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: 2.99). 08/2009; 124(1):156e-64e. DOI: 10.1097/PRS.0b013e3181a8082e
Source: PubMed


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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    • "A wide excision is used for the treatment of Marjolin's ulcer and chemical anti-cancer treatment or radiation treatment accompanies it when it is necessary. However, regardless of active treatment, it is known to present a high proportion of recurrence and bad prognosis compared with other kinds of skin cancer [4]. Therefore, in regards to Marjolin's ulcer, it is important to quickly identify the signs of recurrence of carcinoma after surgical removal to improve the prognosis. "
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    ABSTRACT: Marjolin's ulcer is known to present a high proportion of recurrence and poor prognosis compared to other kinds of skin cancer. Based on our experience, Marjolin's ulcer patients who have received reconstructive surgery present a higher proportion of recurrence when there was disturbed wound healing after surgery. The impact of disturbed wound healing after surgery on the prognosis was examined in this study. A retrospective study was carried out on 26 patients who were diagnosed with Marjolin's ulcer and received surgery in this hospital from 1996 to 2011. Histologic grading, lymph node metastasis at diagnosis, and the wound healing process were evaluated and chi-squared analysis applied in order to determine the correlation with recurrence. The proportion of recurrence increases in patients with a low histologic grade or lymph node metastasis at diagnosis. The proportion of recurrence is even higher when the problem occurs during the wound healing process after surgery. Disturbed wound healing after surgery could be used as a sign to quickly identify the recurrence of carcinoma. Therefore, in the event a problem occurs in the wound healing process after surgery, one should keep in mind that this could be a sign of the possibility of recurrence and proceed with careful observation and active diagnosis through additional physical examinations, general X-ray tests, computed tomographys, magnetic resonance imagings, and so on, to obtain an early diagnosis of recurrence.
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