Malignant transformation in diabetic foot ulcers

Diabetic foot ulcers (DFUs) are a major cause of lower-extremity amputation, hospitalization, and mortality. Although management focuses on wound care, infection control, and limb preservation, malignancies may develop in chronic, nonhealing wounds, and tumors may mimic DFUs. Evidence on malignancy in DFUs is limited, and the diagnostic contribution of routine histopathological examination in surgically treated cases remains unclear. This study aimed to determine the frequency of histopathologically confirmed malignancy in patients undergoing surgery for chronic DFUs and assess its impact on management and care. This retrospective, cross-sectional, single-center study was conducted at a Training and Research Hospital. We included 678 consecutive patients admitted with chronic DFUs between January 2019 and June 2021 who underwent surgical treatment and histopathological examination. Patients managed conservatively and those without a pathology specimen were excluded. Demographic characteristics, ulcer features, surgical procedures, histopathological findings, and changes in treatment and care were obtained from medical records. Statistical analyses were performed using SPSS version 25.0. The malignancy rate and its 95% confidence interval (CI) were calculated using the Clopper-Pearson method. A total of 678 patients were included. Of these, 74% were male, and the mean age was 64.69 ± 10.92 years. Wagner grade 4 ulcers accounted for 61.7% of cases, while 65.0% were classified as PEDIS grade 3. Histopathological examination identified malignancy in 4 patients (0.6%; 95% CI, 0.16-1.50); two of these patients had metastatic involvement. The treatment and care plan was modified for all patients in whom malignancy was detected. Overall, 95.6% of patients healed with wound care after surgery, without further changes to their treatment or care plan. However, 1.9% required amputation at a more proximal level, 1.3% experienced limb loss, and 1.2% died from other diabetes-related complications. Although uncommon, malignancy and metastatic involvement may occur in chronic DFUs. The possibility of malignancy should therefore be considered, particularly in nonhealing, atypical, or clinically suspicious ulcers. Ensuring appropriate histopathological evaluation of such ulcers may help healthcare professionals and wound care nurses identify primary or metastatic malignancies at an earlier stage.