Suhad Hadi, DPM, FACFAS

Soft tissue lesion/mass left foot/heel

HPI: Pt is a 90 year old male seen in consultation today for soft tissue a mass left arch and new skin lesion lateral posterior heel.  His wife and his son are present with him. He was referred by Dermatology and PCP since he is developing new lesions beyond the one on the bottom of his foot in the arch area.  He now has a new lesion to the outside of his left heel. Per pt, he has had a prior punch biopsy in the dermatology clinic of the bottom lesion and was given the diagnosis with findings consistent with hemangiopericytoma. However, due to development of multiple lesions, a concern regarding the accuracy of diagnosis arose.  Patient denies any pain to the area.  He has been ambulating with keeping a large band-aid cover on the foot and a house slipper type shoe on that side. He presents to discuss excisional biopsy of newer lesion and re-do of punch biopsy arch.

PMH: Anemia, Meniere's Dz, Hypertension, Vitamin D Deficiency        

MEDs: -Hydrochlorothiazide 25mg Tab.  Take one tablet by mouth every morning to lower blood pressure
-Vitamin D3 (cholecalciferol) 1000 Unt Tb.  Take two tablets by mouth every day (vitamin d)
-Aspirin  81 Mg Ec Tab.  81mg by mouth every day

ALL: Patient has answered NKA       

SOC. HX: Married, denies tobacco/EtOH, has both sons living in the area and assist in his care, he is very independent and functional alone

VASC: DP AND PT Palpable with CFT intact to digits b/l

NEURO: Epicritic sensation intact b/l

DERM: Nodular 2.4cm mass with stalk noted to plantar medial arch left foot, it has granular/hemorrhagic features and epithelial features and epidermolysis to periphery of the stalk, it stands out approximately 1cm, there is no purulence, no tenderness with palpation of surround skin margins, no surrounding
erythema/cellulitis.  The lateral aspect of the heel demonstrates a much smaller 1.0 cm diameter lesion that is not prominent or nodular but more ulcerative in appearance with surrounding hyperkeratotic tissue, also no SOI are noted.

MUSC: Pes planus b/l with digital contractures b/l

LABS: Reviewed most recent HIV

X-RAY: Osseous structures appear to be intact.  There is a 2.46cm x 1.37cm oval soft tissue mass/density clear on the lateral view with 0.53cm inferior posterior calcification noted on the lateral and AP view at the 1st
metatarsocuneiform joint level

SURGICAL PATH: (Initial Punch Biopsy)
MICROSCOPIC EXAM/DIAGNOSIS:

ADD'L PHOTOGRAPHS:

ASSESSMENT:

• Hemangiopericytoma left foot arch and 2nd lesion lateral heel
• based on prior punch biopsy and further review of dermatology notes and discussion with the dermatologist, there is concern of need for further biopsy sample to allow for more definitive dx in light of 2nd lesion lateral heel prior to further initiation of treatment protocol
• I have explained this to pt and wife and went through plan and procedure in detail
• I explained plan for larger punch biopsy of plantar lesion and total excision of lateral heel lesion in order to allow for final definitive pathological diagnosis
• I did explain to pt and wife risk of need for further excision and risk of malignancies and need for further management/tx long term
• All of patient’s questions were answered
• Photographs with pts consent were taken in clinic today
• Radiographs were also reviewed with pt and wife to demonstrate Soft-tissue extent of lesion, and confirming long term need for further extensive excision and/or treatment protocol
  

A follow up on the lesion and the biopsy is forthcoming in a new edition of Residency Insight.

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