Radical Surgical Treatment for Marjolin Ulcer Occurring after Chronic Osteomyelitis

Post-burn scar malignancy: 5-year management review and experience

The study spotlights a severe uncommon post‐burn complication, Marjolin's ulcer, in upper Egypt plastic and wound care centres. This problem is mainly related to inadequate medical care and awareness. No community or race is immune. The underlying malignant transformation mechanism remains unclear. The study aims, according to our experience, to review the prognostic factors through the management protocol of Marjolin's ulcers. This prospective study was conducted in the Aswan University Plastic & Burn surgery department in South Egypt between 2013 and 2020 and investigated 226 patients with chronic post‐burn ulceration. Nineteen cases were proved to have Marjolin's ulcer, and the other cases that had been excluded from being malignant went for reconstruction with split‐thickness skin graft with/without flap after adequate ulcer debridement. The surgical, oncologic, radiologic indications, and prognostic factors were reviewed according to our management outcome—the assessment with follow‐up period extended over 5 years. Histopathology of ulcers ranged among mild, moderate, and poorly differentiated squamous cell carcinoma. One scalp ulcer case showed basosquamous pathology. Most cases presented at age above 50, but no age was immune. The mean latent period was 29 years on average. The lesions' sites varied in their anatomic location where they involved the upper extremity, the scalp, and the lower extremity that had a predilection. Although surgical excision is the primary management line for tumour ablation, other factors may change the management course. During the follow‐up period, neoplasm recurrence in the form of lymph node enlargement and/or locoregional metastasis was detected in eight cases. Within 1 year after the intervention, six recurrent cases died, and two were saved. In addition to the case study, this paper reviewed the literature and provided our team a good experience in light of the NCCN protocol for non‐melanotic cutaneous carcinoma, although we suffered limited medical resources. It is concluded that early accurate diagnosis, low‐grade malignancy, and well‐planned individualised surgery with adjuvant radiotherapy were the best prognostic factors. The close follow‐up for an early sign of disease recurrence is paramount.

Characteristics of Marjolin's Ulcers in 21st Century: A Retrospective Study, Systematic Review, and Surgical Guideline Recommendation

Marjolin's ulcer is rare and aggressive malignancy. The objective was to conduct a review of Marjolin's ulcer cases to gain a better understanding and its management. A retrospective study of patients with Marjolin's ulcers at our hospital between 2010 and 2019 was conducted. For the systematic review, the electronic database of the National Library of Medicine was searched and articles published between 2000 and 2019 were included. A total of 14 patients were included in the retrospective study. Twelve patients were male. The mean age was 59.71 years. The latency period was 27.78 years. The most common malignancy was squamous cell carcinoma, and 71.43% had developed on the lower extremities. Well-differentiated squamous cell carcinomas occurred in 38.46% of the cases Rates of lymphovascular and perineural invasion were 30.77 and 23.08%, respectively. Results from the literature search yielded 80 case reports (91 cases) and 42 retrospective reviews (1216 cases). Most cases were male and the most common location was lower extremities. The latency period for the acute and chronic periods was 2.75 months and 20.75 years, respectively. The most common malignancy was squamous cell carcinoma (92.27% in the retrospective reviews) and 59.98% of the cases exhibited well-differentiation. Rates of regional lymph node involvement and distant metastases were 10.20 and 12.09%, respectively. Marjolin's ulcer in 21st century is not so rare. The most common is well differentiated squamous cell carcinoma. Early flap surgery or skin grafts for chronic ulcers or burn scars are recommended to reduce risk. Guideline for surgical management is established.

Clinical characteristics, treatment, and prognosis of squamous cell carcinoma arising from extremity chronic osteomyelitis: a synthesis analysis of one hundred and seventy six reported cases

PURPOSE

Squamous cell carcinoma (SCC) arising from extremity chronic osteomyelitis (COM) has not been well-understood due to its low prevalence. This study aimed to synthesize the cases recently published to clarify their clinical characteristics, treatment, and prognosis.

METHODS

PubMed, Embase, and Cochrane Library databases were searched for English literature reporting cases diagnosed of SCC originating from extremity COM between January 1, 1990, and September 30, 2019. The National Institutes of Health (NIH) assessment tool was used to evaluate the quality of reports included, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to summarize the quality of available evidence. The data synthesized for analysis were clinical features, treatment strategy, and incidences of local recurrence, metastasis, all-cause, and SCC-related deaths. In addition, potential factors that might have influenced treatment efficacy and prognosis of SCC were also investigated.

RESULTS

Included for this analysis were 60 studies of 176 patients (a male-to-female ratio of 6.7). COM mostly occurred following trauma (73%), the tibia was the most frequent site (61%), and a sinus tract was the most common symptom (61%). The mean duration from COM to SCC was 27 years. Positive rate of pathogen culture was 90%, with 73% being polymicrobial. Limb amputation was performed in 80.5% of the patients. Incidences of local recurrence, metastasis after treatment, all-cause, and SCC-related mortalities were 16.7%, 12%, 31.1%, and 12.6%, respectively. Patients with local lymphadenopathy at diagnosis had significantly higher risks of local recurrence (P = 0.01), SCC-related (P = 0.02), and all-cause deaths (P = 0.01) than those without. Patients with moderately-to-poorly differentiated SCC types had significantly higher risks of local recurrence (P = 0.01) and all-cause death (P = 0.02) than those with a well-differentiated type.

CONCLUSIONS

SCC arising from extremity COM favoured males and the tibia. Although limb amputation was the mainstay of treatment, the overall incidences of local recurrence, metastasis, and SCC-related death exceeded 10%. Patients with local lymphadenopathy at diagnosis of SCC and those with moderately-to-poorly differentiated SCC types should be followed up closely.

TRIAL REGISTRATION

CRD42020154221.

Malignant transformation in chronic osteomyelitis: recognition and principles of management

Malignant transformation as a result of chronic osteomyelitis represents a relatively rare and late complication with a declining incidence in the modern world. For most patients, the interval between the occurrence of the original bacterial infection and the transformation to malignant degeneration is several years. The diagnosis of malignant transformation in a chronic discharging sinus requires a high index of clinical suspicion. Wound biopsies should be obtained early, especially with the onset of new clinical signs such as increased pain, a foul smell, and changes in wound drainage. Squamous cell carcinoma is the most common presenting malignancy. Definitive treatment is amputation proximal to the tumor or wide local excision, combined with adjuvant chemotherapy and radiation therapy in selected patients. Early diagnosis may sometimes allow for treatment consisting of en bloc excision and limb salvage techniques. However, the most effective treatment is prevention with definitive treatment of the osteomyelitis, including adequate débridement, wide excision of the affected area, and early reconstruction.

Concomitant acute osteomyelitis and squamous cell carcinoma of the foot: a case report

Squamous cell carcinoma of the foot is a common malignant neoplasm with a high potential for metastasis. Squamous cell carcinoma arising in chronic osteomyelitis has been widely reported; however, its presence in combination with acute osteomyelitis of the foot is not well known. This article presents such a case that demonstrates the importance of early recognition with appropriate management for limb salvage and successful oncologic outcome.

Ulcère de Marjolin sur ostéite chronique

PURPOSE OF THE STUDY

Malignant degeneration of chronic wound inflammation is a rare complication which almost always develops late. Unstable wounds and scar tissue related to chronic osteitis can degenerate after a long period of chronic inflammation. We report seven cases.

CASE REPORTS

Seven patients presented squamous-cell carcinoma of the skin which had developed on wounds related to deep bone infections. Three patients had chronic bone infections subsequent to posttraumatic osteitis, two after hematogenous osteomyelitis, one after osteitis which developed on a zone of radiation-induced necrosis, and one after a deep burn was complicated by osteitis. The skin lesions developed over a period of 43 years on average before the diagnosis of malignant degeneration was established. Most of the lesions presented as budding malodorous ulcers. The pathological diagnosis was spinocellular squamous-cell carcinoma in five cases and verrucous squamous-cell carcinoma in two. Conservative treatment with wide resection and flap cover was attempted in all seven patients.

RESULTS

Treatment failed in four patients and three required amputation. One patient died two years after amputation with local recurrence and metastatic dissemination to the brain.

DISCUSSION

The diagnosis of malignant degeneration requires pathological proof. Biopsy material should be obtained whenever there is a modification leading to the development of a fistula or the formation of a scar tissue over a focus of chronic osteitis. Prevention requires adapted treatment of chronic bone infections, avoiding directed wound healing which can lead to fragile unstable scar tissue subject to degeneration.