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CASE REPORT
Year : 2021  |  Volume : 24  |  Issue : 10  |  Page : 1565-1568

Thumb talc granuloma mimicking squamous cell carcinoma: A case report


Department of Surgery, Federal Teaching Hospital, Ido–Ekiti/Afe Babalola University, Ado-Ekiti, Ekiti–State, Nigeria

Date of Submission31-Mar-2020
Date of Acceptance08-Oct-2020
Date of Web Publication16-Oct-2021

Correspondence Address:
Dr. O F Babalola
Department of Surgery, Federal Teaching Hospital, PMB 201, Ido – Ekiti, Ekiti – State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_148_20

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   Abstract 


Application of topical powdery substances to the wound is an age old practice. Talc containing powdery substances are however commonplace and predominant in our environment. This insoluble mineral has been linked to chronic granulomatous reaction particularly in the lungs. We present a case report of a fifty-year-old man with prolonged application of talc containing powdery substances to the left thumb wound and excitation of exuberant granuloma mimicking squamous cell carcinoma. He had complete excision of the mass and satisfactory first dorsal metacarpal artery flap coverage of the soft tissue defect.

Keywords: First dorsal metacarpal artery flap, granulomatous reaction, squamous cell carcinoma, talc powder


How to cite this article:
Babalola O F, Salawu A I, Okunlola A I, Abdullahi Y O. Thumb talc granuloma mimicking squamous cell carcinoma: A case report. Niger J Clin Pract 2021;24:1565-8

How to cite this URL:
Babalola O F, Salawu A I, Okunlola A I, Abdullahi Y O. Thumb talc granuloma mimicking squamous cell carcinoma: A case report. Niger J Clin Pract [serial online] 2021 [cited 2022 Dec 10];24:1565-8. Available from: https://www.njcponline.com/text.asp?2021/24/10/1565/328223




   Introduction Top


The thumb represents about forty percent functional capacity of the hand digital apparatus.[1] It is also readily injured as a result of being frequently deployed in daily activities. The practice of applying powdery substances to wounds especially minor cuts of the hand is commonplace in our environment. Talc containing household powders, pharmaceutical products and herbal substances are the agents frequently abused for local wound care by natives, whose choice of seeking specialist medical care is usually secondary to failed self-medication. We present a report of a fifty-year-old man with chronic left thumb wound and exuberant granuloma formation following prolonged topical application of powdery substances.


   Case History Top


A 50-year-old right-handed man and a commercial vehicle driver presented with a 2-year history of progressively enlarging left thumb wound initiated by a razor blade incision of a painful swelling at the tip of the thumb by the patient. There was foul smelling purulent exudate at onset and was self-managed by application of cicatrin powder and other talc containing powdery substances. The wound however progressively increased in size even though the purulent discharge gave way to slimy exudate and there was associated pain and limitation of movement of the joints of the thumb. There were no comorbid conditions and the past medical history was uneventful.

Examination revealed a middle-aged man with a normal mental status. There was an irregularly shaped 3 cm × 5 cm (width by length) ulcer on the volar surface of the thumb. The edges were raised and the floor was filled with exuberant granulation tissue [Figure 1]. There was a reduced range of motion at the metacarpophalangeal and interphalangeal joints due to pain and stiffness. The sensations were preserved and there was adequate capillary refill. A provisional diagnosis of squamous metaplasia of chronic left thumb wound was made with differentials of pyogenic and foreign body granulomas.
Figure 1: Pre-operative photograph of left thumb talc granuloma

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Plain radiograph of the left thumb showed a soft tissue defect, normal bone appearance and no radiopaque substance. Incisional biopsy for microbiological studies cultured no organism. Histopathological examination of the specimen revealed focally ulcerated stratified squamous epithelium with hyperkeratosis, acanthosis and pseudo epitheliomatous hyperplasia [Figure 2]. The dermis is loose and composed of dense infiltrates of mixed inflammatory cells, comprising neutrophils, lymphocytes and plasma cells [Figure 3]. There are a few foreign body giant cells, debris laden macrophages but no malignant cells.
Figure 2: Photomicrograph at × 10 magnification showing skin tissue with focus of pseudo. epithliomathous hyperplasia (arrow head)

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Figure 3: Micrograph of skin tissue at × 10 magnification showing dense infilterates of mixed inflammatory cells (arrow head) within the dermis consisting of neutrophils, lymphocytes, plasma cells, debris laden macrophages

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He had a gross total excision of the granulomatous lesion and the resultant defect on the phalanx was covered by first dorsal metacarpal artery flap with the Wolfe graft of the secondary defect [Figure 4] and [Figure 5]. He had an uneventful post-operative clinical course. He was commenced on a range of motion physiotherapy and discharged home. He was followed up at the surgical and physiotherapy out-patients' clinics. The last clinic review was 6 months post operation. He had satisfactory wound healing and acceptable range of motion in the interphalangeal joints.
Figure 4: Immediate post-operative photograph after first dorsal metacarpal artery flap coverage of post excision defect

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Figure 5: 3 weeks Post-operative photograph showing consolidating first dorsal metacarpal artery (FDMA) flap and wolfe graft of secondary defect

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   Discussion Top


Talc is an insoluble clay mineral composed of hydrated magnesium silicate. It is commonly used globally in a highly refined form for production of baby powder.[2],[3] Talc also serves as a thickening agent and lubricant in many industries such as paints and paper making, food and rubber, as well as cosmetics and ceramics.[4] In clinical care, sterile talc powder is used as lubricant for gloves, pharmaceutical preparations and in pleuredesis to prevent recurrence of malignant pleural effusion, in the treatment of bronchopleural fistulae and pneumothorax.[3]

Toxicology and carcinogenesis studies have however linked talc exposure to a variety of adverse effects such as chronic granulomatous reactions, squamous metaplasia and squamous cysts, and interstitial fibrosis with attendant functional insufficiency of the lungs.[5] Our patient chronically applied talc containing powdery substances to the thumb for about two years utilizing the antimicrobial properties of cicatrin and with the expectation of epithelialization and healing beneath the obscured wound surface. However, this practice excited a chronic granulomatous reaction typical of talc behavior following prolonged exposure to lung tissue as reported by several authors.[5],[6]

The insoluble nature of the particulate magnesium silicate produces a complex interplay between this chemical, inflammatory and mononuclear cells as well as a wide array of biological mediators resulting in the granuloma formation.[7] Keeping aside the talc implicated in the granuloma pathology of our patient, other chemicals capable of initiating similar granulomatous reaction include silica (silicosis), beryllium (acute and chronic beryllium diseases), and zirconium previously used in deodorants and recognized for causing axillary granulomas.[7] Clinical history of our patient did not reveal exposure to any of these other implicated substances.

Exuberant appearance of the pathology was initially suggestive of a proliferative lesion with squamous cell carcinoma of the cauliflower variant being contemplated. However, absence of everted edges, normal radiological findings and lack of identifiable malignant cells reassured us of the benign nature of the lesion. Even though our other close differential of pyogenic granuloma is most readily encountered in clinical practice, the unusual large size of the mass and the absence of haemangiomatous appearance on histology, typical of pyogenic granuloma (correctly described as lobular capillary haemangioma[8]) foreclosed this possibility. The mushroom-type pyoderma-like variant of pyogenic granuloma described by Wollina et al.,[8] is however the closest differential of this particular clinical appearance.

Our patient had complete excision of the tumor like exuberant granuloma and the exposed distal phalanx of the thumb was covered with flap (FDMA). This option has been reported to be versatile and optimal for a large pulp tissue defect of the thumb with better overall hand function and inconsequential donor site morbidity.[9] While the concern of color mismatch remains, our aim of achieving prompt wound healing in this peculiar circumstance and commencement of physiotherapy to improve joint movement was achieved.

Topical usage of antibiotics in wounds is an age old practice that is not only limited to non-operative wounds but has also crept into the operating rooms presumably to reduce the risk for surgical site infections. Several authors[10],[11] concluded that available evidence has consistently shown no significant advantage conferred on the surgical site wounds and the risk of antimicrobial resistance, systemic toxicity and economic burden associated with this practice outweigh any isolated benefits that might have been recorded. Judicious use of topical application of antiseptics is recommended as possible alternative.[11] Recently, successful use of non-talc containing powdery preparations in chronic wounds have been reported by some authors.[12]

Talc has been associated with pulmonary pathology and talc granuloma in the peritoneal cavity following abdominal surgical procedure is a well-known occurrence. Our case report however highlights the rare presentation of talc complication in chronic extremity wound.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

We acknowledge the contribution of the pathologists who conducted the histopathological examination and provided the photomicrograph. We also acknowledge the patient who gave consent for the publication of this article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Nanayakkara VK, Cotugno G, Vitzilaios N, Venetsanos D, Nanayakkara T, Sahinkaya MN. The role of morphology of the thumb in anthropomorphic grasping: A review. Front Mech Eng 2017;3. doi: 10.3389/fmech.2017.00005.  Back to cited text no. 1
    
2.
Tran TH, Steffen JE, Clancy KM, Bird T, Egilman DS. Talc, asbestos, and epidemiology: Corporate influence and scientific incognizance. Epidemiology 2019;30:783-8.  Back to cited text no. 2
    
3.
Muscat JE, Huncharek MS. Perineal talc use and ovarian cancer: A critical review. Eur J Cancer Prev 2008;17:139-46.  Back to cited text no. 3
    
4.
Boulos TR, Ibrahim SS, Yehia A. The art of talc flotation for different industrial applications. J Miner Mater Charact Eng 2016;4:218-27.  Back to cited text no. 4
    
5.
Low SU, Nicol A. Talc induced pulmonary granulomatosis. J Clin Pathol 2006;59:223.  Back to cited text no. 5
    
6.
Roberts WC. Pulmonary talc granulomas, pulmonary fibrosis, and pulmonary hypertension resulting from intravenous injection of talc-containing drugs intended for oral use. Baylor Univ Med Cent Proc 2002;15:260-1.  Back to cited text no. 6
    
7.
James DG. A clinicopathological classification of granulomatous disorders. Postgrad Med J 2000;76:457-65.  Back to cited text no. 7
    
8.
Wollina U, Langner D, França K, Gianfaldoni S, Lotti T, Tchernev G. Pyogenic granuloma – A common benign vascular tumor with variable clinical presentation: New findings and treatment options. Open Access Maced J Med Sci 2017;5:423-6.  Back to cited text no. 8
    
9.
Prabhu M, Powar R, Sulhyan SR. FDMA flap: A versatile technique to reconstruct the thumb. Int J Pharma Med Bio Sci 2013;2:8-14.  Back to cited text no. 9
    
10.
Fleischman AN, Austin MS. Local intra-wound administration of powdered antibiotics in orthopaedic surgery. J Bone Jt Infect 2016;2:23-8.  Back to cited text no. 10
    
11.
Edmiston CE, Leaper D, Spencer M, Truitt K, Litz Fauerbach L, Graham D, et al. Considering a new domain for antimicrobial stewardship: Topical antibiotics in the open surgical wound. Am J Infect Control 2017;45:1259-66.  Back to cited text no. 11
    
12.
Ghatnekar A V., Elstrom T, Ghatnekar GS, Kelechi T. Novel wound healing powder formulation for the treatment of venous leg ulcers. J Am Col Certif Wound Spec 2011;3:33-41.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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