Beware the masquerading malignancy.

Sir:

As plastic surgeons we often find ourselves operating on all parts of the human body. Indeed, it is this variation, unparalleled among the other surgical specialties, that stands Plastic Surgery out and makes for such a fascinating and captivating choice of career. It is important to remember, however, that with this privilege to operate on a variety of parts and reconstruct a myriad of functional deformities comes also a responsibility to our patients to detect those pathologies that can affect a variety of parts and cause a myriad of deformities. Indeed, through our exposure to such a variety of wounds and lesions, many pathologies, some common others rare, will present to us but many may go undetected if our basic medical acumen does not stay sharp, focused, and up to date.

When presented with a complex contused scalp laceration caused by an episode of acute blunt trauma in an otherwise healthy middle-aged man, we made plans for a routine wash out and debridement under general anesthesia (Fig. 1). The patient denied any previous scalp lesions, and this was confirmed by his wife and children. On debridement, it soon became apparent that the lesion represented more than simply an area of contused soft tissue. This suspicion was fueled by the atypical, fibrotic nature of the lesion, and as such frozen sections were sent. These revealed a high-grade angiosarcoma, and after appropriate patient counseling, a radical debridement followed, which necessitated reconstruction with a free anterolateral thigh flap. Unfortunately, the tumor soon recurred (Fig. 2) and a palliative approach had to be adopted.

Fig. 1.

Preoperative appearance of contused scalp lesion.

Fig. 2.

Tumor recurrence seen at the anterior edge of the anterolateral thigh flap 3 mo after the primary reconstruction.

When, in July 1977, Bob Marley sought medical attention to an unhealing wound on his great toe that he thought he had sustained playing football, he was found to have an ulcerated subungal melanoma. He refused amputation of the toe because of his Rastafarian beliefs and continued to produce music and tour the world. The cancer, however, metastasized and resulted in his untimely death in May 1981.

Clearly, malignant lesions can often present “in disguise,” especially when associated with trauma.[1,2] Moreover, a soft-tissue tumor may initially be misdiagnosed as a simple hematoma,[3,4] illustrating the importance of following up simple lesions to ensure that they do indeed behave as initially predicted. For many of our patients, however, as was the case with Bob Marley, this disguise does indeed deceive and can ultimately lead to a delay in presentation that can prove costly.

As clinicians exposed to traumatic lesions on a daily basis, it is worth remembering that at some point in our career, a seemingly trivial traumatic wound may actually represent a far more sinister pathology and that if our minds and eyes do not remain open to this possibility, then we too risk being deceived.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.