Squamous cell carcinomas in chronic venous leg ulcers. Data of the German Marjolin Registry and review

BACKGROUND

Secondary squamous cell carcinoma (SCC) is a rare complication of chronic venous leg ulcers. So far, little is known about its pathophysiology and clinical behavior. Initiated by the working group "Wound Healing" (AGW) of the German Society of Dermatology (DDG), it is the objective of the current Marjolin registry to collect cases of SCC arising in venous ulcers, in order to evaluate diagnostic characteristics.

PATIENTS AND METHODS

All members of the AGW received questionnaires inquiring about basic patient data, ulcer characteristics, and therapy conducted.

RESULTS

From 2010 to 2013, 30 patients (20 women, 10 men) from six tertiary wound care centers were registered. Mean age was 76.17 years. The average duration of venous leg ulcers prior to SCC diagnosis was 15.93 years. Suspicious wound characteristics primarily included: pain (n = 3), therapy resistance (n = 27), and fetor (n = 12) as well as clinical appearance (n = 10) with atypical morphology, nodular wound bed, and hypergranulation.

CONCLUSIONS

Atypical morphology or changes in appearance as well as therapy resistance despite optimal care (6-12 weeks) should prompt physicians to take spindle-shaped, if necessary multiple and serial, biopsies. Primary risk factors for malignant transformation include patient age and ulcer duration.

Diagnosing and managing venous leg ulcers in patients in the community

Venous leg ulcers (VLUs) are a chronic condition affecting between 0.1% and 0.3% of the population in the UK. Healing rates are variable and recurrence rates are high. The diagnosis, assessment, and management of this patient group is primarily carried out in the community. Assessment of this patient group requires skill and competence to ensure a correct diagnosis is made. When carrying out the assessment, it is important to consider the patient's past medical history, medication, and allergies, as well as to record the ankle brachial pressure index (ABPI), pain level, palpation of pulses, and ankle joint movement, among other aspects of the assessment. VLUs heal with compression therapy, and practitioners should be knowledgeable about the various compression systems available in order to offer patients the most suitable and informed choices.

The Importance of Wound Biopsy in the Accurate Diagnosis of Acral Malignant Melanoma Presenting as a Foot Ulcer

Neoplastic changes arising at the sites of chronic, nonhealing wounds are not uncommon; however, they often go undiagnosed. We report a case of rapidly progressing plantar melanoma presenting as a chronic, nonhealing ulcer. A 46-year-old patient presented at a specialized Wound Healing Center with an enlarging painful ulcer on the right heel of 3 months duration. The wound was biopsied and specimens were sent for examination at the Wound Pathology service at the Department of Dermatology and Cutaneous Surgery, University of Miami. Histology demonstrated features consistent with acral malignant melanoma. Immunohistochemistry using melanocytic markers MART-1, S-100, HMB-45 revealed positive staining indicating the presence of malignant cells, and D2-40 staining showed lymphatic invasion of the tumor in the wound biopsy specimen. The case presented here underscores the importance of wound biopsying in the diagnosis of malignancies associated with nonhealing wounds.

Differential diagnosis of leg ulcers

Leg and foot ulcers are symptoms of very different diseases. The aim of this paper is to demonstrate the differential diagnosis of leg ulcers. The majority of leg ulcers occur in the lower leg or foot. In non-venous ulcers the localization in the foot area is more frequent. The most frequent underlying disease is chronic venous disease. In 354 leg ulcers, Koerber found 75.25% venous leg ulcers, 3.66% arterial leg ulcers, 14.66% ulcers of mixed venous and arterial origin and 13.5% vasculitic ulcers. In the Swedish population of Skaraborg, Nelzen found a venous origin in 54% of the ulcer patients. Each leg ulcer needs a clinical and anamnestic evaluation. Duplex ultrasound is the basic diagnostic tool to exclude vascular anomalies especially chronic venous and arterial occlusive disease. Skin biopsies help to find a correct diagnosis in unclear or non-healing cases. In conclusion, chronic venous disease is the most frequent cause of leg ulcerations. Because 25% of the population have varicose veins or other chronic venous disease the coincidence of pathological venous findings and ulceration is very frequent even in non-venous ulcerations. Leg ulcers without the symptoms of chronic venous disease should be considered as non-venous.

Ten years of experience in chronic ulcers and malignant transformation

Malignant degeneration of wounds is rare and often misdiagnosed. Delay in diagnosis may result in a worse prognosis. The aim of this study is to determine the number of skin cancers associated with chronic skin ulcers in our facility over a period of 10 years. Between January 2002 and December 2012, a total of about 1000 patients had consulted with us for chronic wounds, especially of vascular, diabetic and traumatic origin and pressure ulcers. Thirteen skin cancers had been detected: seven squamous cell and five basal cell carcinomas and one melanoma. We highlight how important it is to be aware of the signs suggesting a malignant change and the importance of biopsy at regular intervals during the life cycle of any chronic wound.