Marjolin's Ulcer: A Preventable Complication of Burns?

Plastic, Reconstructive, and Aesthetic Surgery Department, Medical Faculty, Adnan Menderes University, Aydin, Turkey.
Plastic and Reconstructive Surgery (Impact Factor: 3.33). 08/2009; 124(1):156e-64e. DOI: 10.1097/PRS.0b013e3181a8082e
Source: PubMed

ABSTRACT LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Discuss the clinical features of Marjolin's ulcer. 2. Identify the risk factors for the development of Marjolin's ulcer. 3. Develop a surgical management plan for the treatment of Marjolin's ulcer. SUMMARY: Marjolin's ulcer is a rare and aggressive cutaneous malignancy that arises on previously traumatized and chronically inflamed skin, especially after burns. This clinical condition was first described by Marjolin in 1828. The term "Marjolin's ulcer" has been generally accepted to refer to a long-term malignant complication of the scars resulting from burns. However, vaccination, snake bites, osteomyelitis, pilonidal abscesses, pressure sores, and venous stasis may also induce this tumor. Clinically, reports suggest that atrophic and unstable scars tend to develop into cancer. Various etiological factors have been implicated in the condition, including toxins released from damaged tissues, immunologic factors, cocarcinogens, and miscellaneous factors such as irritation, poor lymphatic regeneration, antibodies, mutations, and local toxins. The incidence of burn scars undergoing malignant transformation has been reported to be 0.77 to 2 percent. All parts of the body can be affected, but the extremities and the scalp are most frequently affected. There are two variants: acute and chronic. In the former, the carcinoma occurs within 1 year of the injury. The chronic form is more frequent and malignancy tends to develop slowly, with an average time to malignant transformation of 35 years. Although many different cell types can be seen in these lesions, the major histological type is squamous cell carcinoma. Marjolin's ulcers are generally considered as very aggressive tumors with a higher rate of regional metastases; radical excision is the treatment of choice, but there is no consensus on lymph node dissection. Marjolin's ulcer can be insidious and often leads to a poor prognosis, and deaths from Marjolin's ulcer are not uncommon. Meticulous wound care is a crucial step in prevention of these lesions.

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    ABSTRACT: Marjolin's ulcer (MU) represents malignant degeneration that typically ensues over a period of time in the post-burned lesions and scars or any other chronic wound. This review highlights various facets of the presentation and management of MUs that originate from post-burned lesions. The incidence of MUs in such lesions is reported to be 0.77%-2%. This malignancy characteristically develops in the areas of full thickness skin burns that had been allowed for weeks to months to heal spontaneously by secondary intention, or burn wounds which never healed completely over years and the unstable post-burned scars. In the majority of cases, the MU is a squamous cell carcinoma (SCC). The MUs contribute to an overall 2% of all SCCs and 0.03% of all basal cell carcinomas of the skin. Clinically MUs present in two major morphologic forms. The commoner form is the flat, indurated, ulcerative variety while the less common form is the exophytic papillary variety. Lower limbs represent the most frequently affected body parts. Surgical resection of the primary tumor with 2-4 cm horizontal clearance margin, nodal clearance and radiotherapy constitute the cornerstones of effective oncologic management. Despite best efforts, the overall mortality is reported to be 21%.
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