Infiltrating basal cell carcinoma in the setting of a venous ulcer

A 77-year-otd man was referred with a 5-year history of an intermittently p ainful, nonhealing right medial ankle ulcer. The ulcer had not responded to multiple treatment modalities, including Unna boots, compression therapy, sclerotherapy, and split-thickness skin grafting. The past medical history was significant for a deep venous thrombosis in th e right leg 30 years earlier (treated with warfarin for 3 months) and a his tory of greater saphenous Vein harvesting for coronary bypass grafting 28 y ears previously. After the vein stripping, the patient had suffered from in creasing right leg edema and stasis changes in the right leg. His history w as also remarkable for coronary artery disease, dyslipidemia, and lymphoma treated with chemotherapy 8 years before presentation, with no evidence of recurrence. He had stopped smoking approximately 20 years earlier. Medicati ons included atenolol, simvastatin, nicardipine, nitroglycerin, and aspirin . Skin examination revealed a 3.0 x 3.5-cm ulcer adjacent to the medial malle olus. The edges of the ulcer appeared raised and rolled (Fig. 1). Centrally , there was granulation tissue, which appeared healthy. There were surround ing dermatitic changes. Dorsalis pedis and the posterior tibial pulses were normal. Noninvasive vascular studies revealed severe Venous incompetence of the rig ht popliteal and superficial veins. Arterial studies and transcutaneous oxi metry were normal. Computed tomographic scan of the pelvis did not reveal a ny adenopathy, and radiographic imaging did not reveal any bony changes sug gestive of osteomyelitis. Biopsy of the ulcer edge and base showed infiltrating basal cell carcinoma (Fig. 2). Mohs' micrographic surgery required three layers; the final exten t of the ulcer was 7.8 x 6.9 cm. A split-thickness skin graft was placed.