Infiltrating basal cell carcinoma in the setting of a venous ulcer

Abstract

A 77-year-old man was referred with a 5-year history of an intermittently painful, nonhealing right medial ankle ulcer. The ulcer had not responded to multiple treatment modalities, including Unna boots, compression therapy, sclerotherapy, and split-thickness skin grafting. The past medical history was significant for a deep venous thrombosis in the right leg 30 years earlier (treated with warfarin for 3 months) and a history of greater saphenous vein harvesting for coronary bypass grafting 28 years previously. After the vein stripping, the patient had suffered from increasing right leg edema and stasis changes in the right leg. His history was also remarkable for coronary artery disease, dyslipidemia, and lymphoma treated with chemotherapy 8 years before presentation, with no evidence of recurrence. He had stopped smoking approximately 20 years earlier. Medications included atenolol, simvastatin, nicardipine, nitroglycerin, and aspirin. Skin examination revealed a 3.0 x 3.5-cm ulcer adjacent to the medial malleolus. The edges of the ulcer appeared raised and rolled (Fig. 1). Centrally, there was granulation tissue, which appeared healthy. There were surrounding dermatitic changes. Dorsalis pedis and the posterior tibial pulses were normal. Noninvasive vascular studies revealed severe venous incompetence of the right popliteal and superficial veins. Arterial studies and transcutaneous oximetry were normal. Computed tomographic scan of the pelvis did not reveal any adenopathy, and radiographic imaging did not reveal any bony changes suggestive of osteomyelitis. Biopsy of the ulcer edge and base showed infiltrating basal cell carcinoma (Fig. 2). Mohs' micrographic surgery required three layers; the final extent of the ulcer was 7.8 x 6.9 cm. A split-thickness skin graft was placed.

Basal Cell Carcinoma Is Not Granulation Tissue in the Venous Leg Ulcer

“…Both SCC and BCC can arise and ulcerate in areas of stasis changes, mimicking or complicating a venous ulcer. 3,[6][7][8]11 In conclusion, there are ulcers that can lead to the development of a skin carcinoma. This must be taken into consideration, especially when a leg ulcer does not respond to appropriate treatment.…”

“…3,[8][9][10][11][12] Malignancy should be considered in venous leg ulcers that are atypical, deteriorating, or not responding to conventional therapy after a few months. 6,[9][10][11][12] Patients with chronic ulcers of any etiology need many biopsies of the margins to exclude malignancy. 6,8 In most of the cases reported in the literature, patients who have developed cancer from leg ulcers are women.…”

Frequency of Malignant Neoplasms in 257 Chronic Leg Ulcers

“…There are contradictory data on the frequency and type of malignancies observed in leg ulcers. The prevalence of BCC or squamous cell carcinoma (SCC) differs in various series …”

Chronic leg ulcers and basal cell carcinoma

“…Basal cell carcinoma is the most common cutaneous malignancy, and it has the ability to masquerade as other entities and to appear in unsuspected areas. Chronic venous ulcers in lower limbs are recognized clinically, and further diagnostic testing is often not warranted 2 . Some reported signs of malignancy in leg ulcers are exuberant granulation tissue rolled over the clinical margins of the ulcer, and failure to heal despite having seemingly excellent granulation tissue 3 …”