A 57-year-old Caucasian male with history of Crohn’s disease, colon cancer, and bilateral deep vein thrombosis (DVT) was referred to the Plastic Surgery Clinic from a dermatologist for a chronic, nonhealing skin lesion over the right lateral tibia, present for the past 13 years. The lesion was previously diagnosed as biopsy-proven pyoderma gangrenosum, being refractory to multiple treatment options, and passing through phases of waxing and waning severity. He is currently taking Humira, which has helped debulk the lesions. Past surgical history includes hydrocele excision, right ventral hernia repair with mesh, left groin lipoma excision, inferior vena cava (IVC) filter, colon resection, splenectomy, cholecystectomy, and leg DVT removal.
Examination of the lesion revealed an irregularly shaped, raised, fungating, exophytic lesion with no bleeding or infection. The entire lesion measures 12.0 cm × 12.0 cm × 1 cm as shown in Fig. 1. Other skin changes seen on physical examination include bilateral hyperpigmentation of lower extremities, consistent with evidence of venous stasis. His Crohn’s disease is currently being managed, and on examination the abdomen was soft, nontender, with normoactive bowel sounds in all four quadrants and no evidence of organomegaly.
The patient has no history of tobacco use or recreational drug use. He quit drinking alcohol 30 years ago.
A punch biopsy of the right lateral tibia was performed four years prior, revealing lobular vascular proliferation within the dermis with associated hemosiderin and spongiosis of the epidermis consistent with stasis dermatitis. More recently, at the time of presentation, punch biopsies of the same area revealed invasive squamous cell carcinoma of verrucous type.
Imaging findings
An extremity venous limited ultrasound performed the month prior showed new partial compressibility of the proximal femoral vein and partial compressibility of the popliteal vein stable from 2019, unable to distinguish between acute nonocclusive thrombus within the proximal femoral vein versus manifestations of chronic DVT. X-ray of the right tibia/fibula, also performed the month prior, showed no acute osseus injury or aggressive osseous destruction of the tibia/fibula. Positron emission tomography/computed tomography from the patient's skull base to thigh performed month of presentation showed a large, intensely hypermetabolic lesion along the skin of the right calf, measuring up to 105 mm, with no clear delineation between the two suspected process, pyoderma gangrenosum and squamous cell carcinoma. Imaging findings displayed hypermetabolic, enlarged right inguinal and external iliac lymph nodes, noted to be a non-specific finding in this context. It was noted that chronic wounds or metastasis may display this pattern, size, and degree of uptake. No evidence of distant metastasis was found.