Diagnostic Dilemma: Chronic Ulceration in a Radiotherapy Site

Case Review[1] A 78-year-old man was referred for a nonhealing ulcer in the left axilla. The patient had a history of lung cancer, which was treated with radiotherapy and chemotherapy three years earlier. About a year ago, he developed an open wound in the left axilla at the site of irradiation. He complained of excessive serous drainage and odor but denied pain. He was cleansing the wound with hydrogen peroxide and leaving it open to the air. According to the patient, his past medical history was significant for prostate cancer, hyperlipidemia, osteoarthritis, multiple basal cell and squamous cell carcinomas of the skin, hypertension, and neuropathy of the hands and feet following chemotherapy. His medication list included simvastatin, rofeoxib, folic acid, felodipine, and amitriptyline. Cutaneous examination revealed a wound in the left axilla measuring 2.5cm in depth and 5x3cm in surface diameter (Figure 1). The margins of the wound were raised with a rim of friable tissue. A green discharge and foul odor were noted. Initial differential diagnoses included post-radiation ulceration, squamous cell carcinoma, and basal cell carcinoma. Wound cultures revealed moderate Streptococcus viridans and moderate Gram-positive bacilli resembling diphtheroids. A biopsy of the raised border demonstrated atypical basaloid epithelium with peripheral nuclear palisading consistent with basal cell carcinoma. The patient was referred back to his dermatologic surgeon and oncologist for management of the basal cell cancer. In the interim, he was treated with a course of Keflex and instructed to pack the wound with iodoform gauze daily. Case Update In consultation with the referring dermatologic surgeon and the patient’s oncologist, it was determined that the presumed basal cell carcinoma could in fact represent a recurrence of metastatic poorly differentiated carcinoma of the axilla. The patient had a very unusual history with several previous malignancies including many cutaneous basal cell carcinomas treated surgically, stage IIB (T2 Nx M0) adenocarcinoma of the prostate treated with TURP plus radiotherapy in 1995 to 1996, colon cancer treated surgically with a hemicolectomy in 1995, a low-grade clear cell carcinoma of the left kidney treated surgically with a nephrectomy in 1995, and most recently, in 2000, a poorly differentiated metastatic carcinoma involving the left axilla with several lung, peri-aortic, and left hilar lymph node metastases. The axillary tumor was believed to arise from a primary lung cancer; however, this has not been definitively proven despite bronchoscopy and computerized tomography (CT) scan. The patient underwent six cycles of chemotherapy from November 2000 to March 2001 and then received radiation therapy to the axilla from July 2001 to April 2002. In late 2002, the patient developed an ulceration in the left axilla and was seen by a dermatologic surgeon who referred him to the authors’ clinic in August 2003. Biopsies taken in the authors’ office were consistent with basal cell carcinoma. Repeat biopsies taken by the referring dermatologic surgeon in September 2003 also showed basal cell carcinoma. In follow up with oncology in September 2003, a CT scan of the chest revealed progression in the size of the pulmonary metastases as well as bilateral adrenal enlargement. Subsequent fine needle aspiration (FNA) of the axilla demonstrated poorly differentiated carcinoma. The pathology report is unclear as to the origin of the specimen (axillary mass or adjacent lymph node). The oncologist believes the tumor in the axilla represents metastatic disease from a primary lung cancer. However, an unusual basal cell carcinoma represents a remote possibility. Unfortunately, the FNA slides have been misplaced, and the final diagnosis remains unclear. Given the patient’s current health status, the final diagnosis may never be definitively proven. Currently, the patient is receiving additional chemotherapy and wound care. Discussion This case emphasizes two important points: first, the importance of obtaining a thorough medical history, and second, the need for improved communication between healthcare providers. Patients generally are not medically trained and, therefore, are not always the best source for medical history. Had the authors known the details of his “lung cancer” the authors would have approached the work up of the axillary mass quite differently. In addition, unknown to the authors, several healthcare providers were performing diagnostic studies on the mass within the relatively same time period. The lack of communication resulted in confusion regarding the source of the biopsy specimen from the FNA. There is no doubt that the patient has metastatic disease of an unknown primary that pathologically resembles poorly differentiated carcinoma. However, what is not clear is the pathology of the ulcerative lesion in the axilla. It is plausible that this patient could have developed an ulcerating BCC in the previously irradiated area. It is equally plausible that the ulcerative lesion could represent a recurrence of his original axillary tumor. Given the discrepancy in biopsy reports and the patient’s current health status, it is unlikely it will ever be known. However, the oncologist feels that because of the extent of the patient’s disease and very poor prognosis, the precise pathologic diagnosis will not make any difference to his management or outcome.