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exophytic lesions at the edge of the skin grafted area
[Figure 1]. The clinical appearance was consistent with
an early recurrence. The patient underwent an urgent
re‑excision with 1 cm margins followed by split‑thickness
skin grafting. Histology confirmed a poorly differentiated
SCC with marked acantholysis and pseudovascular
spaces lined with atypical cells [Figures 2 and 3]. The
differential diagnosis was that of a poorly differentiated
pseudo‑angiosarcomatous SCC or true angiosarcoma
with prominent epithelioid cell morphology.
Immunohistochemistry showed the tumor cells to be
negative for the endothelial/vascularmarkers, erythroblast
transformation specific related gene and cluster of
differentiation 31, and for desmin and carcinoembryonic
antigen. It was concluded that the tumor was a poorly
differentiated acantholytic pseudo‑angiosarcomatous Figure 1: Recurrence of squamous cell carcinoma presenting as exophytic
SCC. Due to the narrow deep excision margin and the lesions (arrows) at the edge of the skin grafted area
aggressiveness of the tumor, further excision was offered
to the patient but this was refused. Less than 4 weeks
from the second wide/local excision, the patient presented
with a new erythematous lesion at the site of the original
excision, which on histologic assessment indicated a
further recurrence. Complete resection of the tumor
was achieved. Several weeks postsurgery, the patient
underwent radiotherapy to target any residual tumor
cells and prevent further recurrence. A staging computed
tomography evaluation did not reveal evidence of distant
metastasis. After completion of the radiotherapy course
and 6 months after her last operation she was evaluated
by plastic surgery and found to be well with no local or
regional recurrence and no lymphadenopathy.

DISCUSSION
Figure 2: Histopathological specimen showing acantholysis with
overlying epidermis (arrows)
Pseudo‑angiosarcomatous or pseudovascular SCC of
the skin is an unusual variant form of acantholytic
(adenoid, pseudoglandular) SCC that mimics the
histopathologic appearance of angiosarcoma. It
[5]
is a relatively rare malignancy with only 19 cases
described in the English literature. It is characterized
[4]
by a pseudoglandular pattern in the histological
study, and although the tumor has the clinical
characteristics of SCC, histologically it may mimic
an angiosarcoma. [4,5] However, careful histological
examination and immunohistochemical study can usually
lead to the correct diagnosis. Acantholytic foci in these
tumors may demonstrate changes in keratinocyte
differentiation markers, and this may explain more
aggressive biological behavior in the pseudovascular
variant of SCC. Pseudovascular SCC share a poorer
[6]
prognosis as they demonstrate a higher degree of
recurrence and metastasis than other variants of SCC. Figure 3: Histopathological specimen showing a pseudovascular space
lined by tumor cells (arrows) and adjacent normal blood vessels
[7] Due to the possibility of early recurrence in these
patients, plastic surgeons should consider evaluating psudovascular SCC, adjuvant radiotherapy has been
patients with pseudovascular SCC more frequently than recommended for cases of SCC with a high risk of
patients with other clinical subtypes of SCC.
recurrence, particularly perineurally invasive disease. The
[8]
Although there have not been specific studies regarding role of systemic chemotherapy and isolated limb perfusion
the role of adjuvant treatment in the management of in cutaneous SCC remains uncertain. [9,10]

Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 89