What You Should Know About Potentially Malignant Wounds

Clinical Editor: Lawrence Karlock, DPM

Even if a wound appears to be benign, one must obviously be vigilant against the possibility of malignancy. These expert panelists discuss identifying malignant wounds, taking biopsies and when one might consider an amputation.

Q: What clinical insights lead you to suspect that a lower extremity wound may have an underlying malignancy?

A: M. Joel Morse, DPM, suspects malignancy if a wound does not look like it should. For example, if a neuropathic wound does not behave like it should with offloading, one should suspect melanoma. If a wound shows inadequate healing and a different treatment does not improve the condition, he suggests obtaining a biopsy.
“Do not be tentative about doing a biopsy,” maintains Dr. Morse. “Many times a melanoma or a squamous cell carcinoma does not ‘look’ like a melanoma or squamous cell carcinoma.”
Bradley Bakotic, DPM, DO, says the most important clue is the disconcordance between the development of the lesion and the clinical setting in which it occurs. In other words, he says an “ischemic” ulceration should not arise in well vascularized patients and “stasis” ulcerations are not expected in patients with normal venous return. Prior to attributing an ulceration to a particular etiology based on its appearance, he advises clinicians to verify that the patient actually has the causative condition.
“It is an undisputable fact that basal cell carcinomas can look identical to stasis ulcerations, melanomas may closely resemble ischemic ulcers and squamous cell carcinomas may mimic neuropathic ulcerations,” explains Dr. Bakotic. “A unifying concept is that ‘spontaneous’ ulcerations should be considered neoplastic until proven otherwise.”
Larry Goss, DPM, and Sabrina Minhas, DPM, say the signs of a possible malignancy include any lesion that appears suddenly and changes appearance in shape, size, border irregularity and color. They also note the potential danger of any chronic wound that persists over a long period of time and does not respond to treatment or signs of healing. They note that these patients may have squamous cell carcinoma or Marjolin’s ulceration.
Furthermore, Drs. Goss and Minhas say any lesion that feels deep on palpation and feels fixed to underlying tissues may be malignant as could a large solid lesion that does not transilluminate light. They note that pain or a history of trauma may not be reliable since some malignancies are painless until later stages.
“Appearance of an enlarging mass, although suspicious, is usually not in itself diagnostic for malignancy because the clinical characteristics of malignant lesions are typically varied,” say Dr. Goss and Dr. Minhas. “Physicians must take note of constitutional signs and symptoms, examine and palpate for lymphadenopathy, and take a thorough history and physical to rule out other systemic metastases.”
Both Dr. Goss and Dr. Minhas warn that clinicians sometimes overlook important information like age (some tumors only occur in a certain age group), usual syndromes (i.e. Gardner’s syndrome, Cowden syndrome, Ollier’s syndrome, etc.) and occupational exposure (i.e. radiation, arsenic, etc.).

Q: What are the most common lower extremity malignant wounds that you encounter?

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