When There Is A Proliferative Keloid On The Dorsal Foot

These authors discuss the diagnostic workup and treatment of a recurrent keloid secondary to Graves’ dermopathy following partial resection of a soft tissue mass along the first MPJ in a 55-year-old patient.

Keloid scar formation is quite common with a high familial correlation and a reported recurrence rate with surgical excision alone of up to 45-100 percent.^1,2 Treatment for keloids has included multiple, intralesional steroid injections, silicone sheets, laser treatment and cryotherapy. Physicians have also utilized chemotherapy, interferon and radiation after surgical excision with some success.³ While radiation therapy can lead to a number of postoperative and local soft tissue complications, including atrophy and hypo/hyperpigmentation, the use of this modality for decreasing recurrence and improving patient satisfaction is well documented in the literature.^4-6

We present a case of extensive keloid formation secondary to Graves’ dermopathy following previous partial resection of soft tissue mass along the first metatarsophalangeal joint.⁷ Multidisciplinary treatment for this recurrent lesion involved a combination of surgical excision and radiation in order to prevent or reduce the risk of recurrence of the keloid formation.

A 55 year-old female returned to our office with a recurrent soft tissue mass to the dorsum of the right first metatarsophalangeal joint. The patient’s history was significant for hypertension, Graves’ hyperthyroidism with exophthalmos and current tobacco use. Her surgical history was pertinent for a right bunionectomy performed approximately seven years ago. Since the bunionectomy, the patient has noticed a slowly growing mass in the area of the surgical site. It was only painful with shoe gear. At that time, the soft tissue mass was firm and extended along the dorsal first metatarsophalangeal joint. Radiographs were negative for any osseous changes. We obtained a MRI and the differential diagnosis for the mass included keloid, Graves’ dermopathy and dermatofibrosarcoma.

Based on this initial MRI and concern for a possible malignancy, we obtained an excisional biopsy from the most painful area. We also educated the patient on smoking cessation prior to the surgery. The patient healed uneventfully and was able to return to shoe gear comfortably. The pathology report revealed keloid formation consistent with Graves’ dermopathy.⁷ Physicians have previously reported Graves’ dermopathy as a rare complication occurring in 1 to 5 percent of people with Graves’ disease.^8,9

Approximately one year later, the patient returned to the clinic complaining of pain due to sudden and rapid regrowth of the mass. At this time, the mass now extended along the dorsal hallux, extending medially and laterally, and proximally along the first metatarsal shaft. The mass was larger than the initial presentation. It was firm, lobulated and immobile (see Figures 1 and 2). Radiographs were again unremarkable. We obtained another MRI, which showed hypertrophy of the soft tissue consistent with keloid formation and Graves’ dermopathy, and the mass was 4.8 x 1.5 x 3.8 cm.

The patient desired surgical removal as the mass had again become painful in shoe gear and she had developed a restricted range of motion. Due to the size and progression of the mass, and the high chance for recurrence, there was a subsequent consult with the radiation oncology department of a local hospital. It was determined that adjunctive radiation treatments would be beneficial to help prevent the recurrence of the keloid. Following total surgical resection of the mass, the patient was scheduled to receive three radiation treatments. This would begin immediately postoperatively followed by subsequent treatments on the first two postoperative days.

Intraoperatively, we performed a primary resection. The skin over the lesion was hyperpigmented, firm and indurated. Throughout our initial dissection, we noted evidence of dense hypertrophy within the soft tissues. Both the epidermal and dermal layers were thickened and the tissue planes were not easily discernable. The extensor apparatus was not involved in the tumor depth (see Figure 3). With a mixture of blunt and sharp dissection, we resected the mass (measuring 6 x 3 x 2 cm) in total (see Figure 4) and tagged the borders of the mass for pathology review. After achieving hemostasis, we used non-absorbable monofilament suture to close the incision without tension.

Immediately following the procedure, she was transferred to radiation oncology where she received the initial dose of radiation (4 Gy (Gray)). She received two subsequent fractions on the first and second postoperative day with each treatment measuring 4 Gy. The total radiation dose was 12Gy (see Figure 5).

Pertinent Insights On The Postoperative Course     

In the initial phases following radiation, we noted significant soft tissue necrosis along the immediate wound edges. This led to dry eschar formation. Eventually, the eschar began to lift and we began superficial debridements. At this time, the wound remained a partial thickness wound. There was no tendon or deeper structure involvement at this time. We initiated daily collagenase treatments and continued to evaluate the patient weekly. We permitted partial weight bearing with the use of a Darco wedge shoe and home nursing provided daily bandage changes.

At approximately nine weeks postoperative, the patient’s wound base was ready for graft application. She received a total of three applications of Grafix^® (Osiris Therapeutics) on a weekly basis. At one week, following final graft application, the wound had closed (see Figures 6 and 7).

At this time, the wound has been closed for approximately 10 weeks and the patient has resumed her normal activity. There has been no recurrence of the soft tissue mass and range of motion remains within normal limits. The contour of the first metatarsophalangeal joint remains near anatomical. The patient has been able to transition to normal shoe gear without discomfort.

In Conclusion

Physicians have used radiation therapy as an adjuvant modality following keloid resection on all areas of the body, including the earlobe and extremities. While recurrence rates of keloids are lower with radiation than surgical excision alone, the incidence of keloid recurrence with radiation treatment is reportedly as high as 14 percent with a dose of 20Gy.¹⁰ If recurrences do occur, they reportedly occur as early as 2 to 36 months postoperatively with a mean recurrence time of 14.8 months.¹¹ Despite the risk of recurrence and soft tissue complications, the use of radiation can be helpful to prevent recurrent keloid formation. Adjuvant radiation therapy remains a viable treatment option for patients with large, disfiguring keloid formation. Our patient currently remains asymptomatic but we will continually evaluate her periodically for recurrence of the keloid over the next few years.

Dr. Spiess is a fourth-year resident with the Podiatric Surgery Residency Program at Temple University Hospital in Philadelphia, PA.

Dr. Pontious is a Professor and Chair of the Department of Podiatric Surgery at the Temple University School of Podiatric Medicine in Philadelphia. She is a Fellow of the American College of Foot and Ankle Surgeons, and a faculty member of the Podiatry Institute.

Dr. Komarnicky is a Professor and Chair of Radiation Oncology at the Drexel University School of Medicine.

References

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