non-caseating granulomatous inflammation, but no malignancy. Acid-fast, fungal, and bacterial cultures of the biopsy were all sterile. DISCUSSION: Less frequently, sarcoidosis has also been associated with digital clubbing, but described cases have been bilateral and typically with involvement of all fingers.[4] Our presented case is unique in that a single finger was clubbed with complete sparing of all other fingers and toes. Typically, the differential diagnosis for a single clubbed finger includes osteoid osteoma, enchondroma, myxochondroma, digital mucoid cyst or glomus tumor. Less frequently, chondrosarcoma, Ewing’s sarcoma, and subungual squamous cell carcinoma have also been described arising from the distal phalanx. Accordingly, cases of isolated single digit clubbing should undergo biopsy because of their malignant potential. CONCLUSIONS: Our case highlights a unique presentation of sarcoidosis with osseous involvement causing a single Hippocratic finger. Digital clubbing found in any patient may herald a variety of significant underlying medical conditions and should prompt further evaluation. Reference #1: 1. Martinez-Lavin, M, Exploring the cause of the most ancient clinical sign of medicine: finger clubbing. Semin Arthritis Rheum, 2007. 36(6): p. 380-5.2. Rutherford, JD, Digital clubbing. Circulation, 2013. 127(19): p. 1997-9. Reference #2: 3. Spicknall, K.E., Zirwas MJ, and English JC. Clubbing: an update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance. J Am Acad Dermatol, 2005. 52(6): p. 1020-8. Reference #3: 4. Yancey J, Luxford W, and Sharma OP, Clubbing of the fingers in sarcoidosis. JAMA, 1972. 222(5): p. 582. DISCLOSURES: No relevant relationships by Kevin Davidson, source=Web Response No relevant relationships by Andrew Levy, source=Web Response

Functional Surgery for Malignant Subungual Tumors: A Case Series and Literature Review

Background and objectivesAmputation is the conventional treatment for malignant subungual tumors (MSUTs), namely, subungual squamous cell carcinoma (SUSCC) and subungual melanoma (SUM). Functional surgery consisting of wide local excision (WLE) of the nail unit can preserve function without modifying prognosis in such cases. We present a series of MSUTs treated with WLE of the nail unit, describe the technique, and review its indications. Material and methodsRetrospective observational study of MSUTs treated with WLE of the nail unit between 2008 and 2017. The technique consisted of en bloc supraperiosteal excision of the nail unit with a margin of 5mm followed by repair with a full-thickness graft. ResultsEleven MSUTs were treated in the study period: 7 SUMs (4 in situ; mean thickness, 1.17mm; range, 0-4mm) and 4 SUSCCs (mean thickness, 3.4mm; range, 1.6-6mm). WLE of the nail unit was performed in 9 patients and amputation in 2 patients with invasive SUM. Mean follow-up was 39 months (range, 12-96 months) and no local or regional recurrences were detected. One of the 2 patients who underwent amputation developed metastasis to the brain and died. In our review of the literature, we identified 5 series of patients with SUSCC treated with WLE of the nail unit (105 patients) and 14 series of patients with SUM (243 patients). Based on an analysis of these cases and ours, it would appear that WLE of the nail unit is associated with a very low rate of local recurrence (<7%) and offers better functional and cosmetic outcomes than amputation. ConclusionsWLE of the nail unit is the treatment of choice for SUSCC without bone involvement and for thin noninvasive SUM (Breslow depth <1mm). It is also feasible in intermediate-thickness SUMs when detailed histologic examination of the margins confirms complete resection. Amputation, by contrast, is the treatment of choice for SUSCCs with bone involvement, very thick SUMs (>4mm), and recurrent tumors.

Cirugía funcional en tumores malignos subungueales. Serie de casos y revisión de la literatura

Background and objectivesAmputation is the conventional treatment for malignant subungual tumors (MSUTs), namely, subungual squamous cell carcinoma (SUSCC) and subungual melanoma (SUM). Functional surgery consisting of wide local excision (WLE) of the nail unit can preserve function without modifying prognosis in such cases. We present a series of MSUTs treated with WLE of the nail unit, describe the technique, and review its indications. Material and methodsRetrospective observational study of MSUTs treated with WLE of the nail unit between 2008 and 2017. The technique consisted of en bloc supraperiosteal excision of the nail unit with a margin of 5mm followed by repair with a full-thickness graft. ResultsEleven MSUTs were treated in the study period: 7 SUMs (4 in situ; mean thickness, 1.17mm; range, 0-4mm) and 4 SUSCCs (mean thickness, 3.4mm; range, 1.6-6mm). WLE of the nail unit was performed in 9 patients and amputation in 2 patients with invasive SUM. Mean follow-up was 39 months (range, 12-96 months) and no local or regional recurrences were detected. One of the 2 patients who underwent amputation developed metastasis to the brain and died. In our review of the literature, we identified 5 series of patients with SUSCC treated with WLE of the nail unit (105 patients) and 14 series of patients with SUM (243 patients). Based on an analysis of these cases and ours, it would appear that WLE of the nail unit is associated with a very low rate of local recurrence (<7%) and offers better functional and cosmetic outcomes than amputation. ConclusionsWLE of the nail unit is the treatment of choice for SUSCC without bone involvement and for thin noninvasive SUM (Breslow depth <1mm). It is also feasible in intermediate-thickness SUMs when detailed histologic examination of the margins confirms complete resection. Amputation, by contrast, is the treatment of choice for SUSCCs with bone involvement, very thick SUMs (>4mm), and recurrent tumors.

Association of subungual melanoma and subungual squamous cell carcinoma: A case series

Subungual squamous cell carcinoma (SSCC) and subungual melanoma (SUM) are rare tumors. Several case reports of association of SSCC with SUM (SSCC-SUM) have been published. We sought to document the clinical, dermoscopic, and histologic features in a case series of SSCC-SUMs and describe their relative frequency compared with those of SSCC and SUM. All patients who underwent surgical exploration of the nail apparatus with a dermatopathologic examination from 2012 to 2015 were reviewed retrospectively to identify all cases of SSCC, SUM, and SSCC-SUM. For patients with SSCC-SUM, clinical characteristics were obtained from electronic medical records. All histologic specimens were reviewed by 3 dermatopathologists. The medical records of 456 patients were reviewed. SSCC was diagnosed in 78 (17%), SUM was diagnosed in 63 (14%), and SSCC-SUM was diagnosed in 9. Patients with SSCC-SUM accounted for 11% of those with a diagnosis of SSCC (9 of 78) and 14% of those with a diagnosis of SUM (9 of 63). This was a single-institution retrospective study. The association of SSCC and SUM is relatively frequent in patients with SUM and warrants further consideration to understand the underlying mechanisms involved.

Dermoscopic Features of Subungual Squamous Cell Carcinoma: A Study of 44 Cases

Background: Subungual squamous cell carcinoma (SSCC) is the most frequent tumor of the nail apparatus. Its diagnosis is often missed or delayed because the clinical presentation is atypical and can mimic other conditions. Accurate diagnosis can only be made by performing an appropriate surgical biopsy, but biopsy is painful and often leaves definitive dystrophic scars. The use of dermoscopy, a noninvasive technique, has been described to be useful for the preoperative evaluation of nail diseases. Objectives: To define the different clinical and dermoscopic presentations of SSCC and to compare them with onychomatricoma-associated clinical and dermoscopic features published in our previous study. Methods: A retrospective review of 44 cases of SSCC seen in our institution over an 8-year period. Six observers scored 19 clinical criteria and 14 dermoscopic criteria as present or absent. Then, we compared those data to a previously published study about the preoperative diagnosis of onychomatricoma. Results: Only 1 dermoscopic criterion was significantly associated with SSCC compared to onychomatricoma: localized hyperkeratosis (odds ratio, OR = 6.25, p = 0.012, 95% confidence interval CI = 1.50-26.01). In contrast, parallel edges (OR = 0.03, p < 0,001, 95% CI = 0.003-0.20) and sharp demarcation of the lesion (OR = 0.24, p = 0.004, 95% CI = 0.09-0.63) can statistically significantly be considered as in favor of onychomatricoma. By contrast, we believe that the presence of unparalleled lateral edges of the nail lesion or of fuzzy edges are more in favor of SSCC. Conclusions: Dermoscopy of the nail plate and of the nail free edge in SSCC provides useful information in order to better select cases to be submitted to biopsy.

Surgical Treatment of Subungual Squamous Cell Carcinoma by Wide Excision of the Nail Unit and Skin Graft Reconstruction

ImportanceThe best surgical treatment modalities for subungual squamous cell carcinoma (SUSCC) without bone invasion need to be determined. The limited available data on Mohs micrographic surgery do not demonstrate its use as a standard procedure. A previous study in a limited series of patients has shown that wide surgical excision of the nail unit was associated with a low rate of recurrence.ObjectivesTo confirm the efficiency of wide surgical excision of the nail unit with full-thickness skin graft reconstruction on a series of patients with SUSCC with an extended follow-up and to evaluate short- and long-term postoperative morbidity and patient satisfaction.Design, Setting, and ParticipantsA consecutive series of 55 patients with biopsy-proven SUSCC without bone invasion treated by wide surgical excision of the nail unit followed by full-thickness skin graft reconstruction from January 1, 2000, to August 31, 2012 were included. After a minimum follow-up of 5 years, the recurrences were collected from the referring physicians. Statistical analysis was conducted from January 1 to June 30, 2016.Main Outcomes and MeasuresDemographic data, pathologic characteristics of tumors, postoperative follow-up, and recurrences were collected from medical records. Patients’ satisfaction with surgery, quality of life, and delayed postoperative morbidity (functional outcome and sensory disorders) were assessed from a questionnaire mailed to patients and physicians.ResultsAmong the 55 patients (23 women and 32 men; mean age, 64 years), the mean follow-up was 6.6 years (range, 5.0-11.2 years), with a minimum follow-up of 5 years. Fifty-two questionnaires (95%) were returned. Two recurrences were observed. Minor early postoperative complications, such as graft infection and delayed wound healing, were seen in 6 patients; 8 patients experienced severe pain. Late postoperative complications included hypersensitivity to mechanical shocks (39 of 51 patients [76%]), mildly increased sensitivity to cold (38 of 51 patients [75%]), loss of fine touch sensation (17 of 35 patients [49%]), and epidermal inclusion cysts (9 of 51 patients [18%]). Most patients were very satisfied with cosmetic and global outcomes of the surgery.Conclusions and RelevanceTotal excision of the nail unit followed by a full-thickness skin graft is a safe and efficient treatment for SUSCC without bone involvement, with satisfying cosmetic and functional outcomes.