Why It Pays To Be Cautious With 'Funny Looking Lesions'
I have performed more than 300 unnecessary excisional biopsies during the past 28 years. They were unnecessary because the pathology reports were negative. The lesions were not malignant. It’s the five positive biopsies that made all this unnecessary surgery worth doing. I learned early in my career about the risk of neglecting to biopsy a “funny looking lesion.”
A lady in her late 50s came to me the first month I was in private practice. She had a very painful ingrown toenail. The toe seemed normal and there was hardly any incurvation of the nail border. The skin was slightly red and sensitive. I removed a small spicule and started her on soaks. A week later, the toe looked the same but was extremely painful. I recommended a partial nail removal. The woman told me she wanted a second opinion and left my office.
Three months later, the patient’s daughter let me know that her mother went to a surgeon who biopsied the painful lesion. It was cancer. I never learned what type.
A waitress who worked in the sleaziest tavern in town came to me with a wart on her heel. It was the biggest, ugliest looking wart I had ever seen. She had no health insurance.
I recommended we excise and curette the “wart.” It did not look or behave like a wart when I started the procedure. It was connected to the subcutaneous tissue with long black fibers. When I finished, there was a gaping, bleeding hole in the woman’s heel. I told the patient I was sending the lesion to a pathologist for biopsy. She told me not to since she was not insured. I sent it anyway. It was malignant. A plastic surgeon performed a wider excision and covered it with a skin graft. The patient is still mad at me about the cost but still pours beers at Frosty’s Tavern. It has been nearly 20 years.
Not all my colleagues are as quick to do a biopsy as I tend to be. A few years back, a very busy and successful DPM from a larger city was treating a lady for a mycotic toenail infection. The skin around the nail became discolored and drained a thick exudate. My colleague diagnosed a Staph infection and started the woman on soaks.
She was not responding and called him to see if he could look at the toe. His schedule was full but his staff suggested she call me because I always have empty appointments.
I saw her that day because I did have an empty slot. Her toenail had a dark brown discoloration extending into the soft tissue. There was drainage from a secondary bacterial infection. As bad as the toe looked, it didn’t hurt. The biopsy was positive for a melanoma. My busy colleague shrugged when I told him. The patient is missing her right great toe. Her name is still in the phone book.
Telling a patient the biopsy is positive is difficult. You can dance around the issue by saying it might be wrong or you can come right to the point: “You have cancer.” I’ve learned being direct is the best approach. I never give the report over the phone. I prefer to have the patient come in accompanied by his or her spouse or some other family member.
Patients react in various ways to the bad news. Some become angry. Some want to kill the messenger (me). Some just resign themselves to the situation. You never know what to expect. I let the angry ones vent. It’s the resigned ones who are most difficult. Denial is a dangerous element when dealing with cancer.
In all cases, I have a referral planned to a surgeon for sentinel node biopsies and to an oncologist for management of the disease. Having plans in place is important to the patients and their families who feel lost and desperate.
My most recent positive biopsy was on a 43-year-old construction worker. He had a small bump on the side of his foot that had been there for years but suddenly became painful. I removed a pea-sized mass that looked like a thrombosed vein. The pain immediately stopped. The patient failed to show for his post-op appointment. He took his own sutures out.
Two weeks after surgery, I had to give him the news that he had a synovial sarcoma via his cell phone while he was on the job. I referred him to an orthopedic/oncologist at the University of Washington. He gets to keep his leg but his survival chances remain less than 50 percent if all goes well.
Dr. McCord (pictured) is a Diplomate with the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.