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Image of the Month—Diagnosis

Image of the Month—Diagnosis Answer: Marjolin Ulcer Clinical suspicion led to an incisional biopsy, the specimen of which demonstrated a verrucous squamous cell carcinoma. Inguinal lymph nodes were not palpable. The patient was taken to the operating room for wide local excision and skin grafting. Further histopathologic examination of the excised lesion revealed a moderately differentiated squamous cell carcinoma measuring 11 × 6.5 cm with a depth of 15 mm and clear excisional margins. The patient made an uneventful recovery. The patient was closely followed up and at 15 months remained free of recurrence. Marjolin ulcer is a malignant change in a long-standing ulcer and/or scar tissue. Commonly, these lesions are treated as chronic ulcers or infections, leading to delayed diagnosis and resulting in the need for more extensive surgery and increased risk of metastasis.1Suspicion of malignant change should be raised with crusting, ulceration of scar tissue, increase in pain or size of the ulcer, and bleeding.2 Marjolin ulcers have a 1% to 2% incidence in all burns but can also develop from previously traumatized and scarred tissue of other etiologies.3The malignant transformation has no predilection for race but is more predominant in the late 50s, with a typical lag time after injury of 20 to 40 years.4 Malignant transformation presents as squamous cell carcinoma in 75% to 96% of the cases. Other neoplasms, such as basal cell carcinomas, melanoma, osteogenic sarcoma, fibrosarcoma, and liposarcoma, have been reported.5,6Grades of differentiation vary and are described as well differentiated (35%), moderately differentiated (55%), and poorly differentiated (10%).7 The exact pathophysiologic mechanism is unknown, although many plausible theories have been postulated. The consensus is that a cancerous environment is formed by the lack of blood supply and decreased immunity in the scar tissue. The epithelium is destroyed by repeated local trauma, healing with increased difficulty each time. The regenerated epithelium is progressively inferior and the persistent stimulation to the marginal epithelium may lead to a loss of tissue restraint and neoplastic changes.8 Malignant ulcers can present as flat with indurated elevated margins or as exophytic (less frequent).6Biopsy of the central area as well as the margin is indicated for diagnosis. The best treatment is to prevent the malignant transformation by skin grafting full-thickness burns, addressing wound infections early, and excising chronic ulcers.9Once a Marjolin ulcer is diagnosed, a wide local excision with excisional margins of at least 2 cm, including muscle fascia, is indicated. Amputation is considered when there is erosion into a large vessel, deep lesions that extend into joint cavities and bone, gangrene, unsatisfactory functional result, or involvement of major nerves. Lymph node dissection is controversial, because some authors advocate sentinel lymph node biopsy or dissection in all cases, and others indicate it when palpable nodes are present or the tumor is high grade.3,10Adjuvant radiation and/or chemotherapy may be indicated in cases where unresectable tumors are present or if the patient refuses surgery.11 Long-term follow-up is recommended in all cases. Survival rates are reported as 52%, 34%, and 23%, respectively, at 5, 10, and 20 years.10Regional lymph node invasion is the most important prognostic indicator. There is a high risk of metastasis to the brain, liver, kidney, and lungs, with a doubled risk in lesions found in the lower extremities.7This report highlights the possibility of malignant change in a chronic wound and the importance of prevention, early identification, and treatment. Correspondence:Francisco J. Agullo, MD, Department of Surgery, Texas Tech University Heath Sciences Center, 4800 Alberta Ave, El Paso, TX 79905-2709 (francisco.agullo@ttuhsc.edu). Accepted for Publication:November 14, 2005. Author Contributions:Study concept and design: Agullo, Santillan, and Miller. Acquisition of data: Miller. Analysis and interpretation of data: Agullo. Drafting of the manuscript: Agullo, Santillan, and Miller. Critical revision of the manuscript for important intellectual content: Agullo, Santillan, and Miller. Administrative, technical, and material support: Agullo, Santillan, and Miller. Study supervision: Agullo, Santillan, and Miller. Financial Disclosure:None reported. References 1. Fishman JRParker MG Malignancy and chronic wounds: Marjolin's ulcer. J Burn Care Rehabil 1991;12218- 223PubMedGoogle ScholarCrossref 2. Thio DClarson JHWMisra A et al. Malignant change after 18 months in a lower limb ulcer: acute Marjolin's revisited. Br J Plast Surg 2003;56825- 828PubMedGoogle ScholarCrossref 3. Fleming MDHunt JLPurdue GF et al. Marjolin's ulcer: a review and reevaluation of a difficult problem. J Burn Care Rehabil 1990;11460- 469PubMedGoogle ScholarCrossref 4. Sabin SRGoldstein GRosenthal HG Aggressive squamous cell carcinoma originating as a Marjolin's ulcer. Dermatol Surg 2004;30229- 230PubMedGoogle ScholarCrossref 5. Novick MGard DAHardy SB Burn scar carcinoma: a review and analysis of 46 cases. J Trauma 1977;17809- 817PubMedGoogle ScholarCrossref 6. Dupree MTBoyer JDCobb MW Marjolin's ulcer arising in a burn scar. Cutis 1998;6249- 51PubMedGoogle Scholar 7. Ozek CCelik N Marjolin's ulcer of the scalp: report of 5 cases and review of the literature. J Burn Care Rehabil 2001;2265- 69PubMedGoogle ScholarCrossref 8. Copcu EAktas ASismant N et al. Thirty-one cases of Marjolin's ulcer. Clin Exp Dermatol 2003;28138- 141PubMedGoogle ScholarCrossref 9. Love RLBreidahl AF Acute squamous cell carcinoma arising within a recent burn scar in a 14-year-old boy. Plast Reconstr Surg 2000;1061069- 1071PubMedGoogle ScholarCrossref 10. Edwards MJHirsch RM Squamous cell carcinoma arising in previously burned or irradiated skin. Arch Surg 1989;124115- 117PubMedGoogle ScholarCrossref 11. Aydogdu EYildirim SAkoz T Is surgery an effective and adequate treatment in advanced Marjolin's ulcer? Burns 2005;31421- 431PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Image of the Month—Diagnosis

Archives of Surgery , Volume 141 (11) – Nov 1, 2006

Image of the Month—Diagnosis

Abstract

Answer: Marjolin Ulcer Clinical suspicion led to an incisional biopsy, the specimen of which demonstrated a verrucous squamous cell carcinoma. Inguinal lymph nodes were not palpable. The patient was taken to the operating room for wide local excision and skin grafting. Further histopathologic examination of the excised lesion revealed a moderately differentiated squamous cell carcinoma measuring 11 × 6.5 cm with a depth of 15 mm and clear excisional margins. The patient made an...
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Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.141.11.1144
Publisher site
See Article on Publisher Site

Abstract

Answer: Marjolin Ulcer Clinical suspicion led to an incisional biopsy, the specimen of which demonstrated a verrucous squamous cell carcinoma. Inguinal lymph nodes were not palpable. The patient was taken to the operating room for wide local excision and skin grafting. Further histopathologic examination of the excised lesion revealed a moderately differentiated squamous cell carcinoma measuring 11 × 6.5 cm with a depth of 15 mm and clear excisional margins. The patient made an uneventful recovery. The patient was closely followed up and at 15 months remained free of recurrence. Marjolin ulcer is a malignant change in a long-standing ulcer and/or scar tissue. Commonly, these lesions are treated as chronic ulcers or infections, leading to delayed diagnosis and resulting in the need for more extensive surgery and increased risk of metastasis.1Suspicion of malignant change should be raised with crusting, ulceration of scar tissue, increase in pain or size of the ulcer, and bleeding.2 Marjolin ulcers have a 1% to 2% incidence in all burns but can also develop from previously traumatized and scarred tissue of other etiologies.3The malignant transformation has no predilection for race but is more predominant in the late 50s, with a typical lag time after injury of 20 to 40 years.4 Malignant transformation presents as squamous cell carcinoma in 75% to 96% of the cases. Other neoplasms, such as basal cell carcinomas, melanoma, osteogenic sarcoma, fibrosarcoma, and liposarcoma, have been reported.5,6Grades of differentiation vary and are described as well differentiated (35%), moderately differentiated (55%), and poorly differentiated (10%).7 The exact pathophysiologic mechanism is unknown, although many plausible theories have been postulated. The consensus is that a cancerous environment is formed by the lack of blood supply and decreased immunity in the scar tissue. The epithelium is destroyed by repeated local trauma, healing with increased difficulty each time. The regenerated epithelium is progressively inferior and the persistent stimulation to the marginal epithelium may lead to a loss of tissue restraint and neoplastic changes.8 Malignant ulcers can present as flat with indurated elevated margins or as exophytic (less frequent).6Biopsy of the central area as well as the margin is indicated for diagnosis. The best treatment is to prevent the malignant transformation by skin grafting full-thickness burns, addressing wound infections early, and excising chronic ulcers.9Once a Marjolin ulcer is diagnosed, a wide local excision with excisional margins of at least 2 cm, including muscle fascia, is indicated. Amputation is considered when there is erosion into a large vessel, deep lesions that extend into joint cavities and bone, gangrene, unsatisfactory functional result, or involvement of major nerves. Lymph node dissection is controversial, because some authors advocate sentinel lymph node biopsy or dissection in all cases, and others indicate it when palpable nodes are present or the tumor is high grade.3,10Adjuvant radiation and/or chemotherapy may be indicated in cases where unresectable tumors are present or if the patient refuses surgery.11 Long-term follow-up is recommended in all cases. Survival rates are reported as 52%, 34%, and 23%, respectively, at 5, 10, and 20 years.10Regional lymph node invasion is the most important prognostic indicator. There is a high risk of metastasis to the brain, liver, kidney, and lungs, with a doubled risk in lesions found in the lower extremities.7This report highlights the possibility of malignant change in a chronic wound and the importance of prevention, early identification, and treatment. Correspondence:Francisco J. Agullo, MD, Department of Surgery, Texas Tech University Heath Sciences Center, 4800 Alberta Ave, El Paso, TX 79905-2709 (francisco.agullo@ttuhsc.edu). Accepted for Publication:November 14, 2005. Author Contributions:Study concept and design: Agullo, Santillan, and Miller. Acquisition of data: Miller. Analysis and interpretation of data: Agullo. Drafting of the manuscript: Agullo, Santillan, and Miller. Critical revision of the manuscript for important intellectual content: Agullo, Santillan, and Miller. Administrative, technical, and material support: Agullo, Santillan, and Miller. Study supervision: Agullo, Santillan, and Miller. Financial Disclosure:None reported. References 1. Fishman JRParker MG Malignancy and chronic wounds: Marjolin's ulcer. J Burn Care Rehabil 1991;12218- 223PubMedGoogle ScholarCrossref 2. Thio DClarson JHWMisra A et al. Malignant change after 18 months in a lower limb ulcer: acute Marjolin's revisited. Br J Plast Surg 2003;56825- 828PubMedGoogle ScholarCrossref 3. Fleming MDHunt JLPurdue GF et al. Marjolin's ulcer: a review and reevaluation of a difficult problem. J Burn Care Rehabil 1990;11460- 469PubMedGoogle ScholarCrossref 4. Sabin SRGoldstein GRosenthal HG Aggressive squamous cell carcinoma originating as a Marjolin's ulcer. Dermatol Surg 2004;30229- 230PubMedGoogle ScholarCrossref 5. Novick MGard DAHardy SB Burn scar carcinoma: a review and analysis of 46 cases. J Trauma 1977;17809- 817PubMedGoogle ScholarCrossref 6. Dupree MTBoyer JDCobb MW Marjolin's ulcer arising in a burn scar. Cutis 1998;6249- 51PubMedGoogle Scholar 7. Ozek CCelik N Marjolin's ulcer of the scalp: report of 5 cases and review of the literature. J Burn Care Rehabil 2001;2265- 69PubMedGoogle ScholarCrossref 8. Copcu EAktas ASismant N et al. Thirty-one cases of Marjolin's ulcer. Clin Exp Dermatol 2003;28138- 141PubMedGoogle ScholarCrossref 9. Love RLBreidahl AF Acute squamous cell carcinoma arising within a recent burn scar in a 14-year-old boy. Plast Reconstr Surg 2000;1061069- 1071PubMedGoogle ScholarCrossref 10. Edwards MJHirsch RM Squamous cell carcinoma arising in previously burned or irradiated skin. Arch Surg 1989;124115- 117PubMedGoogle ScholarCrossref 11. Aydogdu EYildirim SAkoz T Is surgery an effective and adequate treatment in advanced Marjolin's ulcer? Burns 2005;31421- 431PubMedGoogle ScholarCrossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Nov 1, 2006

Keywords: surgical procedures, operative,cicatrix,malignant transformation

References

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