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Malignant Melanoma Masquerading as a Decubitus Heel Ulceration

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Very Interesting

A few years ago, I was presented with a female who had a chronic infected hallux. She was referred by her dermatologist, a personal friend, whom I had just met at a seminar a day earlier. The area was suspicious enough that I took a biopsy and it turned out to be malignant melanoma. She was amputated and sentinal node dissection was done fortunately proving clear. She eventually succumbed to other illness, but the moral of the story is clear.

If your suspicion is high enough, and things are not progressing as planned then biopsy it. You can NEVER be faulted for this.

 

I AGREE!If I see a wound that is not progressing or changes color,size,shape, then I do like to biopsy.A chronic wound can lead to Marjolin's ulcer which is malignant.Chronicity is a sort of red flag.When in doubt,biopsy.

 

Biopsy for ulcer

I see patients at a Wound Center. When they come in if their history is unclear regarding the time of non-healing I get a biopsy even if the wound looks great.

I have had a relatively significant number of wounds with good granular bases that came back as Squamous cell carcinoma or basal cell.

As others have said, it can never hurt to do a biopsy.


Marc Katz, DPM
Tampa, FL
dr_mkatz@yahoo.com
http://www.thetampapodiatrist.com

 

Having worked for many years in a Diabetic Foot Clinic in the UK, any ulcer that I saw which I was suspicious about that had been non healing for more than 3 months I would arrange biopsy of. I worked closely with a range of Physicians and Surgeons including Dermatologists, Vasc Surgeons, Orthopods and Endocrinologists. The dermatologists were invaluable in these cases, and unusually (for the UK that is) I had direct referral rights to all from my community clinics as well as hospital clinics. Speed can be of the essence in these cases.

In the UK we see many non-healing Diabetic Foot wounds which can remain unhealed for years even, and due to the way that the NHS works and is funded it can be difficult to cross refer, and as most Podiatrists do not have ability to request biopsy I'm sure many of the types of lesions that can become (or already are) malignant are missed.
Close working with other disciplines can make all the difference.

 

Liked this poem by one of our UK students, Ananda Fletcher at Huddersfield University.

Vascular spasm – cardiac depression,
The patient has learned this vital lesson,
High blood glucose – occluded blood flow,
Induced cyanosis within the great toe,
Metformin used for diabetes control,
A perforating ulcer – a necrotised hole,
Swelling causes endothelial changes,
Poor glucose control stimulates dangers,
Osteomyelitis of the talus,
Charcot joint with thickened callus,
Proliferation of the skin,
Destructive phase will now begin,
Inflammation – T cell divide,
Immune response this will provide
Nitric Oxide – glucose is changed,
Into fructose – covalent bonds rearrange,
Glucose attached to blood corpuscles,
Decrease in oxygen – ischemic muscles,
Red cells cling to capillary walls,
Eventually blood flow stops or stalls,
Prothrombin converts in clotting cascade,
Respectively a fibrin meshwork is made,
A thrombus is formed – risk of a stroke,
Vasoconstriction – why do you smoke?
Dermatophyte thriving between the toes,
As blood glucose rises – fungus grows,
Good control of diabetes,
Means that you can earn your sweeties
Blood glucose of four to nine,
In good control – this reading’s fine.​

 

Regards to the poem:lol

 

Marjolin's ulcer. A 10 year experience in a diabetic foot unit
Garcia-Mar?n JA, de Alcala Martinez-Gomez D, Campillo-Soto A, Aguayo-Albasini JL
Cir Cir. 2015 Aug 7. pii: S0009-7411(15)00159-0. doi: 10.1016/j.circir.2015.06.029

 

Fatal epidural abscess from diabetic foot disease
Aditi Sharma et al
Endocrinol Diabetes Metab Case Rep. 2021 Feb 9;2021