ARTICLE
This clinical-pathological picture is consistent with subungual squamous
cell carcinoma.
A disarticulation of the little finger was then performed. Routine blood
tests gave normal values, chest x-ray and medical examination were normal.
The patient underwent a regular follow-up composed of medical examination
every 6 months, chest X-ray and abdomen echography every year. During
2 years of follow-up signs of metastasis or recurrence have been detected.
Comments
Subungual malignancies are a relatively uncommon condition [1-5] in
which a delay in diagnosis may be the rule because the clinical presentation
is not specific and mimicks several other conditions [6-8].
The neoplasms more frequently found in subungual tissues are the squamous
cell carcinomas, comprising Bowen's disease, the melanomas, the basal
cell carcinomas, the keratoacanthomas.
Subungual squamous cell carcinoma is a neoplasm that may develop in
the epithelium of the nail bed, the nail matrix, the nail grooves or the
lateral nail folds [9].
When the neoplastic process involves the nail matrix even the nail plate
shows clinical changes.
The presenting symptoms are different and the tumour may clinically
mimic paronychia, onychomycosis, verruca vulgaris, pyogenic granuloma,
glomus tumour, chronic osteomyelitis, fibroma, herpetic whitlow, eczema
or other neoplastic processes.
Diagnosis can be made only by biopsy, and delay in diagnosis is the
rule, varying from several months to many years.
Subungual squamous cell carcinoma tends to occur in an older age group
than other periungual neoplasms [10], the incidence is highest in the
50-69 year range [4].
The tumours grow slowly with a mean duration of 4.5 years [11], the
fingers of the hand are most commonly involved, in most cases only one
digit is involved and the thumb is the most common site affected.
Different etiological factors have been suggested, among them trauma
[12], chronic infections, long-term exposure to radiation or tar products
[13], viral agents with particular attention to HPV infections [11] and
chronic radiodermatitis [14].
With the exception of the last condition, although it is impossible
to demonstrate the etiological role, the conditions mentioned cannot be
excluded.
Subungual squamous cell carcinoma is a low-grade malignancy with little
tendency to metastasize [15]. Bone involvement is frequent, its incidence
varying from 20% [16] to 55% [7]. Probably the high incidence of bone
invasion may be the result of the delay in diagnosis.
The treatment of choice will depend on the histology and the extent
of the tumour. For invasive squamous cell carcinoma, amputation of the
affected digit is recommended [17].
Our case fulfils all the classic clinical criteria for a subungual squamous
cell carcinoma: a chronic inflammatory lesion of the little finger in
an aged man, a relatively long delay in diagnosis and involvement of the
underlying bone with no apparent metastasis after 2 years follow-up.
This report is presented to stimulate awareness of all persistent or
recurrent diseases of the subungual region recalcitrant to therapy and
to encourage the consideration of a biopsy as an easy and safe method
for the diagnosis of such lesions.
Article accepted on 18/10/99
REFERENCES
1. Lumpkin LR, Rosen T, Tschen JA. Subungual squamous cell carcinoma.
J Am Acad Dermatol 1984; 11: 735-8.
2. Hoffman S. Basal cell carcinoma of the nail. Arch Dermatol
1973; 108: 828.
3. Das Gupta T, Brasfield R. Subungual melanoma-25 year review
of cases. Ann Surg 1965; 161: 545-52.
4. Mikhail GR. Subungual epidermoid carcinoma. J Am Acad Dermatol
1984; 11: 291-8.
5. Oliwiecki S, Peachey RDG, Bradfield JWB, Ellis J, Lovell CR.
Subungual keratoacanthoma-a report of four cases and review of the literature.
Clin Exp Derm 1994; 19: 230-5.
6. Lamp JC, Graham HSH, Urbach F, Bourboon CF. Keratoacanthoma
of the subungual region. J Bone Joint Surg 1964; 46-A: 1721-31.
7. Shapiro L, Baraf CS. Subungual epidermoid carcinoma and keratoacanthoma.
Cancer 1970; 25: 141-52.
8. Eibel P. Squamous cell carcinoma of the nail bed. Clin
Orthop 1971; 74: 155-60.
9. Pardo-Castello V, Pardo OA. Epithelioma of the nail bed. In:
Thomas CC, ed. Diseases of the nails. 3rd ed. Springfield, IL:
Publisher, 1960: 80-1.
10. Downs MR, Ward KA, Peachey RDG. Subungual squamous cell carcinoma
in Darier's disease. Clin Exp Derm 1997; 22: 277-9.
11. Ashinoff R, Li JJ, Jacobson M, et al. Detection of
human papillomavirus DNA in squamous cell carcinoma of the nail bed and
finger determined by polymerase chain reaction. Arch Dermatol 1993;
127: 1813-8.
12. Gelmann SB. Primary carcinoma of the nail bed. NY State
J Med 1963; 63: 2408-10.
13. John HT. Primary skin cancer of the fingers simulating chronic
infection. Lancet 1956; 1: 662-4.
14. Guitard J, Bergfeld W, Tuthill RJ, Tubbs RR, Zienowicz R,
Fleegler EJ. Squamous cell carcinoma of the nail bed: a clinicopathological
study of 12 cases. Br J Dermatol 1990; 123: 215-22.
15. Attiyeh FF, Shah J, Booher RJ, Knapper WH. Surgical squamous
cell carcinoma. JAMA 1979; 241: 262-3.
16. Salasche SS, Garland LD. Tumor of the nail. Dermatologic
Clinics 1985; 3: 501-19.
17. Carroll RE. Squamous cell carcinoma of the nail bed. J
Hand Surg 1976; 1: 92-7.
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