Bleeding Plantar Heel Mass

[unseennude]

An 87-year-old Filipino man presents to the emergency department with a protuberant mass on his right heel that he first noticed 2 months ago. Since then, the mass has enlarged and has become increasingly uncomfortable with walking. The mass is otherwise painless, but it frequently oozes blood after walks or minor trauma. The patient denies having previous local trauma or walking outdoors in bare feet. He otherwise feels well, without fever, rashes, leg swelling, systemic symptoms, or other unusual lesions.



On physical examination the patient is a well-appearing, elderly man in no apparent distress who is wearing a blood-soaked bandage over his right heel. On the plantar aspect of his heel is a 2-cm, fungating, nontender mass with areas of central necrosis. The lesion is raised, with ill-defined borders and areas of uneven tan discoloration and erythema. He has no palpable inguinal or popliteal adenopathy, lower-extremity edema, rash, or pathologic lesions elsewhere.

What is the diagnosis?

Hint:Most of these lesions occur in sun-exposed areas, but a few occur in nonexposed areas.

[Oak]

I guess its a rare presentation of SCC in the sole of a foot.

[unseennude]

Malignant melanoma: Malignant melanoma can occur on any area of the skin or mucosa, even in non–sun-exposed skin, as in this patient. Except for the acral-lentiginous subtype of melanoma, the vast majority occurs in sun-exposed areas. Other clinical-histopathologic subtypes are nodular (as in this patient), superficial spreading, and lentigo maligna. Most melanomas occur in people of Caucasian descent who have fair skin and a history of multiple or severe sunburns. The incidence of melanomas in this group is 5 times that of individuals without fair skin, who are most likely to have acral-lentiginous subtype. Therefore, in patients without fair skin, particular attention must be focused on pigmented lesions on the soles, palms, nails, and mucosal surfaces.

Any nonhealing, bleeding, unusual, or ulcerated skin lesion should be considered suspicious and studied with biopsy. An ABCD mnemonic can be used as a guide for evaluating suspicious lesions, where A = asymmetry, B = border irregularity, C = color, and D = diameter larger than 6 mm. Any change in the shape, color, or size of a preexisting nevus should raise concern. Pruritus, pain, or tenderness also suggests melanoma. Bleeding and ulceration suggest that advanced disease is likely.

All patients with suspicious lesions should be referred to a dermatologist for possible biopsy. If melanoma is diagnosed with biopsy, its thickness should be measured. If it is greater than 1 mm, biopsy of a sentinel lymph node should be performed to adequately stage the tumor.

Patients with melanomas in situ have a 5-year survival rate of nearly 100%. Those with tumors <0.75 mm in thickness without nodal involvement have a 5-year survival rate of more than 95%. However, with widespread lymphatic involvement, the 5-year survival rate is approximately 25%, even with the most aggressive treatment. Advanced age, male sex, ulceration, increasing tumor thickness, location in the head or neck, and acral and/or mucosal involvement are associated with a worsened prognosis.

Treatment for nonmetastatic, localized melanoma involves excision with tumor-free margins of at least 1 cm for melanomas less than 2 mm in thickness or at least 2 cm margins for tumors 2 mm or thicker. If localized nodal involvement is found on clinical evaluation or biopsy of the sentinel lymph node, therapeutic lymph-node dissection may be indicated. Metastatic malignant melanoma can be treated medically with high-dose interferon-alpha, which improves recurrence-free survival rates. The use of chemotherapy and melanoma vaccine shows promise. Still, the current prognosis for patients with metastatic disease remains poor.

Risk factors for melanoma include being fair skinned or easily sunburned or having a history of blistering sunburns before the age of 12 years or a family or personal history of melanoma or several dysplastic nevi. Individuals with risk factors should use sun protection, such as wearing protective clothing and wide-brimmed hats and avoiding direct exposure to the sun from 10 AM to 3 PM. Sunscreen, though useful in preventing basal and squamous cell carcinomas, does not protect against melanoma. The use of sunscreen may ironically provide a false sense of security, as it protects against burning UVB rays but not the UVA rays that promote melanoma. Finally, individuals with a personal history of melanoma are at the highest risk and should undergo complete skin examination performed by a dermatologist at least once or twice yearly.
For more information on malignant melanoma, see Malignant Melanoma (within the Dermatology specialty), Malignant Melanoma (within the Internal Medicine specialty)

[JNUS]

Me thinking of same dx (MM). too.

[Anup'da]

that means hat is better than the sunblock cream here, great piece o information
anup'da