A 90-year-old woman presents for evaluation and treatment of an ulceration that has been on her left leg for >1 year. The ulcer had been ascribed to venous insufficiency and was treated conservatively elsewhere. The patient’s medical history is positive for hypertension, hypercholesterolemia, and breast cancer. Physical examination reveals sparse, superficial, bluish, tortuous varicosities in many places on the left lower leg, and mild pitting edema is noted to the dorsum of the left foot. The ulceration for which she is seeking treatment is sizeable and is above the medial malleolar aspect of the left leg. When lightly debrided, the ulceration displays an erythematous granular base.
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The association of a chronic leg wound with basal cell carcinoma is uncommon. In this case, the diagnosis was suspected on clinical grounds and confirmed by biopsy.
Basal cell carcinoma is the most common form of skin cancer, however. It usually develops on sun-exposed areas on light-skinned individuals. Most basal cell carcinomas present as small, dome-shaped papules with a pearly appearance and well-defined borders. Lesions are typically slow-growing and rarely metastasize. Although the majority of basal cell carcinomas occur on the head and neck, approximately 8% occur on the lower extremities.1
Malignant degeneration of wounds is rare. Wounds that undergo neoplastic transformation are referred to as Marjolin ulcerations, after the French physician who documented the first occurrence in 1827.2 Basal cell carcinoma and squamous cell carcinoma are the most frequently encountered ulcerative malignancies affecting the lower extremities.3 A study of 125 cases found that 25% of those with basal cell carcinoma had concomitant chronic venous stasis, suggesting a relationship between venous disease and basal cell carcinoma.4
Wounds that appear atypical should undergo biopsy regardless of wound duration. Histopathologic analysis is necessary to confirm the presence or absence of malignancy. Local invasion into bone has been reported. Plain radiographs and magnetic resonance imaging may reveal early osteolysis and are valuable tools in delineating the nature and extent of soft tissue invasion and bone involvement.5 Natural progression from ulceration to dysplasia may be insidious, and periodic inspection of the wound for unusual changes is recommended.
Aroob Moin, DPM, is a podiatry-dermatology fellow at St. Luke’s University Hospital in Bethlehem, Pennsylvania, and at the DermDOX Center for Dermatology in Hazleton, Pennsylvania, and Stephen Schleicher, MD, is an associate professor of medicine at the Commonwealth Medical College in Scranton, Pennsylvania, and an adjunct assistant professor of dermatology at the Perelman School of Medicine of the University of Pennsylvania in Philadelphia. He practices dermatology in Hazleton, Pennsylvania.
- Phillips TJ, Salman SM, Rogers GS. Nonhealing leg ulcers: a manifestation of basal cell carcinoma. J Am Acad Deramatol. 1991;25(1 Pt 1):47-49.
- Marjolin JN. Ulcers. In: Adelon NP (ed). Dictionnaire de médicine. Paris: Bèchet;1828:T.21.
- Hansson C, Andersson E. Malignant skin lesions on the legs and feet at a dermatological leg ulcer clinic during five years. Acta Derm Venereol. 1998;78(2):147-148.
- Aloi F, Tomasini C, Margiotta A, Pippione M. Chronic venous stasis: not a predisposing factor for basal cell carcinoma on the leg. A histopathological study. Dermatology. 1994;188(2):91-93.
- Chiang KH, Chou AS, Hsu YH, el al. Marjolin’s ulcer: MR appearance. AJR Am J Roentgenol. 2006;186(3):819-820.