Dermatology Online Journal

Ulceroproliferative growth on the heel: Epithelioma cuniculatum
Vandana Mehta Rai MD DNB¹, C Balachandran MD¹, Ranjini Kudva MD²
Dermatology Online Journal 12 (4): 8

1. Department of Skin and STD, KMC Manipal. vandanamht@yahoo.com
2. Department of Pathology, KMC Manipal

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Abstract

Verrucous papules and plaques on the plantar surfaces should not be assumed to be mere warts, especially if the history is unusual. We present a patient with an ulceroproliferative growth on the heel which was found to represent the epithelioma cuniculatum form of squamous cell carcinoma.

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Clinical synopsis

Figure 1	Figure 2
Figure 1. Ulceratoproliferative growth on the heel
Figure 2. Histology section of lesion at low power

Figure 3	Figure 4
Figure 3. Close-up view showing extravasated erythrocytes
Figure 4. Close-up view showing keratin pearls

A 55-year-old man presented with an ulceroproliferative growth on the right heel of 3-months duration. There was no history of trauma. Initially, a discreet, clavus-like hyperkeratosis had been present; this was excised leading to the development of an ulcer. Over time, a cauliflower like growth developed at the ulcer site and was associated with pain and bleeding. Clinical examination revealed an ulceroproliferative, cauliflower-like growth measuring 10 × 10 cm on the right heel; right-sided inguinal adenopathy was also present. Fine needle aspiration from the lymph node showed only reactive lymphadenitis. A wedge biopsy from the lesion on the right heel showed a hyperkeratotic, acanthotic epidermis adjoining an ulcerated tumor covered by hemorrhagic hyperkeratosis. The tumor was composed of infiltrating nests and islands of malignant squamous cells with hyperchromatic nuclei, dyskeratosis, and extensive keratin pearl formation in a scanty stroma. The clinical and histologic findings were consistent with a diagnosis of epithelioma cuniculatum.

Discussion

Squamous cell carcinoma (SCC) is a neoplasm arising from the keratinocytes of the epidermis and contiguous mucous membranes. Although along with basal cell carcinoma it forms the majority of cases of non-melanoma skin cancer it occurs less frequently than the former [1]. Squamous cell carcinoma usually develops at sites of prior or chronic damage to the skin. In light-skinned patients this usually results from prolonged cumulative exposure to sunlight as in patients with outdoor occupations (farmers, sailors). In contrast, in darker skinned patients, SCC is not predominantly a solar induced phenomenon. It is seen at the sites of chronic inflammation and irritation such as at the edges of non-healing ulcers, in sinuses [2], in burn-related ulcers or scars [3], in post-vaccination scars [4], at sites of chronic friction (saree or a dhoti tying sites), and at sites of prolonged heat exposure (kangri contact). Environmental carcinogens such as coal and tar may also predispose to the development of SCC. There are also reports of this cancer developing in chronic graft versus host disease [5]. An infective etiology (human papilloma virus) has been proposed in patients with SCC of finger and nail bed [6] and with verrucous carcinoma [7], but this has not been substantiated in all cases. The tumor is typically located on the sun-exposed areas but may occur on any body part. Males outnumber females and although SCC is generally a cancer of old age, more young people are developing it due to long hours of sun exposure. It may present as a nodular proliferative plaque with ulceration, a thickened, verrucous plaque or as a chronic, persistent ulcer arising in chronic scars. The skin surrounding the tumor may show signs of actinic damage. Verrucous carcinoma, described by Ackerman in 1948 [8], is a warty, superficial, indolent tumor with a protracted course. The prognosis is good as dissemination is rare, although regional lymph nodes may be involved. Epithelioma cuniculatum is a type of verrucous carcinoma presenting as a bulbous mass on the distal part of the sole. Multiple sinuses are present that emit foul smelling toothpaste-like material. Several histopathological variants of SCC have been reported (spindle cell, adenoid, mucinous, verrucous, and clear cell). Our patient's diagnosis was epithelioma cuniculatum with histopathological features of well-differentiated, verrucous-type squamous cell carcinoma. Surgical excision is the treatment of choice in SCC with a margin of 1-2 cm. Our patient responded well to surgical excision of the tumor mass followed by split thickness skin grafting.

References

1.Harris TJ. Squamous cell carcinoma. In: AJJ Emmett, MGE O'Rourke, eds.Malignant skin tumours.2nd edition. London: Churchill-Livingstone 1991;143- 56

2. Humphrey LJ, Playforth H, Leavell UW. Squamous cell carcinoma arising in hidradenitis suppurativa. Arch Dermatol 1969;100:59

3. Ikegawa S, Saida T, Takizawa Y. Vimentin positive Squamous cell carcinoma arising in burns scar. Arch Dermatol 1989;125:672-6

4. Reed WB, Wilson JE. Malignant tumours a late complication of vaccination. Arch Dermatol 1968;98:132

5. Howe NR, Lang PG. Squamous cell carcinoma of the sole in a patient with chronic graft versus host disease. Arch Dermatol 1988;124:1244-5

6. Ashinoff R, Li JJ, Jacobson M, Friedmann AE. Detection of human papilloma virus DNA in squamous cell carcinoma of the nail bed and finger detected by Polymerase Chain Reaction. Arch Dermatol 1991;127:1813-8

7. Yeager JK, Findly RF, Mc Alear IM. Penile verrucous carcinoma. Arch Dermatol 1990;126:1208-10

8. Brown SM, Freeman RG. Epithelioma cuniculatum. Arch Dermatol 1976;112:1295-6

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