The term "Marjolin ulcer" has traditionally been used to refer to a squamous cell carcinoma that originated from a chronic ulcer or burn (Xiang, Song, & Huang, 2019). However, histopathological analyses of multiple specimens have shown that although originating from squamous cell carcinomas in 80%-90% of cases, Marjolin ulcers may also originate from basal cell carcinomas, melanomas, dermatofibrosarcomas, mucoepidermoid carcinomas, and leiomyosarcomas (Onesti, Fino, Fioramonti, Amorosi, & Scuderi, 2015). Consequently, the current definition of Marjolin ulcer includes all types of malignant tumors transforming to ulcers, scars, or chronic injuries (Das, Chakaraborty, Rahman, & Khandkar, 2015).
CASE REPORT
We report the case of a 92-year-old woman presenting with hypertrophic granulation tissue on her right arm. The tissue had developed over the past 3 months in an area that had been burned 85 years ago. The woman's deep partial-thickness burn had been treated by secondary-intention healing, with acceptable aesthetic and functional results.
Initially, the patient had consulted her primary care physician about an ulcer that appeared in the center of the burn scar. The ulcer was managed conservatively with hydrophilic silver dressings, but no epithelialization was achieved. The woman was referred to our Plastic Surgery Department because of continued slow growth of the ulcer. Physical examination revealed a 14 x 8-cm area of exophytic granulation tissue on the burn scar (i.e., tumor tissue that grows outward beyond the surface epithelium from which it originated; Figure 1). Malignant transformation of the tissue was suspected.
Magnetic resonance imaging showed subcutaneous tissue infiltration of the tumor and direct contact with the deep brachial fascia without obvious infiltration. No lymph node or distant metastases were found.
Total excision of the lesion and deep fascia was performed. Histological analysis of the specimen confirmed the diagnosis of squamous cell carcinoma (Figure 2), and microscopic examination verified the resection margins were tumor free. The postoperative recovery period was uneventful. After 2 years of follow-up, the patient did not show signs of local recurrence or metastatic disease.
DISCUSSION
To avoid delay in diagnosis and uncontrolled growth of the lesion, it is critically important for plastic surgeons and nurses to consider the possibility of malignant transformation of chronic wounds, especially in the case of an old acute injury with no history of wound trauma. Burns are the most common type of wounds leading to the development of Marjolin ulcers, particularly burn wounds that have been allowed to heal by secondary intention (Elkins-Williams, Marston, & Hultman, 2017).
In most cases, Marjolin ulcers are well-differentiated lesions but they are also aggressive with a poor prognosis and a high rate of recurrence. Metastases are found in up to 27% of patients. Notably, this is much greater than the 3% incidence of metastasis seen in patients with ordinary squamous cell carcinomas (Copcu, 2009). Therefore, any questionable, chronic, nonhealing, or ulcerative lesion should be biopsied to confirm or eliminate the diagnosis of Marjolin ulcer (Castanares, 1961).
Other clinical signs include the formation of exophytic granulation tissue, bleeding, and regional lymphadenopathy (Saaiq & Ashraf, 2014). The patient's lymph nodes should be examined in all suspicious cases (Elkins-Williams et al., 2017).
There is no standard protocol for managing Marjolin ulcers; however, excision with histological examination of surgical margins is the most widely accepted treatment of nonmetastatic cases. To prevent recurrences due to micrometastases, some plastic surgeons recommend complete excision of both scar and tumor (Xiao et al., 2019). However, there is a lack of strong evidence to support this recommendation; therefore, the decision to perform preventive scar and tumor resection must be determined on the basis of the individual patient. In our experience, excision of the lesion and ensuring clear surgical margins provided successful and definitive treatment without causing additional morbidity.
CONCLUSION
The term "Marjolin ulcer" refers to malignant transformations of ulcers, scars, and chronic injuries. Infrequent presentations, such as exophytic granulation tissue within a burn scar, should be evaluated as a potential Marjolin ulcer. It is important for plastic surgeons and nurses to maintain a high level of suspicion and promptly biopsy the questionable lesion so that malignancy can be ruled out and the least aggressive surgery can be performed before the disease spreads systemically.
REFERENCES