Subungual squamous cell carcinoma: radiation therapy as an alternative to amputation and review of the literature

Subungal squamous cell carcinoma of the thumb - Implications for patient setup and radiotherapy planning

Subungal squamous cell carcinoma (SSCC) is a rare malignancy of the nail bed. We present the case of a woman diagnosed with a SSCC of the right thumb. Initial management consisted of surgically excision followed by adjuvant radiotherapy due to a positive bone margin. We describe the patient set-up, immobilisation technique, target volume delineation, radiotherapy planning, fractionation schedule, image guidance and patient outcomes.

Photon irradiation using a water bath technique for treatment of confluent carcinoma in situ of the hand, digits, and nail bed: a case report

Background

Confluent squamous cell carcinoma in situ, or Bowen’s disease, involving the hand, digit, and nail bed is rare and represents a significant therapeutic challenge. Surgical excision is recommended as first-line treatment but in cases of extensive disease can lead to unacceptable functional morbidity or cosmetic outcomes. Radiation therapy has been shown to be equally efficacious to surgery in the treatment of carcinoma in situ but its use has historically been limited due to concerns regarding toxicity. In this case report we present a novel therapeutic technique that may enable radiotherapy to be employed as a definitive treatment option in these challenging cases.

Case presentation

A 75-year-old white man with a previous history of carcinoma in situ of his right hand previously treated with 5-fluorouracil presented with recurrent biopsy-proven confluent squamous cell carcinoma in situ of multiple surfaces of his right hand and digits with involvement of nail beds. To avoid extensive resection and possible amputation he was offered definitive external beam radiation therapy utilizing a water bath as a tissue-equivalent bolus material. This protocol enabled improved dose homogeneity to the target volume while minimizing acute toxicity. He experienced complete clinical resolution of the disease with only minimal acute edema and hyperpigmentation. Twenty months following treatment completion he remains disease-free with normal function and excellent cosmesis.

Conclusions

Therapeutic radiation utilizing water as a tissue-equivalent bolus in this complicated case enabled definitive treatment of disease without compromising functional or cosmetic outcomes. Radiotherapy may therefore be an alternative and under-utilized approach to surgical excision in difficult-to-treat cases of carcinoma in situ.

Subungual squamous cell carcinoma

Although subungual squamous cell carcinoma is rare, it is the most common primary malignant neoplasms in this location. The higher incidence occurs in the fingernails, but involvement of the toenails is also possible. Subungual squamous cell carcinoma often looks like other more common benign lesions, such as fungal infection, onychomycosis, or viral wart. These factors, together with a general lack of awareness of this disease among physicians, often result in delayed diagnosis. Therefore, it is underdiagnosed, with few reports in the literature. The authors present a case of a man with a diagnosis of subungual squamous cell carcinoma in the hallux, without bone involvement, which was submitted to the appropriate surgical treatment.

Serum level of receptor activator of nuclear factor kappa-B ligand in patients with psoriasis

BACKGROUND

Psoriasis usually precedes the onset of psoriatic arthritis by an average of 10 years in about 70% of patients. Receptor activator of nuclear factor kappa-B ligand (RANKL) is a natural and necessary surface-bound molecule, which is a ligand for osteoprotegrin and functions as a key factor for osteoclast differentiation and activation.

OBJECTIVE

Evaluation of the serum level of RANKL in psoriasis and psoriatic arthritis and its correlation with severity of the disease as a trial to predict the occurrence of psoriatic arthritis in such patients.

METHOD

This study included 80 subjects; 40 patients had chronic plaque psoriasis, 20 patients had chronic plaque psoriasis with psoriatic arthritis, and 20 were healthy controls. Patients with psoriasis were divided into three subgroups according to psoriasis area severity index score: mild, moderate, and severe. Serum RANKL levels were estimated for all subjects using enzyme-linked immunosorbent assay.

RESULTS

Serum RANKL level in psoriatic arthritis was significantly higher compared to both patients with plaque psoriasis and control groups. Serum RANKL level significantly correlated to the severity of psoriasis, with a very high correlation coefficient in groups I and II. The diagnostic performance of serum RANKL level for the early prediction of psoriatic arthritis in patients with psoriasis was >170 pg/ml.

CONCLUSION

Serum RANKL level could be considered as a useful diagnostic marker for the early prediction of psoriatic arthritis in patients with moderate and severe psoriasis. Assessment of soluble RANKL in psoriasis could identify those at increased risk for psoriatic arthritis, and anti-RANKL agents may be effective in decreasing incidence of psoriatic arthritis.

An unusual lesion of the finger presenting to the emergency department

•

Digital squamous cell carcinoma commonly mimics chronic granulomatous or fungal infections.

•

Chronic non-healing lesions of the digits should be viewed with suspicion.

•

It usually has an indolent course but can be locally destructive.

•

Excisional biopsy, providing a clear margin, where possible is usually sufficient in the absence of metastatic spread.

Introduction

Squamous cell carcinoma (SCC) of the finger, especially those arising from the nail bed matrix and lateral skin folds are common, especially after the fifth decade of life. A variety of aetiological factors and associations have been described. The appearance can be so ambiguous and appear benign that it can lead to a delay in presentation and diagnosis.

Presentation of the case

We report a case of a 66 year old retired Engineer who presented to our Emergency Department with a 2-year history of a painless swelling of his left ring finger. Examination revealed a diffuse circumferential swelling of the left ring finger involving the middle and distal phalanx. The tip was insensate. The differential diagnoses included pyogenic granuloma, soft tissue sarcoma and chronic granulomatous infection. An excisional biopsy confirmed the diagnosis of a well differentiated squamous cell carcinoma.

Discussion

This case highlights how digital squamous cell carcinoma can appear benign, mimic a wide variety of conditions leading to a delay in diagnosis and treatment. It usually runs an indolent course but can be locally destructive. Excisional biopsy, providing a clear margin where possible is usually sufficient in the absence of metastatic spread.

Conclusion

Chronic, non-healing lesions of the digits should be viewed with suspicion. Digital squamous cell carcinoma commonly mimics a variety of benign conditions and efforts should be made to rule out other possible diagnoses and to institute early treatment.