| Sumario: | Background Long-standing wounds are at risk of developing malignant degeneration, including leiomyosarcomas. These exceedingly rare malignant tumours originate from smooth muscle cells and are considered superficial if they affect the dermis and/or subcutis. Hypothesis To exclude malignancy, a biopsy should be performed on chronic skin ulcers with atypical features or evolutions. Methods We report the case of a 62-year-old male with a history of a two-year old chronic venous ulcer who presented with a tumour developing over three months, progressively increasing in size on the surface of the wound. As the clinical aspect strongly suggested a malignant tumour arising within a chronic venous ulcer (the initial suspicion was of squamous cell carcinoma), a biopsy from the edge of the lesion was performed. Results Histopathological and immunohistochemical examinations revealed a diagnosis of leiomyosarcoma. The patient refused further medical care. The tumour arose in the context of severe cutaneous changes of venous insufficiency and had aggressive clinical behaviour. Histopathological and immunohistochemical analysis of the tissue sample is essential for establishing the final diagnosis, as no pathognomonic clinical features of leiomyosarcoma exist. Conclusions Our case emphasises the importance of considering malignancy in chronic ulcers with atypical features or evolution. Biopsy of atypical skin ulcers is crucial for establishing a diagnosis and initiating therapy at the rightful moment. Implications for clinical practice The findings from this case highlight the importance of an early diagnosis of atypical, non-healing wounds, based on tissue samples, to decide the optimal approach. Patient denial may interfere with the proper management of this particular clinical context.
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