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Online Exclusives

When A Lower Extremity Wound Turns Out To Be Squamous Cell Carcinoma

Taking a closer look at a case involving a longstanding non-healing wound in a 61-year-old male, who attributed the wound to a fall, this author emphasizes prompt assessment and biopsy when clinical findings suggest potential malignancy.

Over the past 40 years, skin cancer incidence has continued to rise, increasing, on average, four to eight percent annually.1 Non-melanoma cancers make up the majority (97 percent) of skin cancers with basal cell carcinomas accounting for 80 percent of these lesions and squamous cell carcinomas rounding out the remaining 20 percent.1 Due to the increasing commonality of skin cancers, wound care providers are likely to encounter these malignancies over the course of their clinical practice. Malignant wounds can manifest and present in several ways. Frequently, wounds can develop from primary skin cancers eroding the surrounding tissue. 

The presentation of malignant wounds primarily depends on the rate of growth and the level of infiltration of the malignancy.2 Initially, the development of a non-tender nodule can occur. As the nodule enlarges, it may begin to interfere with the function of skin and the underlying vascular and lymph vessels.2 In time, this can lead to lack of skin perfusion, edema, skin breakdown and necrosis.2 Clinically, these ulcerative wounds can resemble a crater with raised or abnormal borders. Alternatively, proliferative wounds will appear to be fungating or raised like a cauliflower. Some malignant wounds can demonstrate both patterns of growth. If left unmanaged, these tumors may continue to grow and penetrate deep structures such as subcutaneous tissues, tendon and bone.3 It is not uncommon for malignant wounds to cause pain, exhibit excessive exudate, have malodor and bleed profusely.3 These wounds rarely heal and often deteriorate despite adequate wound care. 

With this in mind, let us take a closer look involving a case of patient with a biopsy-proven squamous cell carcinoma who presented at the wound care center with a lower extremity wound. Successful treatment included wide surgical excision paired with a primary repair utilizing a unique suture closure device. 

When A 61-Year-Old Male Presents With A Non-Healing And Expanding Lower Extremity Wound

A 61-year-old male was referred to the wound care center by his primary care physician with the chief complaint of a non-healing wound on his right lower leg. He related a remote history of a fall at work six months ago. At that time, the patient said he sustained an abrasion to the area of trauma that never really seemed to heal. He noticed the wound getting larger roughly four months ago. The patient saw his primary care physician who prescribed oral cephalexin (Keflex) and recommended application of triple antibiotic ointment to the area daily. When symptoms continued to worsen, the patient received a referral to the wound care center for evaluation. 

Upon presentation to the wound care center, the patient had a wound on his right anterior shin that measured 2.3 cm x 1.8 cm (see first photo above). The wound was painful and elevated with irregular margins. The wound base included a mix of hypergranular and dry hyperkeratotic tissue. The periwound skin was mildly erythematous with slight local edema. There was faint malodor with moderate amounts of serosanguinous drainage present on the patient’s bandage. He had dopplerable dorsalis pedis and posterior tibial pulses. The remaining clinical evaluation was unremarkable. 

The patient’s past medical history is positive for atrial fibrillation, hypertension, hypothyroidism, type 2 diabetes, degenerative joint disease, obesity and sleep apnea. His past surgical history included a right knee replacement in 2011.

Based on the wound presentation, the patient exam and past medical history, I suspected a possible malignancy, and performed a 3.5 mm punch biopsy on the day of the patient’s initial presentation to the wound care center. The histopathology report confirmed the diagnosis of squamous cell carcinoma. 

After an extensive discussion with the patient, we determined that surgical excision of the lesion and referral to oncology for a comprehensive workup as the best treatment plan. 

The patient had complete excision of the tumorous lesion under monitored anesthesia. The use of vertical elliptical skin incisions allowed for resection of the wound in toto, including a wide margin of normal-appearing tissue (see second photo above). I used a suture to mark the specimen for orientation and subsequently sent the specimen for frozen section to confirm complete removal of the malignancy and that excised tissue margins were free of malignant transformation. 

I reapproximated the deep tissue layers anatomically and performed interrupted stitch closure of the skin. The use of an adhesive retention suture device (HEMIGARD®, SUTUREGARD Medical) enhanced wound closure and prevented damage to the fragile periwound skin (see third photo above). This device assists in zero-tension primary closure by removing shear force from the skin edge to prevent surgical dehiscence.4

The patient presented for weekly postoperative visits at the wound care center where the wound healed completely without sequelae. Oncology evaluation revealed no systemic or local malignant spread. The patient will continue with close oncology monitoring at regular intervals. 

What You Should Know About Squamous Cell Carcinoma

Squamous cell carcinoma (SCC) is most commonly detected in sun-exposed areas including the head, neck, chest, upper back, ears, arms, hands, legs and feet.5 Although squamous cell carcinoma is a relatively slow growing form of skin cancer, it has the ability to spread deeply into tissues, bones and adjacent lymph nodes.6 With early detection, as demonstrated in the above case report, one can successfully treat squamous cell carcinoma. 

Squamous cell carcinoma may begin as a nodule or red, scaly patch of skin, which is rough, crust-covered and bleeds easily.6 Although anyone can develop squamous cell carcinoma, certain traits such as advanced age, chronic wounds, previous trauma, fair skin, excessive sun-exposure, burns, long-term chemical exposure, tanning bed use, immunocompromised states and inherited conditions can be predisposing factors in the development of the condition.

Although uncommon, cutaneous malignancies presenting as chronic wounds, similar to the aforementioned case involving squamous cell carcinoma, are well documented.  In 1827, Marjolin first reported this pathophysiological process when he noted a malignant change in the periwound tissue in a chronic ulceration.7 The etiological factors leading to the development of what is commonly known as a Marjolin’s ulcer have been a subject of debate for over 100 years. One such theory is that chronic irritation in areas of previous injury and scar tissue formation may stimulate cell proliferation and increase cellular mutations, causing the development of carcinomas.8 

Kirsner and colleagues estimate that 1.7 percent of chronic wounds have  malignant degeneration.9 Specifically, this phenomenon appears to be most prevalent in men 40 to 70 years of age who have a history of osteomyelitis and chronic wounds.There are reports of squamous cell carcinoma secondary to burns, trauma, diabetes and radionecrosis.10 

In the above case study, the patient had previous knee surgery on the right limb paired with a more recent history of fall with skin tear. Taking these factors into consideration, it is hard to determine if the development of squamous cell carcinoma was the primary cause of the ulcerative lesion or if this wound was in fact a Marjolin’s ulcer. In either case, early diagnosis and aggressive treatment are key. Early-stage, well-differentiated lesions are less aggressive and have an overall better prognosis.11 The five-year survival rate for patients having a wide excision of a Marjolin’s ulcer is 60 percent.11  

Final Notes 

In summary, when chronic wounds do not respond to good wound care therapies, tissue biopsy must be a strong consideration. It is a good rule of thumb that if one does not note evidence of wound healing within the first four weeks of initiating standard wound care, a biopsy is indicated. When wounds do not fit a typical pattern, fail to progress in a timely fashion or continually break down, one should rule out malignancy. Early diagnosis and treatment will limit skin damage, deep destruction of tissues and metastasis.

Dr. Cole is an Adjunct Professor and Director of Wound Care Research at the Kent State University College of Podiatric Medicine. She is board-certified by the American Board of Wound Management and the American Board of Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons.  

Online Exclusives
By Windy Cole, DPM, CWSP
References

1.Nicoletti G, Brenta F, Malovini A, Musumarra G, Scevola S, Faga A. Study to determine whether intraoperative frozen section biopsy improves surgical treatment of non-melanoma skin cancer. Mol Clin Oncol. 2013;1(2):390-394. 

2. Naylor W. Malignant wounds: aetiology and principles of management. Nurs Stand. 2002;16(52):45-53

3. Alexander S. Malignant fungating wounds: epidemiology, aetiology, presentation and assessment. J Wound Care. 2009;18(7):273-280.

4.Suturegard Medical. HEMIGARD ARS Device. Available at: https://suturegard.com/hemigard . Accessed January 5, 2021.

5. Yan W, Wistuba II, Emmert-Buck MR, Erickson HS. Squamous cell carcinoma - similarities and differences among anatomical sites. Am J Cancer Res. 2011;1(3):275-300.

6. American Cancer Society. Basal and squamous cell skin cancer. Available at: https://www.cancer.org/cancer/basal-and-squamous-cell-skin-cancer.html . Accessed January 5, 2021.

7.Trent JT, Kirsner RS. Wounds and Malignancy. Adv Skin Wound Care. 2003;16(1):31-34 

8. Kerr-Valentic MA, Samimi K, Rohlen BH, Agarwal JP, Rockwell WB. Marjolin's ulcer: modern analysis of an ancient problem. Plast Reconstr Surg. 2009;123(1):184-191.

9. Kirsner RS, Spencer J, Falanga V, Garland, LE, Kerdel FA. Squamous cell carcinoma arising in osteomyelitis and chronic wounds. Dermatol Surg. 1996;22(12):1015-1018.

10. Ackroyd JS, Young AE. Leg ulcers that do not heal. Br Med J (Clin Res Ed). 1983;286(6360):207-208. 

11. Hill BB, Sloan DA, Lee EY, McGrath PC, Kenady DE. Marjolin's ulcer of the foot caused by nonburn trauma. South Med J. 1996;89(7):707-710.

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