The Case

A 57 year-old white man had a heart transplant in December of 2012. Approximately 2 years later, in January 2015, he noted a growing, painful, foul-smelling mass on the right hand and wrist ( Figure 1 ) and 3 months later sought medical care. When examined, the mass measured 18 × 15 × 3.5 cm and was 8 cm from the proximal skin margin. He was known to have obstructive sleep apnea, hypertension, and depression. His immunosuppressive therapy included tacrolimus, 2 mg a.m. /1 mg p.m. and mycophenolate mofetil, 500 mg.

Images of a large mass on the hand of a cardiac posttranplant patient. (A) Photograph of the right hand of the patient with the large mass. (B) Photomicrograph of the tumor showing nests of squamous cell carcinoma with abundant keratinization (200× magnification). (C) Photomicrograph of the tumor (lower portion) adjacent to bone (upper portion) without invasion of bone (20× magnification).

The mass involved underlying soft tissue, abutting the periosteum of the radius and first metacarpal bones ( Figure 1 ). Tissue adjacent to bone showed inflammation and periosteal new bone formation but no direct invasion of bone. The patient elected to undergo amputation of his arm below the elbow as this was believed to be the best curative option. Histopathologic evaluation of the mass confirmed it to be a well differentiated squamous carcinoma infiltrating deeply into subcutaneous tissue ( Figure 1 ).