In March 2005 a 68-year-old female patient presented to our outpatient clinic with a 4 × 5 cm sized exulcerating tumor at the left hand in the area of a congenital symbrachydactyly at the digiti II and III. (). The tumor showed rapid progression and caused local pain. About four months prior to admission on our clinic the tumor was seen for the first time by a physician. The tumor was initially diagnosed as seborrheic keratosis, and for months it was treated with topical medication only. Additionally the patient was treated with antibiotics because of local inflammatory signs. The patient herself was in good general condition and had no B-symptoms and no increased lymph nodes were palpable.\nAn urgent biopsy of the tumor was performed, which confirmed our suspicion of a squamous cell carcinoma. Preoperative staging including MRI of the affected hand (Figures and ), plain thoracic X-ray, abdominal ultrasound scan, and thoracoabdominal CT scan was performed. We diagnosed a soft-tissue tumor with evidence of malignancy, but with no evidence of bony infiltration nor intrathoracic or intra-abdominal metastasis. However we detected an enlarged sentinel lymph node in the left axilla. Further workup for abnormal lymph nodes showed two suspicious axillary enhancements.\nUnder curative intention we performed an amputation of the second and third ray of the left hand at the metacarpal level and additionally an axillar revision and lymph node dissection under general anesthesia.\nThe definite histological examination confirmed the preoperative suspicion of a squamous cell carcinoma, fortunately without affection of any lymph nodes (histological TNM staging: pT4 N0 M0 G1-2).\nThe postoperative course was without complications except a recurring lymphoid seroma developing in the left axilla, which was successfully treated by repetitive aspiration. With intensive ergotherapy the patient reached an excellent functional result of the operated left hand (Figures and ). 9 years after the surgery there was no clinical sign of any tumor recurrence. The patient could perform fine motor skills like sewing. The measurements of the motor function showed decreased strength of the operated left hand compared with the dominant right hand with finger pinch side-to-end (left 3.5 kg and right 7 kg), end-to-end (left 2 kg and right 5 kg), and hand grip (left 11 kg and right 26 kg).
A 46-year-old white female was referred from the dermatology clinic with a biopsy-proven squamous cell carcinoma of the left ring finger perionychium. Physical examination demonstrated erythematous scaly lesions with the absence of a nail plate at the left thumb, index finger, and ring finger as well as the right long finger, without associated lymphadenopathy (Fig ). She described chronic onychomycosis of the nails attributed to her job as a dishwasher.\nPast medical history was significant for chronic onychomycosis. Social history demonstrated a 40 pack-year smoking habit. She denied alcohol use, exposure to aniline dyes, radiation, or arsenic exposure.\nThe decision was made to biopsy all digits with scaly lesions. She was advised to stop smoking and counseled about the likely need for partial amputation. Pathology demonstrated squamous cell carcinoma of all biopsy sites. Wide local excision with partial amputation was performed on all involved digits with preservation of the left thumb interphalangeal joint and left index finger, left ring finger, and right long finger proximal interphalangeal (Fig ).\nSurgical pathology demonstrated positive margins on the left thumb and left ring finger necessitating reexcision. All final margins are clear and all incisions have healed nicely (Fig ).\nDue to the extensive nature of the patients' cancer and longstanding history, we elected to perform amputation as opposed to other treatment modalities, which will be described further in the discussion. The patient is currently about 1 year out from surgery and has returned to normal activities and displays no evidence of recurrence.