Marjolin's ulcer explained

Marjolin's ulcer refers to an aggressive ulcerating squamous cell carcinoma presenting in an area of previously traumatized,^[1] chronically inflamed,^[2] or scarred skin.^{[3] [4]} They are commonly present in the context of chronic wounds including burn injuries, varicose veins, venous ulcers,^[5] ulcers from osteomyelitis,^[6] and post radiotherapy scars.

The term was named after French surgeon, Jean-Nicolas Marjolin, who first described the condition in 1828.^[7] The term was later coined by J C De Costa.

Presentation

Slow growth, painlessness (as the ulcer is usually not associated with nerve tissue), and absence of lymphatic spread due to local destruction of lymphatic channels.^[8]

Histology

Histologically, the tumour is a well-differentiated squamous cell carcinoma. This carcinoma is aggressive in nature, spreads locally and is associated with a poor prognosis.^[7] The cancer has a 18-38% rate of metastasis.^[9] 40% occur on the lower limb and the malignant change is usually painless. This malignant change of the wound happens a long time after initial trauma, usually 10–25 years later. Its edge is everted and not always raised. More recent transcriptional analysis suggests that chronically impeded extracellular matrix turnover and epithelium-to-mesenchyme transitions in neglected scar tissue might give rise to this malignancy.^[10]

Diagnosis

Wedge biopsy is the favored method of diagnosis. Tissue specimens obtained should be taken from both the centre and margin of lesion, as the central ulcerated deposits may be necrotic.

Treatment

Treatment is usually surgical, with a wide excision of the lesion; typically a 1 cm margin all around is required.

See also

• Saree cancer

Notes and References

1. Esther RJ, Lamps L, Schwartz HS . Marjolin ulcers: secondary carcinomas in chronic wounds . J South Orthop Assoc . 8 . 3 . 181–7 . 1999 . 12132863 .
2. Simmons MA, Edwards JM, Nigam A . Marjolin's ulcer presenting in the neck . J Laryngol Otol . 114 . 12 . 980–2 . December 2000 . 11177375 . 10.1258/0022215001904545. 40966501 .
3. Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. .
4. Phillips TJ, Salman SM, Bhawan J, Rogers GS . Burn scar carcinoma. Diagnosis and management . Dermatol Surg . 24 . 5 . 561–5 . May 1998 . 9598012 . 10.1016/S1076-0512(98)00022-3.
5. Book: Varicose Veins and Related Disorders. 9781483193762. Tibbs. David J.. 2013-10-22.
6. Smidt LS, Smidt LF, Chedid MB, Bavaresco CS, Chedid MF . Radical surgical treatment for Marjolin ulcer occurring after chronic osteomyelitis . South. Med. J. . 98 . 10 . 1053 . October 2005 . 16295826 . 10.1097/01.smj.0000182509.78816.7b.
7. Chong AJ, Klein MB . Images in clinical medicine. Marjolin's ulcer . N. Engl. J. Med. . 352 . 10 . e9 . March 2005 . 15758002 . 10.1056/NEJMicm040020 .
8. Paredes F . [Marjölin ulcer] . pt . Acta Med Port . 11 . 2 . 185–7 . February 1998 . 9567417 .
9. Motley, T., White, K. and Clyde, J. (2014). Squamous cell carcinoma of the foot: A case report. The Foot and Ankle Online Journal, 7(2): 2. http://faoj.org/2014/06/30/squamous-cell-carcinoma-of-the-foot-a-case-report/
10. Sinha S, Su S, Workentine M, Agabalyan N, Cheng M, Gabriel V, Biernaskie J . Transcriptional Analysis Reveals Evidence of Chronically Impeded ECM Turnover and Epithelium-to-Mesenchyme Transition in Scar Tissue Giving Rise to Marjolin's Ulcer . J Burn Care Res . 38 . 1 . e14–e22 . January 2017 . 10.1097/BCR.0000000000000432. 27679957. 3702018 .