Vascular Wound or Advanced Melanoma?
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Benedetta Galli, MD, shares backgroung and key insights from her case report, "Leg Skin Ulcer With Atypical Features: Vascular Wound or Advanced Melanoma?" Coauthors on the article included Paola Monari, MD; and Piergiacomo Calzavara Pinton, MD. Read the full paper here.
Transcript:
Hello, I am Dr. Benedetta Galli, and I am a dermatology and venerology resident at the University of Brescia. The title of my case report is “Leg Skin Ulcer with Atypical Features: Vascular Wound or Advanced Melanoma?” The theme of our case report is the issue of misdiagnosis and delayed recognition of malignant wounds with a particular focus on melanoma-based ulcers, erroneously labeled as vascular wounds. The prevalence of malignant wounds shows a significant variability which could potentially be influenced by the field of expertise of the physician conducting the evaluation.
Our research underscores the urgency of early detection of these lesions by recognition of a malignant potential and, therefore, a referral to a dermatologist for clinical observation, dermoscopy and biopsy. We present a case study detailing a lower limb melanoma misdiagnosed over several years as a venous-insufficiency-based wound, resulting in late recognition at an advanced disease stage when the prognosis was regrettably poor. As authors, we wanted to emphasize the importance of ruling out malignancy between various possible of chronic leg wounds, and also to stress the crucial role of a timely referral to dermatologists for a suspicious and/or non-responsive ulcers.
Our motivation for this study stems from the observed prevalence of misdiagnosis in malignant wounds. The consequences of delayed diagnosis as evidenced in our case study are dramatic, and that's why we wanted to encourage heightened awareness among healthcare professionals regarding the importance of considering neoplasia as one of the possible diagnoses and, if suspected, referring the patient to the competent specialist.
One surprising aspect was the significant variability we observed in reported prevalence, ranging from 0.4% in geriatric and vascular surgery reports to 3 to 23% in other dermatological literature, suggesting that the physician’s specialty might influence the diagnosis. Sadly, as a dermatologist, we happen to see advanced melanomas more often than we hope, usually in generally neglected patients who are not used to seeking medical care.
This case was particularly disturbing, because the patient was, in fact, evaluated by multiple specialists who described the lesion in many reports and ultimately sent the patient to our dermatological care for indication on treatment and the medication of the ulcer, but still assuming that it had a vascular origin. When we saw the patient, he had already an advanced disease stage, revealing cutaneous and distant metastasis, and also on oncologic evaluation, no treatment was indicated due to the poor conditions of the patient who already had a cerebral stroke, possibly due to neoplastic embolization was inactive sepsis, and sadly passed away 6 weeks after our evaluation.
The future of research in this area should prioritize improved physician training to recognize red flags of potential malignancy. Training nonspecialists and professionals to recognize suspicious skin lesions is a key aspect that needs attention and further exploration. Another crucial aspect will be understanding and addressing barriers to accessing dermatological care, including social, economic, and geographical factors. We suggest further investigation into implementing referral systems and initiatives to enhance early detection of malignant wounds and skin lesions in general, which are already active in our area but may be not sufficiently accessible or advertised to the population.
