Suhad Hadi, DPM, FACFAS

Soft tissue lesion/mass left foot/heel
Part 2

This Residency Insight case presentation is a follow up to a previous edition, "Soft tissue lesion/mass left foot/heel Part 1".

It was the acute suspicion of the dermatologist which resulted in questioning of the initial diagnosis and further cooperative team consultation.  Suspicion of multiple ulcerative lesions which developed after the primary lesion was the trigger which caused doubt in the initial diagnosis.  If the lesion were hemangiopericytoma, these lesions are usually seen in isolation as opposed to the Kaposi’s lesions which can be multiple.  The stalk with granular mushroom ulcerative top lesion was very characteristic of the Kaposi’s lesion as well.  Due to these factors, together appropriate biopsies and margins were taken and diagnosis was twice confirmed. Given the high association with HIV, appropriate testing was performed with patient consent and found to be negative.

With the confirmed diagnosis, treatment options were discussed with the patient and excision of the plantar lesion was given as an option versus weekly treatment with liquid nitrogen. The patient expressed that he did not want a plantar wound that may be larger and difficult to heal, therefore, he elected to proceed with the liquid nitrogen treatment. The patient returned weekly for eight weeks and underwent treatment. Application of the liquid nitrogen was taken to a one-minute blanch-time with each application. During the treatment period, the patient remained full weight-bearing and applied a dry 4x4 gauze with hypofix tape to secure it daily and after showering. After the 1st week of treatment, the patient noticed two more 0.5 to 0.75 cm ulcerative lesions to the posterior and medial heel. Treatment was then applied in similar fashion to these lesions. By the 5th week, the plantar lesion had fully necrosed the stalk and cap and the two smaller lesions followed suit. By week 7, the lesions were superficial wounds and by the 8th week the patient returned with the areas fully epithelialized and had no further development of lesions. He was discharged with a six month follow up appointment and if remains lesion-free will progress to annual evaluations.

There are various treatment options discussed for the management of Kaposi's Sarcoma lesions. Although radiation therapy had been the cornerstone of therapy, reports support varied treatments from intra lesional therapy, cryotherapy, laser therapy to excision of the lesions. In a report by Tappero et al, local radiation was an effective palliative treatment in lesions creating a mass effect. However there was only a 50% decrease in lesion size in one-half of the cases. Intra lesional injections with vinblastine, rTNF and alpha interferon have only been moderately effective. And similar to systemic chemotherapy, these treatments are not as readily available in the clinical setting.

A report by Gonzalez-Martinez et al., determined surgical excision to be the treatment of choice for nodular KS. They describe blunt dissection technique with a freer elevator to just approach the superficial fascia to scoop out the lesion, in essence similar to a verrucous type lesion. They reported no recurrence of the lesion and less scarring was reported with this technique (1,7). One also achieves preservation of the entire lesion with this technique making pathologic examination less difficult.

Cryotherapy has been a successful treatment modality given ease of application, and it is readily available in the clinical setting, inexpensive and safe. The success of cryotherapy is attributed to development of small intracellular ice crystals which with a longer thawing, result in greater tissue destruction due to the coalescence of small ice crystals to form larger ones, creating tissue death (2). Destruction of the KS lesion with cryotherapy has been shown to be 70-75% successful within the literature, with recurrence noted between 6-12 months should it recur. Tappero reported an 85% complete or partial response to cryotherapy. They concluded that cryotherapy may be best for isolated lesions or as an adjunctive therapy to systemic chemotherapy to aid in achieving a better cosmetic result.

In summary successful outcomes are reported with all mentioned modalities. As with any treatment, it is important to take into consideration patient selection, number and location of the lesion(s), and the availability/ease of treatment on an individual basis.

Figure 1a and 1b: Patient 2 weeks after initiation of treatment with Liquid nitrogen
Figure 1a	Figure 1b

Figure 2a and 2b: Patient 5 weeks after initiation of treatment with liquid nitrogen
Figure 2a	Figure 2b

Figure 3a and 3b: Patient 7 weeks after initiation of treatment with liquid nitrogen
Figure 3a	Figure 3b

Articles of Interest:

1. Gonzaolez-Martinez R, et al. Nodular Kaposi’s sarcoma as a presenting feature of HIV infection.  Int J Dermatology 35:813, 1996.
2. Tappero JW, et al.  Cryotherapy for Cutaneous Kaposi’s Sarcoma (KS)….A Phase II Trial.  Journal of Acquired Immune Deficiency Syndromes: September 1991, Vol. 4, Issue 9.
3. Kline, A. Kaposi’s Saracoma of the Foot:  A Case Report.   The Foot & Ankle Journal 1(3) , March 1, 2008.
4. Tappero JW, Conant MA, Wolfe SF, et al.  Kaposi's sarcoma: epidemiology, pathogenesis, histology, clinical spectrum, staging criteria and therapy.  Journal of the American Academy of Dermatology: Vol. 28, Issue 3, March 1993

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