PMC1192822_01
Epithelioid sarcoma a) Conglomerate of tumor nodules with central necrosis mimicking a necrotizing granulomatous process at low magnification (hematoxylin and eosin x4) b) Epithelioid cells with abundant eosinophilic cytoplasm and prominent nuclear atypia, appreciated at high magnification (hematoxylin and eosin x40), distinguishes epithelioid sarcoma from its benign mimics. Note the presence of a mitotic figure.
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F1
Review of surgical pathology at our institution confirmed this diagnosis (Figure 1a and 1b).
Preoperative lymphoscintigraphy identifies uptake of the radiolabelled tracer in a single axillary lymph node.
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F2
Preoperative lymphoscintography (figure 2) identified a single "hot" ipsilateral axillary lymph node, which was successfully removed.
The appearance of the hand is shown following wide excision of skin, palmar fascia, flexor tendons, lumbricals, and neurovascular bundles. The small and ring fingers are postured in extension due to the absence of flexor tendons. The resection specimen is shown above.
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F3
The excision plane was carried down to the level of the fascia of the interossei, along the volar shafts of the metacarpals (Figure 3).
Sural nerve grafts, reversed Y-vein graft for digital revascularization of the small and ring fingers, and first-stage tendon reconstruction with silicone rod insertion is seen here. The construct was then covered with a contralateral free radial forearm flap.
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F4
Reconstruction included the placement of silicone rods to the small and ring fingers for the first part of a 2-stage flexor tendon reconstruction (Figure 4).
Prior to second-stage tendon grafting, the patient had a well-healed radial forearm flap on his right palm. The donor site on the left forearm was satisfactory.
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F5
At six months post-procedure, the radial forearm flap and donor site were well healed (Figure 5).
The final appearance of both hands after staged tendon grafting to the right ring and small fingers. There is functional restoration of composite finger flexion.
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F6
He has regained acceptable hand function, with small and ring finger individual joint range of motion of 90 degrees at the metacarpal-phalangeal joints, 30 degrees at the proximal interphalyngeal joints, and 30 degrees at the distal interphalangeal joints (Figure 6).