TY - JOUR
AU1 - MD, Chi Young Bang,
AU2 - PhD, Sang Hyun Woo, MD,
AB - Abstract Marjolin’s ulcer is the malignant transformation of chronic nonhealing ulcers that have developed in burn scars or in any other chronic wound. Development of this malignancy tends to be slow and insidious, but it becomes more aggressive when the Marjolin’s ulcer breaks free of the scar. We reviewed 24 cases of patients who complained of chronic burn wounds suspected to be Marjolin’s ulcers. Histologically, chronic ulcer and pseudoepitheliomatous hyperplasia were 21%, respectively, and malignancy, including squamous cell carcinoma and leiomyosarcoma, were 58%. The mean latency period was 31.6 ± 13.0 years, and the majority of lesions occurred in the extremities. Pseudoepitheliomatous hyperplasia in chronic burn wounds, which is difficult to distinguish from squamous cell carcinoma and considered as a transitional state to becoming a malignant tumor, should be treated as a malignancy. An aggressive excision and reconstruction with free tissue transfer or regional flap transposition should be adopted for adequate ablation and definitive coverage, rather than skin graft and regular surveillance. Marjolin’s ulcer (MU) is defined as a malignancy caused by pathological changes resulting from prolonged repetitive trauma after full-thickness skin loss.1 Malignant degeneration has been reported to occur in 0.77 to 2% of post burn wounds and scars,2 and post burn wounds and scars contribute to 2% of all squamous cell carcinoma (SCC) and 0.03% of all basal cell carcinomas of the skin.1,3–5 If malignant transformation occurs, it shows a low tendency of metastasis at the beginning of the course but has unique characteristics of rapid disease progression and a high mortality rate once recurrence or metastasis has occurred.3,6 In the past, skin grafts were preferred to avoid obscuring recurrence. However, MUs are histologically heterogeneous and more aggressive than a typical SCC. A well-organized eradication and reconstruction plan and strategy for adjuvant therapy or nodal management should be formulated for each pathological entity. The authors analyzed 24 lesions suspected as MU. Pathological diagnosis, treatment modality, and prognosis were analyzed, and related articles were reviewed. METHODS This study was performed after approval from the Institutional Ethics Committee (P01-201510-21-005). Nonhealing chronic burn wounds with a latent period of more than 10 years received the ablative and reconstructive procedures by senior author (S.H. Woo) over 14 years between 1997 and 2010. Twenty-four cases were suspected as MU at the time of initial presentation. Data were retrieved from 24 patients’ medical records, photographs, and histopathological findings. Age and sex, mode of initial burn injury, site of lesion, tumor pathology, latency period, treatment modality, follow-up period, and prognosis were analyzed retrospectively. Data represented were expressed by mean ± standard deviation. Descriptive statistics were used and analyzed by SPSS v22.0 statistical program. RESULTS Of the 24 patients, 16 were male and eight were female, and the mean age at diagnosis was 47.9 ± 17.2 years. The latency period ranged from 10 to 66 years with an average of 31.6 ± 13.0 years between the initial burn injury and the time at which the diagnoses were made. The patients had only conservative treatments at home or by primary physicians after initial burn injuries. The majority of lesions developed in the extremities (87.5%); the lower limb was most frequently affected (79.1%; Table 1). Characteristic clinical manifestations were ulceration with elevated margin within burn scars. Purulent drainage with a foul odor was reported in 10 patients. Enlarged lymph nodes were palpated in three cases (12.5%) on initial physical examination. Regional lymphadenectomies revealed one case of metastatic SCC, and the remaining two cases were reactive hyperplasia. In the case of leiomyosarcoma, metastatic work up revealed multiple small lung nodules. Table 1. Detailed demography of chronic burn wounds suspected as Marjolin’s Ulcers Case No. Age/Sex Primary Cause (Burn) Site Lag Period (years) Final Diagnosis Treatment Modality Follow-Up (months) Prognosis 1 57/F Contact Sacrum 20 SCC Conservative LTF 2 32/F Flame Lt popliteal 26 SCC LMF + SG 129 NED 3 52/M Flame Rt popliteal 43 SCC LMF + SG 121 DOD 4 26/M Flame Back 19 CU SG 119 NED 5 57/M Scalding Rt post. thigh 50 PEH SG 112 NED 6 18/M Contact Scalp 14 iSCC FMF + SG, RT 97 DOD 7 67/M Flame Lt foot dorsum 10 SCC LMF + SG 95 Dead 8 60/M Scalding Rt antetibial 20 CU LMF + SG LTF 9 28/F Flame Rt heel 24 SCC FMF + SG LTF 10 84/F Flame Rt lat. thigh 20 PEH FMF + SG 75 NED 11 45/F Flame Lt popliteal 41 CU SG LTF 12 59/M Scalding Lt lat. thigh 32 CU Conservative LTF 13 33/M Flame Lt popliteal 26 PEH FMF + SG 50 NED 14 37/M Flame Lt heel 28 SCC FMF + SG 56 NED 15 39/M Flame Lt popliteal 34 SCC SG 36 NED 16 25/F Scalding Rt forearm 22 SCC SG 42 PD 17 62/M Scalding Rt ankle 42 SCC FMF +SG 16 NED 18 70/M Scalding Rt forearm 66 iSCC SG 17 NED 19 60/M Flame Rt antetibial 45 iSCC FMF + SG, RT 23 NED 20 44/M Flame Lt knee 40 PEH LMF + SG 31 NED 21 38/M Flame Lt antetibial 33 PEH FMF + SG 14 NED 22 73/M Scalding Lt plantar 45 iSCC Conservative 14 AWD 23 45/M Flame Rt distal lower leg 25 LMS FMF + SG, CT 11 AWD 24 38/M Flame Rt dist. lower leg 33 CU SG 12 NED Case No. Age/Sex Primary Cause (Burn) Site Lag Period (years) Final Diagnosis Treatment Modality Follow-Up (months) Prognosis 1 57/F Contact Sacrum 20 SCC Conservative LTF 2 32/F Flame Lt popliteal 26 SCC LMF + SG 129 NED 3 52/M Flame Rt popliteal 43 SCC LMF + SG 121 DOD 4 26/M Flame Back 19 CU SG 119 NED 5 57/M Scalding Rt post. thigh 50 PEH SG 112 NED 6 18/M Contact Scalp 14 iSCC FMF + SG, RT 97 DOD 7 67/M Flame Lt foot dorsum 10 SCC LMF + SG 95 Dead 8 60/M Scalding Rt antetibial 20 CU LMF + SG LTF 9 28/F Flame Rt heel 24 SCC FMF + SG LTF 10 84/F Flame Rt lat. thigh 20 PEH FMF + SG 75 NED 11 45/F Flame Lt popliteal 41 CU SG LTF 12 59/M Scalding Lt lat. thigh 32 CU Conservative LTF 13 33/M Flame Lt popliteal 26 PEH FMF + SG 50 NED 14 37/M Flame Lt heel 28 SCC FMF + SG 56 NED 15 39/M Flame Lt popliteal 34 SCC SG 36 NED 16 25/F Scalding Rt forearm 22 SCC SG 42 PD 17 62/M Scalding Rt ankle 42 SCC FMF +SG 16 NED 18 70/M Scalding Rt forearm 66 iSCC SG 17 NED 19 60/M Flame Rt antetibial 45 iSCC FMF + SG, RT 23 NED 20 44/M Flame Lt knee 40 PEH LMF + SG 31 NED 21 38/M Flame Lt antetibial 33 PEH FMF + SG 14 NED 22 73/M Scalding Lt plantar 45 iSCC Conservative 14 AWD 23 45/M Flame Rt distal lower leg 25 LMS FMF + SG, CT 11 AWD 24 38/M Flame Rt dist. lower leg 33 CU SG 12 NED AWD, alive with disease; CT, chemotherapy; CU, chronic ulcer; DOD, dead of disease; FMF, free muscle flap; iSCC, invasive squamous cell carcinoma; LMF, local muscle flap; LMS, leiomyosarcoma; LTF, lost to follow-up; NED, no evidence of disease; PD, progressive disease; PEH, pseudoepitheliomatous hyperplasia; RT, radiotherapy; SG, skin graft. View Large Table 1. Detailed demography of chronic burn wounds suspected as Marjolin’s Ulcers Case No. Age/Sex Primary Cause (Burn) Site Lag Period (years) Final Diagnosis Treatment Modality Follow-Up (months) Prognosis 1 57/F Contact Sacrum 20 SCC Conservative LTF 2 32/F Flame Lt popliteal 26 SCC LMF + SG 129 NED 3 52/M Flame Rt popliteal 43 SCC LMF + SG 121 DOD 4 26/M Flame Back 19 CU SG 119 NED 5 57/M Scalding Rt post. thigh 50 PEH SG 112 NED 6 18/M Contact Scalp 14 iSCC FMF + SG, RT 97 DOD 7 67/M Flame Lt foot dorsum 10 SCC LMF + SG 95 Dead 8 60/M Scalding Rt antetibial 20 CU LMF + SG LTF 9 28/F Flame Rt heel 24 SCC FMF + SG LTF 10 84/F Flame Rt lat. thigh 20 PEH FMF + SG 75 NED 11 45/F Flame Lt popliteal 41 CU SG LTF 12 59/M Scalding Lt lat. thigh 32 CU Conservative LTF 13 33/M Flame Lt popliteal 26 PEH FMF + SG 50 NED 14 37/M Flame Lt heel 28 SCC FMF + SG 56 NED 15 39/M Flame Lt popliteal 34 SCC SG 36 NED 16 25/F Scalding Rt forearm 22 SCC SG 42 PD 17 62/M Scalding Rt ankle 42 SCC FMF +SG 16 NED 18 70/M Scalding Rt forearm 66 iSCC SG 17 NED 19 60/M Flame Rt antetibial 45 iSCC FMF + SG, RT 23 NED 20 44/M Flame Lt knee 40 PEH LMF + SG 31 NED 21 38/M Flame Lt antetibial 33 PEH FMF + SG 14 NED 22 73/M Scalding Lt plantar 45 iSCC Conservative 14 AWD 23 45/M Flame Rt distal lower leg 25 LMS FMF + SG, CT 11 AWD 24 38/M Flame Rt dist. lower leg 33 CU SG 12 NED Case No. Age/Sex Primary Cause (Burn) Site Lag Period (years) Final Diagnosis Treatment Modality Follow-Up (months) Prognosis 1 57/F Contact Sacrum 20 SCC Conservative LTF 2 32/F Flame Lt popliteal 26 SCC LMF + SG 129 NED 3 52/M Flame Rt popliteal 43 SCC LMF + SG 121 DOD 4 26/M Flame Back 19 CU SG 119 NED 5 57/M Scalding Rt post. thigh 50 PEH SG 112 NED 6 18/M Contact Scalp 14 iSCC FMF + SG, RT 97 DOD 7 67/M Flame Lt foot dorsum 10 SCC LMF + SG 95 Dead 8 60/M Scalding Rt antetibial 20 CU LMF + SG LTF 9 28/F Flame Rt heel 24 SCC FMF + SG LTF 10 84/F Flame Rt lat. thigh 20 PEH FMF + SG 75 NED 11 45/F Flame Lt popliteal 41 CU SG LTF 12 59/M Scalding Lt lat. thigh 32 CU Conservative LTF 13 33/M Flame Lt popliteal 26 PEH FMF + SG 50 NED 14 37/M Flame Lt heel 28 SCC FMF + SG 56 NED 15 39/M Flame Lt popliteal 34 SCC SG 36 NED 16 25/F Scalding Rt forearm 22 SCC SG 42 PD 17 62/M Scalding Rt ankle 42 SCC FMF +SG 16 NED 18 70/M Scalding Rt forearm 66 iSCC SG 17 NED 19 60/M Flame Rt antetibial 45 iSCC FMF + SG, RT 23 NED 20 44/M Flame Lt knee 40 PEH LMF + SG 31 NED 21 38/M Flame Lt antetibial 33 PEH FMF + SG 14 NED 22 73/M Scalding Lt plantar 45 iSCC Conservative 14 AWD 23 45/M Flame Rt distal lower leg 25 LMS FMF + SG, CT 11 AWD 24 38/M Flame Rt dist. lower leg 33 CU SG 12 NED AWD, alive with disease; CT, chemotherapy; CU, chronic ulcer; DOD, dead of disease; FMF, free muscle flap; iSCC, invasive squamous cell carcinoma; LMF, local muscle flap; LMS, leiomyosarcoma; LTF, lost to follow-up; NED, no evidence of disease; PD, progressive disease; PEH, pseudoepitheliomatous hyperplasia; RT, radiotherapy; SG, skin graft. View Large Histological diagnosis were five cases of chronic ulcer (CU; 21%), five cases of pseudoepitheliomatous hyperplasia (PEH; 21%), and 14 cases of malignancy (58%); 13 were SCC and one was leiomyosarcoma. No significant differences in age and latency period were found between three pathologic groups (P > .05 by Kruskal–Wallis test). Five cases of CU were treated with excision and skin grafting or regional flap transposition, but one case required secondary grafting for two repeated wound recurrences. In the 14 cases of SCC and leiomyosarcoma, the mean neoplastic latency period was 31.7 ± 15.0 years. A safety margin of at least 2 cm of normal skin was initially planned and further resection was added in case of a positive margin on frozen biopsy. Initial depth was planned deep to the muscle fascia. Defects after wide excision were resurfaced with five free muscle flaps and three regional muscle transpositions. Conservative treatment and skin grafting were performed in five cases with patient refusal to take definitive measures or with severe comorbid morbidity. Recurrence developed in three patients. Five cases of PEH were treated the same as malignancy; a wide excision with a free margin and underlying muscle fascia were performed, and the defects were covered with surgical flaps. The skin graft had been performed in one case with severe comorbid morbidity. No recurrence was noted during the mean period of 56 months of follow-up. Three representative cases are described as follows. Case No. 21: PEH, No Recurrence After Excision and Free Tissue Transfer A 38-year-old woman had a depigmented pretibial scar with 5 × 3 cm, 10 × 11 cm-sized ulcers over her leg. At 5 years old, she suffered a flame burn on the left lower leg but had no definitive treatment aside from conservative measures. She underwent a scar excision, contracture release, and grafting procedure when she was at the age of 18. One year before her admission, she had ulcerative wounds at proximal and distal margins. Representative histological sections showed irregular epidermal hyperplasia projected into the dermis but confined within the basement membrane. Focal atypical epithelial cells were found. Immunohistochemical staining revealed positive p53, suggestive of PEH. Ulcers sized 10 × 6 cm and 14 × 12 cm, as well as the surrounding scar tissues, were excised. Immediate reconstruction was performed using combined latissimus dorsi and serratus anterior muscle free flap with skin graft. There have been no recurrences during 14 months of follow-up (Figure 1). Figure 1. View largeDownload slide A 38-year-old patient had suffered ulcerations in a burn scar of the left lower leg (A). After wide excision of two separate lesions, combined latissimus dorsi and serratus anterior muscle free flap with skin graft was used to reconstruct the defect (B). Pseudoepitheliomatous hyperplasia showed prominent acanthosis of epidermis and downward growth of epidermis and more mature mitotic figures than those observed in squamous cell carcinoma (hematoxylin & eosin stain, ×40 [C], ×100 [D]). Figure 1. View largeDownload slide A 38-year-old patient had suffered ulcerations in a burn scar of the left lower leg (A). After wide excision of two separate lesions, combined latissimus dorsi and serratus anterior muscle free flap with skin graft was used to reconstruct the defect (B). Pseudoepitheliomatous hyperplasia showed prominent acanthosis of epidermis and downward growth of epidermis and more mature mitotic figures than those observed in squamous cell carcinoma (hematoxylin & eosin stain, ×40 [C], ×100 [D]). Case No. 13: PEH, No Evidence of Disease After Excision and Free Tissue Transfer The patient was a 33-year-old man who had sustained a flame burn at 3 years of age on his left popliteal area, but he had not taken any steps toward its treatment. An ulcer arose and enlarged in the form of an ulcerovegetative mass over the past 4 years. The presumptive diagnosis was MU. Excision with a 2 cm safety margin and the underlying muscle fascia was performed and the defect was covered with a free latissimus dorsi muscle flap and split thickness graft. There have not been any recurrences during 50 months of follow-up (Figure 2). Figure 2. View largeDownload slide A 33-year-old man complained of a chronic ulcer in the burn scar of the left popliteal area (A). Latissimus dorsi myocutaneous free flap with skin graft was performed after wide excision (B). Pseudoepitheliomatous hyperplasia: higher magnification view showing reactive-appearing squamous down growth with no evidence of malignant cytologic features. The dermis shows mild chronic inflammation and granulation tissue formation (hematoxylin & eosin stain, ×40 [C], ×100 [D]). Figure 2. View largeDownload slide A 33-year-old man complained of a chronic ulcer in the burn scar of the left popliteal area (A). Latissimus dorsi myocutaneous free flap with skin graft was performed after wide excision (B). Pseudoepitheliomatous hyperplasia: higher magnification view showing reactive-appearing squamous down growth with no evidence of malignant cytologic features. The dermis shows mild chronic inflammation and granulation tissue formation (hematoxylin & eosin stain, ×40 [C], ×100 [D]). Case No. 6: SCC, Dead of Disease After Incomplete Removal and Free Tissue Transfer, Radiation Therapy An 18-year-old man suffered from a large nonhealing wound on his left parietal scalp. He sustained a briquette-contact burn to his face and scalp at the age of 1 year. Severe burn scars distorted his facial features with contracture. Simple roentgenogram and chemotherapy revealed a coin-like osteolytic lesion on the left parietal bone, but no brain parenchymal involvement. Incisional biopsy revealed invasive SCC. Removal of the parietal bone and dura was planned, but complete removal was impossible because of sagittal sinus involvement. The surgical defect was covered with a free latissimus dorsi muscle flap and skin graft and adjuvant radiation therapy of 4500 cGy was added. Six months after the operation, magnetic resonance imaging showed brain parenchymal infiltration. The patient underwent conservative treatments and died 6 months later. DISCUSSION MU is a rare but highly aggressive malignancy that can be prevented by proper treatment of the full-thickness skin defect at an acute stage. If an initially neglected or mismanaged burn wound presents later with ulceration or frequent wounding, secondary prevention with excision and resurfacing can be instituted before malignant transformation occurs.1,3,7 If we two chances pass without success, effective treatments for MU could be the last resort to address this aggressive malignancy. The mean neoplastic latency of our study was 31.7 ± 15.0 years, a period consistent with other reports.4,8,9 Extremities are the most common sites of MU due to their frequent involvement in burn injury and predisposition to activity-related repeated trauma.1,3,8–12 This preponderance was also noted in our cases; 19 cases (79.1%) were on the lower extremities and 10 of them were malignant. Heterotopic ossification (HO) is an infrequently encountered complication of a burn that can result in significantly compromised limb function. Time to wound closure significantly impacts the risk of development of HO.13 But conventional radiographs failed to confirm the clinical diagnosis of HO in our patients. PEH is a benign condition characterized by hyperplasia of the epidermis and the adnexal epithelium, closely simulating SCC.14 Histology shows elongated downward projections of the epidermis usually with jagged borders and a sharply pointed base.15 Another characteristic feature of PEH is the “keratin pearls,” concentric layers of unusual looking keratinocytes with a focus of central keratinization. The keratinocytes may show a minor degree of cytological atypia, mostly in the stratum basale, and keratinocyte necrosis is usually absent. Atypical cytology could be found at the keratinocytes in stratum basale but keratinocyte necrosis or atypical mitosis was not expected.14,16 It is difficult to distinguish PEH from SCC, but it is important to differentiate between them. The expression of p53 protein, immunohistochemical staining for intermediate filaments, and the levels of matrix metalloproteinases were used but their interpretations are not clear-cut.1,4,17–19 An experiment performed by Arons et al2 on rats suggested “a pattern of malignant change in trauma starting with acanthosis, proceeding through stages of basal cell hyperplasia and PEH with atypical basal cell changes, and finally ending with epidermoid carcinoma.” Moreover, progression from initial epidermal hyperplasia to an overt carcinoma can take place anywhere during ulceration and repetitive traumas.18 Although PEH is a benign condition by definition, a therapeutic approach should be contemplated as SCC when associated with a burn wound. Preoperative analyses and clinical workups failed to predict and differentiate between the three pathologic conditions beforehand. Radical excision is imperative for several reasons. Malignant transformation occurs mainly from the edges of the ulcers during healing by secondary intention,4,20 but the focal nature of the malignant change increases the risk of obtaining a false-negative diagnostic biopsy.1,11 The oncological clearance entails excision of the primary lesion with 2 to 4 cm horizontal safety margins and vertical clearance of the un-involved next barrier structure.3 Usually, fascial level debridement is the minimum requirement. Deep muscle involvement requires further excision up to the periosteal level and even involving cortical bone. Amputation of an extremity or even forequarter amputation can be considered in case of a lower probability to maintain function after massive bone and joint involvement or extensive local tissue invasion.1,7,11 Adequate reconstruction should be instituted after resection. Skin grafting after excision has been proposed for early detection of recurrence from the tumor bed,1,5,7,9 but is a rather less elastic covering; repeated ulceration and protracted regeneration could be induced within tense scars. Nowadays imaging studies provides reliable information to make up for the potential disadvantages of placing tissues on a potential tumor bed and the added hindrance of inspection and palpation.21 One-stage transfer of well-vascularized tissue with surgical flaps can provide more supple coverage to withstand continued injury over the joint or prominent area, as well as the defect over an artificial implant.5 Aggressive contracture release of the bone, joins, tendons, and soft tissue is required in the correction of severe post burn contractures, especially in hand deformities. Various flaps including fasciocutaneous free flap used to reconstruct the defect provide early motion, appropriate thinness, and excellent cosmesis.22 In addition, it can provide a stable platform on which adjuvant radiotherapy can be instituted. Preference for surgical flap coverage does not mean that excision and grafting cannot provide adequate ablation and reconstruction. On the other hand, the extent of ablation should not be confined by the reconstructive modalities chosen. Insufficient resection may result in impaired wound healing or lesion recurrence. Various attempts have been applied to improve outcomes but the effects of chemotherapy, radiotherapy, and prophylactic lymph node dissection are controversial.1 Sadek et al23 reported successful complete or partial remissions with cisplatin, 5-fluorouracil, and bleomycin but many studies cast doubt on the efficacy of cytotoxic chemotherapy.23,24 The suggested indications for radiotherapy are as follows: “1) inoperable regional lymph node metastasis; 2) grade 3 lesions with positive lymph nodes after nodal dissection; 3) tumors with a diameter greater than 10 cm and with positive lymph nodes after regional lymph node dissection; 4) grade 3 lesions with a tumor diameter greater than 10 cm and negative lymph nodes after regional lymph dissection; and 5) lesions of the head and neck with positive lymph nodes after regional lymph node dissection.”3,11 Several authors have suggested prophylactic lymph node dissection on the basis of histological tumor grade11 or the suitability of sentinel lymph node dissection.3 Prophylactic nodal treatment seems rational because of the aggressive biological behavior of MU; it has been recommended that regional lymph node dissection should be performed only in the clinically positive nodal basins1,5,8 or if lymph nodes are positive on fine needle aspiration histology.7,20 Das et al12 reported a prospective observational study of 140 patients with chronic burn scar ulcers. Forty-six patients (32.85%) were found to have malignancy, whereas four (2.85%) had PEH, one had verruca plantaris, and the remaining 89 (63.57%) had CUs. Our study was a retrospective analysis of the fate of chronic burn wounds suspected as MU at the time of initial presentation. Fifty six percentage of 24 patients underwent malignant changes, a higher figure than the prospective study of chronic burn scar ulceration. CONCLUSIONS In the retrospective study of 24 patients who underwent surgery with a clinical diagnosis of MU, malignancy including SCC represented 56% of cases. The mean latency period at diagnosis of malignancy was 31.7 years. PEH in chronic burn wound, which is difficult to distinguish from SCC and considered as a transitional state to malignant tumor, should be treated as malignancy. Radical excision should be performed to fulfill the objective of tumor eradication and reconstruction with free tissue transfer or regional flap transposition was superior to skin graft in providing adequate excision and stable coverage. REFERENCES 1. Phillips TJ , Salman SM , Bhawan J , Rogers GS . Burn scar carcinoma. Diagnosis and management . Dermatol Surg 1998 ; 24 : 561 – 5 . Google Scholar PubMed 2. Arons MS , Rodin AE , Lynch JB , Lewis SR , Blocker TG Jr . Scar tissue carcinoma: II. An experimental study with special reference to burn scar carcinoma . Ann Surg 1966 ; 163 : 445 – 60 . Google Scholar CrossRef Search ADS PubMed 3. Saaiq M , Ashraf B . Marjolin’s ulcers in the post-burned lesions and scars . World J Clin Cases 2014 ; 2 : 507 – 14 . Google Scholar CrossRef Search ADS PubMed 4. Kowal-Vern A , Criswell BK . Burn scar neoplasms: a literature review and statistical analysis . Burns 2005 ; 31 : 403 – 13 . Google Scholar CrossRef Search ADS PubMed 5. Copcu E . 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TI - The Fate of Chronic Burn Wounds Suspected as Marjolin’s Ulcers
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0000000000000564
DA - 2017-12-27
UR - https://www.deepdyve.com/lp/oxford-university-press/the-fate-of-chronic-burn-wounds-suspected-as-marjolin-s-ulcers-Qe7GbZnf08
SP - 1
EP - 153
VL - Advance Article
IS - 1
DP - DeepDyve
ER -