Malignant tumours arising in chronic leg ulcers: three cases and a review of the literature
Abstract
The precancerous potential of chronic leg ulcers is well-established but the number of reported cases overall is small. Delay in diagnosis may result in a worse prognosis, loss of the affected limb or occurrence of metastases. We report a case series of three patients with long-standing history of recalcitrant leg ulcers, which finally showed malignancy when histologically investigated. In addition, we discuss the literature concerning malignant transformation of chronic leg ulcers and try to bring forward the controversial question of how to differentiate primary and secondary malignancies in chronic ulcers. Although hypotheses about altered wound healing mechanisms, influence of chronic inflammation and irritation or tissue damage through infections are conclusive, further investigations are necessary to clarify the exact pathogenetic mechanisms of tumour development in chronic wounds.
Malignant transformation is a rare complication of chronic leg ulcers. First described by Marjolin as the appearance of squamous cell carcinoma (SCC) on chronic scars in the early 19th century,1 for many authors the term ‘Marjolin's ulcer’ currently comprises any form of carcinoma arising in long-standing wounds.2
Tumour development is reported in chronic wounds secondary to vascular diseases, burn scars, chronic lymphoedema or osteomyelitis. Malignancies mainly comprise SCC,3 with the transformation into basal cell carcinoma (BCC), malignant melanoma, lymphoma or sarcoma as a result of a long-standing wounds yet to be discussed. For these entities, it is often difficult to differentiate between malignant degradation of a chronic wound into a carcinoma and malignancies presenting as ulcerations.4
An 84-year-old man was referred to the department with a chronic leg ulcer on the right lower leg, first arising in 1992. The patient had been seen in the clinic several years previously and, at that time, skin biopsy specimens from various sites of the ulcer were negative for malignant transformation. The diagnosis of a venous leg ulcer (VLU) was established, although the patient did not show up for the further visits.
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