A Surprise Diagnosis & What I Did to Treat!
Have you ever performed an excisional biopsy and the result came back a diagnosis you were not suspecting, not one of your differentials?
I'm sure we've all been there.
Last week, I presented a case study about a patient that showed up with a large, non-fixed, smooth, pink tumor superior to his left elbow (above left picture).
I, then, discussed with you the different biopsy techniques that could have potentially been performed. I decided a full excisional biopsy was the best option for this patient. If you missed that in our community newsletter last week, here it is for reference…
https://theresasurgdermnp.mykajabi.com/blog/ExcisionalBiopsy
Once the excisional biopsy was performed, the pathology results showed, to my surprise…Leiomyosarcoma.
In the 10 years of being a dermatology NP, this is a diagnosis I’ve never encountered before.
So, as I quickly pulled up literature to read more about it, I discovered that this is a rare, malignant, smooth muscle tumor that can affect many body systems.
Leiomyosarcoma of the skin is most common in middle-aged patients with a history of prior trauma, radiation exposure, and immunosuppression. May also be painful.
Presentations can be polymorphic appearing as a smooth, pink-to-red nodule, indurated, lobulated, scaly, verruca-like, ulcerated, hemorrhagic, or pedunculated.
Cutaneous leiomyosarcoma has a favorable prognosis and treatment recommendation is surgical excision, with 1-2 cm clinical margins, as the cornerstone of care. Evaluation for possible metastatic disease is indicated if the patient presents with multiple lesions. Chemotherapy or radiation therapy may also be considered if more involvement suspected.
This case study is a perfect example of when to recognize when to collaborate with your supervising physician. In rare cases like this, it is paramount in order for your patient to get the safest, most appropriate care needed.
When deep extension with fascial involvement may be present, higher tumor grade, and/or metastases suspected, always defer care and involve your collaborating physician.
As dermatology NPs/PAs, we are an extension of care for our practice. We are also grateful to be able to have our collaborating physicians to help guide us with complex cases that are beyond our scope.
Thankfully, once I consulted with our Mohs surgeon about this patient, he was able to further evaluate and treat the patient by re-excising the entire original surgery site with 1 cm margins (above right picture).
Pathology reported….”Margins Clear!” 🙌🏼
The patient healed well, and he very much appreciated the collaborative effort of the whole...entire... dermatologic...team.
I hope this case study helped give you insight next time you encounter a complex, rare case like this.
In order to provide our patients with the safest care possible, remember what our scope of practice is (as derm NPs/PAs) and the importance of working in partnership with our collaborating physicians.
(Source: https://www.visualdx.com/visualdx/diagnosis/cutaneous+leiomyosarcoma?diagnosisId=51824&moduleId=101)
ALL my best,
Theresa Talens, DNP, FNP-C (TheresaSurgDermNP) ❤️
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