Nonhealing leg ulcers: A manifestation of basal cell
.
carCInoma
Tania J. Phillips, MD, Salah M. Salman, MD, and Gary S. Rogers, MD
Boston, Massachusetts
Seven patients with basal cell carcinomas presenting as nonhealing ulcers are reported. The
importance of considering malignancy and taking biopsy specimens of leg ulcers that fail to
respond to treatment is emphasized. (J AM ACAD DERMATOL 1991;25:47-9.)
In 1828, Marjolin 1 first described malignant
changes in areas of ulceration in chronic burn scars.
Since then, there have been similar reports in chronic
ulcers from osteomyelitis and perineal fistulas with
chronic drainage, radiotherapy sites, and hidraden-
itis suppurativa. 2-s
Malignancy in chronic venous ulcers has been re-
ported to be "exceedingly rare,,6 and when they oc-
cur are most commonly squamous cell carcino-
mas. 7. 11 Basal cell carcinoma (BCC) appears to be
much rarer. 12-14
The development of frank carcinoma in an ulcer
is usually characterized by a vegetative lesion that
fails to respond to ulcer therapy.lS We have been
impressed by the banal appearance of seven chronic
leg ulcers, in which BCC was found in biopsy spec-
imens. By banal, we mean that no clinical features
suggested malignancy.
CLINICAL DATA
Eight patients from 39 to 94 years of age (five
women and two men), had ulceration of the lower
limbs. Six ulcers were on right legs and two on the
left legs. The clinical diagnosis in all but one of the
patients was venous ulceration; the remaining pa-
tient had Klippel-Trenaunay-Weber syndrome. The
duration of ulceration varied from 1 month to 6
years and size varied from 2 to 120 cm2. Only two
patients had a previous history of skin cancer (Ta-
ble I). Clinically, the ulcers looked innocuous and
lacked any of the features characteristic of BeC
From the Department of Dermatology, Boston University School of
Medicine,
Accepted for publication Feb. 27, 1991.
Reprints not available.
16/1/29102
(Fig. 1). However, a biopsy specimen contained a
BCC in each case.
DISCUSSION
Carcinoma in chronic leg ulcers is thought to be
rare. Ryan and Wilkinson6reported only three cases
of squamous epitheliomas in approximately 2000
ulcers. Tenopyr and Silverman8 considered that
malignancies in ulcers occurred by chance alone.
However, now several reports have established a
clear association between chronic wounds such as leg
ulcers and squamous cell carcino.mas. 2-10 Associa-
tion with BCC seems to be much more unusual, and
sarcoma and malignant fibrous histiocytoma are
exceedingly rare,16, 17
BCC is probably the commonest type of skin
cancer, accounting for approximately 65% to 75% of
all skin cancers. 18 BCC is most common on the head
and neck,20, 21 but also can occur elsewhere. In one
study, 16 of 202 BCCs occurred on the legs. 21 The
U.S. annual incidence of Bces on the legs is
0.00025% in men and 0.0004% in women. In our
clinic, a tertiary referral center, the incidence of
BCC in leg ulcers was high (9%). The figure was
probably elevated because ofthe nature ofthe clinic;
we tend to see referrals of problematic, chronic ul-
cers that have failed to respond to conventional
therapy. The question arises whether in our patients,
the malignancy was primary or secondary to the
chronic ulceration. This question is difficult to an-
swer. Chronic ulceration may give rise to skin can-
cer. Alternatively, 8% of BCCs (16 of 202) arise on
the lower extremity; thus the tumor may have arisen
de novo.
In a recent clinicopathologic review of 135 malig-
nant ulcers, the most common histologic types
included lymphoma (35%), squamous cell carci-
47
 Journal of the
American Academy of
48 Phillips et al. Dermatology

Fig. 1. Nonhealing ulcer present for 18 months on left leg of 76-year-old woman. Appear-
ance before biopsy. Biopsy specimen taken from upper margin, including portion ofulcer base.

Table I. ease summaries

Case Size of Previous history
No. Site ulceration (cm2 ) Clinical diagnosis of skin cancer

1 76 F Lateral aspect L leg 2.0 Venous 18 mo No

2 77 F Outer aspect R leg 6.0 Venous 5 rno No
3 94 F R outer leg 1.0 Venous 1 mo Yes
4 70 M R outer leg 32.0 Venous >15 mo No
Medial malleolus 120.0
5 75 M L medial malleolus 9.0 Venous 2 yr Yes
6 39 F Rknee 1.0 Klippel-Trenaunay 6 yr No
syndrome
7 87 F Rshin 3.8 Venous 2 yr No
8 62 M Rshin 6.2 Venous 6 mo No

noma (27%), Bee (5% to 15%), and malignant
melanoma (9.6%). Leukemia cutis, metastatic car-
cinoma, and sarcomas occurred less frequently. 22
Most of our patients were women. It has been
postulated that the higher incidence of Bee on the
legs of women is due to increased sun exposure be-
cause of styles of dress. 23 We were impressed by the
innocuous appearance of Bee in all our patients.
Many had varicose veins, or changes of venous
insufficiency, with hemosiderin pigmentation around
the ulcer and pitting edema of the ankles. Some pa-
tients also had lipodermatosc1erosis.
All the ulcers appeared benign, with apparently
healthy granulation tissue at the base, and no
evidence of the rolled pearly border or surface
telangiectasia classically seen with BCe. All ulcers
were subjected to biopsy because of failure to
improve after several months of treatment.
It has been reported that BCC of the proximal
extremities (axillae and inguinal region) generally
demonstrates the characteristic clinical features, but
these features are frequently absent in tumors lo-
cated more distally.24 Thus the possibility of malig-
nancy in any chronic, nonhealing wound should be
considered.
Biopsy of a chronic ulcer can be performed in an
outpatient setting, with minimal risk to the patient.
The margin and base of the ulcer may be sampled
by punch technique. Ifno suspect site exists, and the
ulcer is larger, several areas should be excised to
avoid sampling error. Depth of the biopsy should in~
elude the ulcer base at a minimum. Hemostasis can
be achieved by direct pressure or a hemostatic agent
(e.g., an absorbable gelatin sponge [Gelfoam D.
Cautery should be avoided as this may further delay
wound healing. Suturing the biopsy site is not
Volume 25
Number I, Part 1
July 1991
advised because of tissue friability and high bacterial
counts in the chronic ulcer.
Biopsy sites at the edges of ulcers usually heal
rapidly, with epithelialization ceasing at the ulcer
margin. 25 We have not experienced any complica-
tions in patients with chronic ulcers from whom bi-
opsy specimens were taken to exclude malignancy.
Various authors differ as to optimal biopsy time.
Some advocate biopsy of all ulcers at initial pre-
sentation,25 whereas others recommend waiting
longer. 26 We recommend biopsy of any leg ulcer that
does not at least begin to respond to treatment within
3 months.
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