A 50-year-old man comes to the office due to a persistent ulcer on his left leg for the past 2 months. Ten years ago, he sustained full-thickness burns to the left pretibial and ankle areas that required extensive wound care and skin autografting and resulted in significant scarring. The patient had been doing well until 2 months ago, when he developed an ulcer associated with pain and bloody drainage within the region of the prior skin graft. He has tried local wound care with antibiotic ointment, but the lesion has not healed. On physical examination, there is a 3-cm, irregularly shaped ulcer on the left lower leg just proximal to the medial malleolus. The ulcer has red granulation tissue at the base that bleeds easily when touched. Pedal pulses are 2+ bilaterally. The legs are symmetric in girth; there is no edema in the legs or feet. Which of the following is the most likely diagnosis?

Question

A 50-year-old man comes to the office due to a persistent ulcer on his left leg for the past 2 months.  Ten years ago, he sustained full-thickness burns to the left pretibial and ankle areas that required extensive wound care and skin autografting and resulted in significant scarring.  The patient had been doing well until 2 months ago, when he developed an ulcer associated with pain and bloody drainage within the region of the prior skin graft.  He has tried local wound care with antibiotic ointment, but the lesion has not healed.  On physical examination, there is a 3-cm, irregularly shaped ulcer on the left lower leg just proximal to the medial malleolus.  The ulcer has red granulation tissue at the base that bleeds easily when touched.  Pedal pulses are 2+ bilaterally.  The legs are symmetric in girth; there is no edema in the legs or feet.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's nonhealing ulcer at the site of a chronic burn scar is most concerning for squamous cell carcinoma (SCC). Although sun exposure is the most common cause of cutaneous SCC, SCC may also arise within chronic wounds (eg, venous stasis ulcers) or scars (eg, healed burns). The exact mechanism of malignant degeneration is unknown; however, contributing factors likely include chronic inflammation and vascular compromise (from scarring) that shield the area from immune surveillance. When malignant transformation does occur, the average latency period is 30 years, but it can occur early (eg, within a year of injury). SCC from wounds or scars (Marjolin ulcer) typically presents as an enlarging, nonhealing ulcer; it may have excessive granulation tissue that bleeds easily on contact and/or rolled or everted wound margins. Less commonly, it may exhibit a nodular, a verrucous, or an exophytic appearance. This type of cancer tends to be aggressive, with a high risk for recurrence, local invasion, and metastasis; skin biopsy should be obtained for timely diagnosis. Treatment can include excision with wide margins, Mohs micrographic surgery, and amputation proximal to the ulcer, depending on tumor characteristics. (Choice A) By far, SCC is the most common cancer arising from chronic wounds or scars, although basal cell carcinoma may also develop in a minority of cases. (Choice B) Cutaneous T-cell lymphoma, sometimes referred to as mycosis fungoides, most commonly appears as pruritic, eczematous patches or plaques. It does not typically arise from an old scar or burn wound. plaques (Choice C) Skin graft failure, in which a skin graft does not adhere to the wound bed and subsequently necroses, is most commonly caused by factors (eg, mechanical friction, underlying seroma/hematoma) that impair the new graft's ability to receive nutrients from the wound bed and undergo neovascularization. When failure occurs, it is typically within the first week of the graft, not years later. (Choice E) Although venous stasis ulcers frequently occur in the medial malleolar region, they are a manifestation of late-stage venous insufficiency and are typically accompanied by pedal and/or leg edema, features absent in this patient. edema Educational objective: A nonhealing ulcer arising from a chronic wound or scar is concerning for squamous cell carcinoma. These neoplasms tend to be aggressive, with a high risk for recurrence, local invasion, and metastasis. Timely diagnosis with biopsy is required. References: Marjolin's ulcer in chronic wounds-review of available literature. (http://www.ncbi.nlm.nih.gov/pubmed/29180925)

A 50-Year-Old Man Comes to the Office Due to a Persistent