SLR - October 2022 - Raveena Sharma, DPM
Reference: Lyundup AV, Balyasin MV, Maksimova NV, Kovina MV, Krasheninnikov ME, Dyuzheva TG, Yakovenko SA, Appolonova SA, Schiöth HB, Klabukov ID. Misdiagnosis of diabetic foot ulcer in patients with undiagnosed skin malignancies. Int Wound J. 2022 May;19(4):871-887. doi: 10.1111/iwj.13688. Epub 2021 Oct 29. PMID: 34713964; PMCID: PMC9013580 .
Level of Evidence: 1
Scientific Literature Review
Reviewed By: Raveena Sharma, DPM
Residency Program: Carl T. Hayden VA, Phoenix, Arizona
Podiatric Relevance: Diabetic foot ulcers (DFU) are a very integral part of a podiatrists every day practice. However, not all foot ulcers are secondary to diabetes, there are some which can actually be related to dermal malignancies such as malignant melanoma and squamous cell carcinoma. Often, these malignancies are initially misdiagnosed as diabetic foot ulcers. As podiatrists, it is important to understand that malignancy can mimic diabetic foot ulcers or DFUs may even transform into a malignancy. Through this article, the authors were aiming to provide information about factors contributing to these misdiagnoses. It is extremely important to understand these factors as a misdiagnosis or a delay in diagnosis can lead to increased risks and poorer outcomes.
Methods: This was a systematic review where the authors searched the PubMed database using a combination of keywords to find articles that discussed the misdiagnosis of DFUs in patients with malignancy. Some of the key words included 'cancer', 'melanoma', 'sarcoma', 'malignancy' and 'misdiagnosed'. The inclusion criteria were studies on misdiagnosis of DFU in patients who were then diagnosed with cancer. The authors aimed to include participants who had DM and foot lesions which were initially thought to be secondary to DM. The authors obtained the malignancy type, number of patients, DM type and duration, DM complications and wound description and duration from the studies. The authors then performed statistical analysis of the cases studies.
Results: The authors found 25 articles that met the inclusion criteria. The main result the authors found was that advanced age increased the likelihood of a lesion being initially misdiagnosed as a DFU and subsequently found to be cancer. They found that lesions misdiagnosed as DFU were later diagnosed to be a malignancy ranging from melanoma to Kaposi's sarcoma to squamous cell carcinoma. The authors found the being age 65+ was associated with increased incidence of suspicion.
Conclusions: Diabetic foot ulcers have a high potential to be misdiagnosed when these lesions unfortunately may truly be a malignancy. This article was the first to systematically review clinical cases in which a foot ulcer was misdiagnosed as a DFU when in fact it was a foot malignancy. The study found that age was a contributing factor to a foot ulcer being a malignancy versus a DFU. The study also commented that DFU could transform into a malignancy, however no specific link between diabetes complications and ulcer transformation into a malignancy was found. The article also stated that there could be other risk factors such as immunosuppressive treatment, history of other malignancies of the patient or family members, as well as poor lifestyle habits in diabetic patients for why these lesions turned into malignancies, however this area still needs more research. Overall, the information provided in this article is extremely beneficial and helps podiatrists who are usually the ones treating these foot lesions to be aware of the factors that a patient might have that could be more strongly related to a dermal malignancy versus just a DFU.