What does one do when a wound does not respond to traditional treatment? In this discussion, panelists share when a biopsy is an appropriate choice, pearls on technique and their experience with individual patient cases.
What signs, symptoms or circumstances do you look for that suggest when a neoplasm should be part of the differential diagnosis related to a wound?
History taking can be illuminating, shares Kazu Suzuki, DPM, CWS. Factors such as sun exposure, even in a patient’s youth, may increase the risk for neoplasm. He adds that any wound not responding to conventional best practices of wound therapy, despite lack of infection or ischemia, should raise suspicion. Dusty Haverly, DPM, FACFAS agrees.
“If something with the story of the wound does not match up, I do not hesitate to biopsy,” says Dr. Haverly, who cites the age of the wound as a key consideration in the context of the etiology.
Windy Cole, DPM, FACFAS echoes the importance of considering the timeline and response to treatment of a given wound. She adds that atypical signs such as rolled wound edges, exuberant granulation tissue, malodorous drainage, a friable bleeding tissue base or an increase in devitalized tissue should all raise concern, and possibly inspire a clinician to biopsy. Additionally, biopsy may assist in ruling an inflammatory condition in or out.
When should biopsy become part of the assessment of a wound? What biopsy technique(s) do you employ and why?
Outside of the aforementioned concerning factors, Dr. Cole advocates for biopsy in wounds not responding after three months of good wound care. Due to the possibility of malignant transformation occurring at the cellular level in a wound, Dr. Cole recommends taking biopsies at the wound edge where these transitional cells can be found. Ideally, this will be a 3 mm punch biopsy and contain wound bed and margins. For larger lesions, an additional biopsy from the center of the wound base will aid in diagnosis, according to Dr. Cole.
Dr. Haverly will routinely perform this type of punch biopsy and include the second wound bed sample in an effort to give the pathologist as much tissue to work with as possible. However, Dr. Suzuki feels that a biopsy at four weeks of unresponsiveness to treatment is warranted and prefers an excisional biopsy with 3 mm margins along the wound edges when possible. In smaller wounds, he says this can be both diagnostic and curative. If the margins are malignant, then Dr. Suzuki would plan for another resection of the target wound. After excision, Dr. Suzuki shares that he will either employ primary closure or split-thickness skin grafting as necessary.
“Some clinicians may be reluctant to biopsy an ulcer but most biopsy sites heal well without complications,” says Dr. Cole.
She shares her recent participation in a randomized controlled trial, “Bacterial fluorescence image guidance of antimicrobial decision making and stewardship: a multi-site clinical trial,” which has been submitted for publication. The researchers obtained samples from 412 patients with a 6 mm punch biopsy, evaluating wounds for moderate to high bacterial levels. Dr. Cole points out that only 0.24 percent of the study population with chronic wounds of various etiologies experienced adverse events with one patient developing an infection that resolved with oral antibiotics. Dr. Haverly concurs that a physician is seldom wrong to biopsy a wound and also cites additional ascertainable diagnoses one may get from doing so.
What steps do you take if your biopsy of a wound reveals malignancy? Do you order any further testing, referrals or evaluation? Do you have a surgical algorithm for these cases?
All three panelists advocate for a multidisciplinary approach in these cases and appropriate oncology referral. Dr. Suzuki shares his positive experience with the Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute and their orthopedic oncology department. Dr. Cole also feels a skilled histopathologist is invaluable and adds physical therapists and pedorthists as possible collaborators.
Dr. Suzuki feels that he is adequately trained to excise small squamous cell or basal cell cancers until he has achieved clear margins, and will employ skin grafting when necessary for closure. He will refer out melanomas, sarcomas or complicated malignancies.
Dr. Cole also surgically addresses malignancies that are solely in the skin, surgically excising them and obtaining frozen section pathology. She also marks the tumor for orientation for the pathologist, placing a long suture at the proximal edge and a short suture at the medial edge.
“Larger destructive tumors such as fibrosarcoma or aggressive lesions such as invasive melanomas greater than 1 mm may necessitate amputation,” relates Dr. Cole. “MRI is very helpful in determining the level of amputation and incision planning.”
Dr. Cole notes that one should perform an amputation, when indicated, to provide optimal functional outcomes for the patient.
Do you have any interesting cases you can briefly recall as to when a wound turned out to be a neoplasm?
Dr. Haverly shares the case of a male in his 70s who presented with a years-long history of non-healing, circumferential wounds on both legs. While the patient had previously been treated for venous insufficiency, the wounds persisted. On his first visit with the patient, Dr. Haverly performed a biopsy, which revealed amelanotic melanoma. The patient sought treatment at a cancer center in Philadelphia and pursued suppression therapy only as his only curative option was amputation. The patient did not consent to the amputation.
Dr. Cole relates when she saw a 78-year-old female patient, who presented with a non-healing wound of the right medial midfoot for five months. History and examination did not reveal an identifiable etiology so she performed a punch biopsy. That biopsy revealed squamous cell carcinoma and Dr. Cole performed a complete excision. The procedure was successful and without sequelae.
Dr. Suzuki recalls a case of a middle-aged male with a mildly painful foreign body-like growth on his calf. He relates it felt like a toothpick under the skin but there was no history of trauma. Convinced it was benign scar tissue, Dr. Suzuki excised the mass and pathology revealed sarcoma. An oncology-orthopedic surgeon colleague later performed a wide excision followed by a round of radiation treatment. In the end, the patient made a full recovery, preserved his leg (amputation was one of the treatment options, but the patient resisted) and was declared in remission.
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 Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Haverly is board-certified by the American Board of Foot and Ankle Surgery and a Fellow of the American College of Foot and Ankle Surgeons. He is in private practice with OAA Orthopaedic Specialists in Allentown and Bethlehem, Pa.
Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles, CA. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles, CA. He can be reached at Kazu.Suzuki@cshs.org.