By Tedler D. Depaynos, MD
Her debut would still be several years when she felt an enlarging non-painful mass at her right shoulder. Since she was asymptomatic she continued with her usual activities of going to school. It was after 1 or 2 weeks when the mass was observed to be more bulging and appeared to be with “pus” so that accompanied by her mother they consulted their family doctor. She was prescribed the usual antibiotics which she took diligently. An “incision and drainage” was later done to remove the pus but still the wound was far from healing and appeared to be enlarging with more necrotic tissues after several days.
Their family doctor referred her then to a general surgeon who under general anesthesia cleaned the wound thoroughly. Since grossly it was “abscess looking”, only a routine “culture and sensitivity” was done to isolate the apparent resistant bacteria and to test for the appropriate antibiotics. Despite the extensive surgical procedure and the appropriate antibiotics, the wound kept on enlarging and with more necrotic tissues and even bleeding. It was then that a more serious diagnosis was entertained especially so that the patient was still in her teenage years.
A repeat “surgical cleansing” was done with wider debridement and biopsy. True enough it turned out to be a malignant lesion originating from the fibro-muscular tissues called “sarcoma”. She was then referred to a cancer specialist surgeon who requested that the specimen be sent to a highly specialized hospital in Metro Manila for a second opinion and for a more extensive study because of the rareness of the disease entity. Unfortunately for the patient the malignant lesion was confirmed.
The cancer surgeon thought of doing a more extensive surgery which may consist of excising at least 4 cm. or more of the normal tissues from the surrounding necrotic borders or in extreme instance amputation which includes the shoulder. Upon further work up however a metastatic lesion was seen in the lungs. Surgery was no longer curative so that she was referred to an Oncologist for possible extensive chemotherapy and radiation. Although older surgical textbooks mention that the response of such treatments in “Sarcoma” is poor, some young Oncologists or doctors who specialized in cancer treatment who even studied in well known Cancer Centers abroad give a better prognosis. Of course, this is their expertise with more advanced methods of treatment!
Over a cup of Starbucks coffee the general surgeon could recall that the other similar case he encountered was around 2 decades ago. It started likewise as an ordinary “abscess” in a 53 years old bus driver which was located at the left lower anterior chest wall. Because of the malignant diagnosis and the required extensive surgery which was removal of a section of his anterior chest wall he was referred to a more experienced Hospital Center in Metro Manila. He was not aware if the patient underwent the recommended surgery however.
These are rare cases and may appear as ordinary abscesses. What is characteristic of these lesions is that they refuse to heal, are painless, very malignant and metastasize early especially in younger individuals.
In contrast, there are also non-healing lesions or simply chronic ulcers which may become malignant with time.
The general surgeon upon extended cups of coffee could recall a patient who usually goes to work riding a motorcycle provided by his company. He met an accident one day and after hospitalization he went home with a wide open wound at his right lower extremity. Skin grafting was advised but for some reasons, it was not pushed thru. The wound got infected and eventually affected his bones. Because of the possibility of amputation he feared hospitalization and it was only 12 years after when he could no longer bear the pain and had difficulty of ambulation that he finally consented to be admitted. The orthopedic surgeon consulted gave the unwavering impression of malignancy arising from the chronic wound so that he immediately did a biopsy to confirm his diagnosis. It was “Epidermoid Carcinoma” and since it apparently extended into the bony parts of the lower extremity, amputation was eventually done. From his experience, the orthopedic surgeon had encountered several similar cases so that he cannot say that this is a rare case.
“Epidermoid Carcinoma” in contrast to “Sarcoma” is slow growing so that the patient after extensive work up revealed no metastasis. He is now in the process of acquiring an artificial leg so he could return to his profession as an electrical contractor. **
