Ulceroproliferative growth on the heel: Epithelioma cuniculatum
1. Department of Skin and STD, KMC Manipal. email@example.com
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.
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.
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 . 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 , in burn-related ulcers or scars , in post-vaccination scars , 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 . An infective etiology (human papilloma virus) has been proposed in patients with SCC of finger and nail bed  and with verrucous carcinoma , 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 , 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.
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