Marjolin's Ulcers: A Case Series and Literature Review
Marjolin's Ulcers: A Case Series and Literature Review
An 80 year old male presented with a 22 cm x 20 cm enlarged, painful flank ulcer with foul drainage (Figure 1a). There had been an ulcer present for more than 50 years within a skin-grafted area following a burn. Punch biopsies revealed invasive moderately well-differentiated squamous cell carcinoma. No distant metastases were demonstrated on CT scans of the chest, abdomen, and pelvis. The entire lesion was widely excised to at least the level of Scarpa's fascia. Centrally there was penetration deep to Scarpa's fascia noted on frozen sections necessitating further excision. The wound was packed and permanent sections demonstrated a small area of positive margin deep in the center that was part of the paraspinous muscle fascia. This was further resected, and after the permanent sections revealed no tumor, a 19 cm x 18 cm split-thickness skin graft was applied (Figure 1b).
(Enlarge Image)
Figure 1.
(A) Large fungating ulcer with area of unstable burn scar. Ulcer had been present intermittently for approximately 50 years. (B) Healed wound 2 months after wide excision and skin graft. (C) Recurrent tumor 3 months after excision.
Within 3 months, 2 fungating ulcerated masses were noted in the center of the grafted area (Figure 1c). An additional 15 cm x 10 cm excision was done that included part of the paraspinal muscles and the quadratus lumborum. Permanent pathology sections revealed negative margins but lymphovascular invasion was noted. A skin graft was applied and the wound healed. Irradiation (45 Gy) was administered locally but there was noted metastasis to the lung. The patient declined further therapy and died in hospice with progressive disease 4 months after excision of the recurrent Marjolin's ulcer.
A 61-year-old male presented with a nonhealing right leg wound (Figures 2a and 2b). Both legs were amputated above the knee in Vietnam secondary to injuries sustained in a helicopter crash. He did not wear prosthetics. Three years prior to his consultation he developed a wound on his right stump that did not heal with local wound care. On exam the wound was foul smelling with poor quality granulation tissue and an ulcer measuring 22 cm x 20 cm wide with central ulceration and exposed bone. An x-ray showed hypertrophic osteitis of the distal femur. There was an additional 6 cm diameter area of unstable scar posteriorly within a skin-grafted area. As he did not wear a prosthesis, amputation higher on the proximal femur was recommended to include the ulcer and the unstable scar. During the operation, approximately 10 cm of femur was resected with the ulceration and the stump was covered with muscle and thigh skin or skin graft.
(Enlarge Image)
Figure 2.
(A,B) Chronic wound of 3 years duration arising in area of unstable split-thickness skin graft. Squamous cell carcinoma was present throughout the ulcer.
Pathology revealed squamous cell carcinoma with clear margins but extension of the tumor to within 6 mm of the margin in one area. Computed tomography and positron emission tomography (PET) scans were obtained. These showed a solitary lymph node with positive uptake. The patient underwent percutaneous lymph node biopsy. Cytopathology demonstrated the node was positive for squamous cell carcinoma. The tumor board recommended irradiation and not lymphadenectomy. Irradiation (60 Gy) was administered to the right inguinal and iliac nodes. Repeat PET demonstrated persistent uptake in the right inguinal and external iliac basin. A plastic surgery consultation recommended therapeutic lymph node dissection but this was not done. Thirty weeks postoperatively, magnetic resonance imaging (MRI) and PET scans showed likely recurrence at the stump as well as persistent inguinal and iliac adenopathy. The patient later died from metastatic disease.
A 50-year-old male, who was paraplegic secondary to a car accident 20 years earlier, presented with a foul-smelling sacral ulcer. He had a previous successful flap closure of a sacral pressure ulcer. The ulcer in the present case measured 25 cm x 18 cm and had been present for nearly 2 years, but had increased in size dramatically in the previous year. Gross infection and necrotic material was present. The granulation tissue appeared unusually friable and exophytic in some areas and partially eroded sacral cortex was palpable. The patient underwent wide local debridement and partial sacrum resection and closure with bilateral rotational flaps. Several areas of the deep margin on permanent section revealed keratinizing squamous cell carcinoma.
Within 2 weeks of surgery wound breakdown and partial necrosis of the flap occurred. A CT scan showed extensive erosion of the sacrum. The patient was then taken back to the operating room for debridement (Figure 3a and 3b). The sacrum was completely necrotic and was excised, as was a portion of the left ilium. The wound was left open pending review of the final pathology report, which again revealed tumors at both the bone and deep soft tissue margins. Further workup showed widely metastatic disease, and the patient died a few months later.
(Enlarge Image)
Figure 3.
(A) Necrotic, friable ulcer overlying the sacrum. (B) Computerized tomography scan showing erosion of sacrum.
Materials and Methods
Case 1
An 80 year old male presented with a 22 cm x 20 cm enlarged, painful flank ulcer with foul drainage (Figure 1a). There had been an ulcer present for more than 50 years within a skin-grafted area following a burn. Punch biopsies revealed invasive moderately well-differentiated squamous cell carcinoma. No distant metastases were demonstrated on CT scans of the chest, abdomen, and pelvis. The entire lesion was widely excised to at least the level of Scarpa's fascia. Centrally there was penetration deep to Scarpa's fascia noted on frozen sections necessitating further excision. The wound was packed and permanent sections demonstrated a small area of positive margin deep in the center that was part of the paraspinous muscle fascia. This was further resected, and after the permanent sections revealed no tumor, a 19 cm x 18 cm split-thickness skin graft was applied (Figure 1b).
(Enlarge Image)
Figure 1.
(A) Large fungating ulcer with area of unstable burn scar. Ulcer had been present intermittently for approximately 50 years. (B) Healed wound 2 months after wide excision and skin graft. (C) Recurrent tumor 3 months after excision.
Within 3 months, 2 fungating ulcerated masses were noted in the center of the grafted area (Figure 1c). An additional 15 cm x 10 cm excision was done that included part of the paraspinal muscles and the quadratus lumborum. Permanent pathology sections revealed negative margins but lymphovascular invasion was noted. A skin graft was applied and the wound healed. Irradiation (45 Gy) was administered locally but there was noted metastasis to the lung. The patient declined further therapy and died in hospice with progressive disease 4 months after excision of the recurrent Marjolin's ulcer.
Case 2
A 61-year-old male presented with a nonhealing right leg wound (Figures 2a and 2b). Both legs were amputated above the knee in Vietnam secondary to injuries sustained in a helicopter crash. He did not wear prosthetics. Three years prior to his consultation he developed a wound on his right stump that did not heal with local wound care. On exam the wound was foul smelling with poor quality granulation tissue and an ulcer measuring 22 cm x 20 cm wide with central ulceration and exposed bone. An x-ray showed hypertrophic osteitis of the distal femur. There was an additional 6 cm diameter area of unstable scar posteriorly within a skin-grafted area. As he did not wear a prosthesis, amputation higher on the proximal femur was recommended to include the ulcer and the unstable scar. During the operation, approximately 10 cm of femur was resected with the ulceration and the stump was covered with muscle and thigh skin or skin graft.
(Enlarge Image)
Figure 2.
(A,B) Chronic wound of 3 years duration arising in area of unstable split-thickness skin graft. Squamous cell carcinoma was present throughout the ulcer.
Pathology revealed squamous cell carcinoma with clear margins but extension of the tumor to within 6 mm of the margin in one area. Computed tomography and positron emission tomography (PET) scans were obtained. These showed a solitary lymph node with positive uptake. The patient underwent percutaneous lymph node biopsy. Cytopathology demonstrated the node was positive for squamous cell carcinoma. The tumor board recommended irradiation and not lymphadenectomy. Irradiation (60 Gy) was administered to the right inguinal and iliac nodes. Repeat PET demonstrated persistent uptake in the right inguinal and external iliac basin. A plastic surgery consultation recommended therapeutic lymph node dissection but this was not done. Thirty weeks postoperatively, magnetic resonance imaging (MRI) and PET scans showed likely recurrence at the stump as well as persistent inguinal and iliac adenopathy. The patient later died from metastatic disease.
Case 3
A 50-year-old male, who was paraplegic secondary to a car accident 20 years earlier, presented with a foul-smelling sacral ulcer. He had a previous successful flap closure of a sacral pressure ulcer. The ulcer in the present case measured 25 cm x 18 cm and had been present for nearly 2 years, but had increased in size dramatically in the previous year. Gross infection and necrotic material was present. The granulation tissue appeared unusually friable and exophytic in some areas and partially eroded sacral cortex was palpable. The patient underwent wide local debridement and partial sacrum resection and closure with bilateral rotational flaps. Several areas of the deep margin on permanent section revealed keratinizing squamous cell carcinoma.
Within 2 weeks of surgery wound breakdown and partial necrosis of the flap occurred. A CT scan showed extensive erosion of the sacrum. The patient was then taken back to the operating room for debridement (Figure 3a and 3b). The sacrum was completely necrotic and was excised, as was a portion of the left ilium. The wound was left open pending review of the final pathology report, which again revealed tumors at both the bone and deep soft tissue margins. Further workup showed widely metastatic disease, and the patient died a few months later.
(Enlarge Image)
Figure 3.
(A) Necrotic, friable ulcer overlying the sacrum. (B) Computerized tomography scan showing erosion of sacrum.