Cath Lab Digest

S quamous cell cancer (SCC) represents a type of epidermoid carcinoma of the skin; 20% of all dermatological malignancies are SCC, second only to basal cell cancers (BCC). Clinicians agree that damage from the sun may manifest many years after exposure. In the United States, clinicians uncover approximately 600,000 new cases of SCC and BCC each year. Sun-exposed surfaces of the head and neck on fair skinned individuals appear most vulnerable, although tumors arising from non-sun exposed areas have been reported in the literature.¹

Immunosuppression plays an important role. Many of these cancers are associated with human papilloma virus (HPV) types 5 and 8.² Clinically, they usually present as shallow ulcerations with a crust and elevated borders. Pathologists usually grade tumors by the degree of differentiation based upon how closely the tumor resembles normal squamous epithelium (ie, well, moderately, poorly). These lesions represent locally aggressive cancers with the possibility of recurrence, especially in poorly differentiated tumors. A small but definite risk of metastasis occurs with SCC yet varies depending upon the site and histologic type. Metastasis usually involves the regional lymph nodes but rarely the lungs and skin. Ultraviolet radiation exposure represents the major known risk factor in the occurrence of non-melanoma skin cancers (NMSC), in which HPV may be a cofactor for SCC.

Many lesions originally diagnosed as venous ulcers show characteristics strikingly similar to skin cancers and might represent sites of primary carcinomas (see Figures 1 and 2). Therefore, detecting the frequency of malignancy in patients previously diagnosed with venous ulcer disease and evaluating the possibility of uncommon Marjolin's ulcer could yield important diagnostic data.

Materials and Methods

All charts of patients with a preliminary diagnosis of venous ulceration evaluated between January 1 and December 31, 2000 at a wound center in Florida were reviewed. Patients were identified based on IDC-9 codes for varicose veins with stasis ulcer (454.0), varicose veins with ulcer and inflammation (454.2), and venous peripheral insufficiency (459.81). To be included in the review, the following criteria for diagnosis of a venous ulcer also had to be met³: ulcer location on the medial or lateral aspects of the lower legs and the presence of varicosities, brawny edema, and/or hyperpigmentation in the affected extremity. After obtaining all charts, documentation related to follow-up and biopsy results was abstracted.

Results

Sixty (60) patients met the criteria for a diagnosis of venous ulcer disease. Of these, 20 underwent biopsies because their lesions were documented to appear clinically suspicious for epidermoid skin cancers (ie, raised borders, chronic scaling).

Biopsy results showed malignancy in 15 of the 20 lesions. Seven had well-differentiated SCC; one had mixed squamous/basal cell and one had squamous/stasis dermatitis; one lesion was a moderately differentiated SCC; three were BCCs; one was a malignant melanoma; and another ulcer had SCC that appeared to emanate from a sinus tract caused by osteomyelitis (Marjolin's ulcer). Thus, in this cohort of patients, 25% of ulcers initially classified as venous ulcers were found to be malignant lesions.