Marjolin's ulcers: theories, prognostic factors and their peculiarities in spina bifida patients

Unresectable squamous cell carcinoma in a patient with spina bifida

Spina bifida is a congenital malformation of foetal neural structures which may present as a skin fold or sac containing cerebrospinal fluid and neural structures with a variety of neurological deficits. Surgical repairs of spina bifida may not ensure complete functions, neural improvement or recovery. We present this palliative report of an adult male in his early 40s with a medical history of meningocele repair in his infancy, with long-standing Marjolin ulcers, fractures, contractures, diverting ileostomy and urostomy and a fungating mass externally measuring 33×25 cm. The mass involved the buttocks, perineum and scrotum with a tumour overlying the meningocele and extending into the thigh through an internally draining tract. Factors such as immobility, pressure injuries and poor social support in the setting of chronic disability led to a conservative approach in the management of this unresectable carcinoma.

Marjolin's ulcer in an ischial pressure sore presented with necrotizing soft tissue infection: A case report

RATIONALE

Marjolin's ulcer (MU) is a rare skin malignancy derived from a chronic wound. Pressure ulcer related MU possesses poor prognosis and high metastatic rate, and it is difficult to be differentiated, especially when superimposed infection.

PATIENT CONCERNS

Here we report a case with pressure ulcer related MU which presented as necrotizing soft tissue infection (NSTI) to demonstrate the manifestation, treatment, and prognosis of this rare disease.

DIAGNOSES

A 45-year-old male patient had spinal cord injury at age 2 years. He presented ischial pressure sore complicated with NSTI initially. After serial debridements and antibiotic treatment, the infection subsided. For the persistent verruca-like skin lesion, he underwent wide excision which revealed well-differentiated squamous cell carcinoma. Further image studies showed localized residual tumor without distant metastasis.

INTERVENTIONS

He then underwent hip disarticulation and anterior thigh fillet flap reconstruction. Local recurrence developed 3 months later, and re-wide excision and inguinal lymph node dissection were performed. No lymph node metastasis was noted and adjuvant radiotherapy was given.

OUTCOMES

He was followed for 34 months and no recurrence or metastasis was found. The patient can move with a wheelchair or a hip prosthesis, and is partially dependent for daily activities.

LESSONS

MU can masquerade as NSTI and one should be alert to its malignant potential. Due to its aggressive nature, limb sacrifice can be considered in circumstances of profound involvement. As for the reconstruction method, pedicled fillet flap provided good wound coverage.

Post-Traumatic Sarcomas: Do They Exist?

Patients often cite a history of trauma prior to the diagnosis of a sarcoma. Sparse literature suggests that there may be a link between sarcoma development and trauma. A 10-year review of academic tertiary-referral sarcoma center database was examined to identify patients who developed a sarcoma after having a history of a significant musculoskeletal trauma. A total of 501 patients were treated for a sarcoma during this time period. Six patients were identified as previously having a significant musculoskeletal trauma at the site of sarcoma development. Half of the sarcomas arose in bone and the other half in soft tissue. Five (83%) patients had multiple operations for the injury with 3 (50%) patients having a postoperative wound infection. The average time from injury to development of the sarcoma was 19.8 years. Survival after diagnosis was poor, and 4 (67%) of the patients died due to their metastatic disease within 3 years of diagnosis. Our findings suggest the possibility of post-traumatic sarcomas.

Clinical features and treatment of 140 cases of Marjolin's ulcer at a major burn center in southwest China

Marjolin's ulcer is a type of malignant tumor that occurs in scar tissue. The present study aimed to summarize and analyze the aetiology, clinical characteristics, treatment methods, metastasis and prognosis of this disease. A total of 140 cases of Marjolin's ulcer encountered at the Institute of Burn Research, Southwest Hospital (Chongqing, China) between January 2013 and December 2017 were retrospectively analyzed. Demographic data, clinical characteristics, occurrence of bone invasion and lymph node metastasis, as well as treatment and prognosis were statistically analyzed. Among the 140 patients, the initial injury or primary disease occurred at 1–75 years of age, while Marjolin's ulcer occurred at 15–85 years of age (mean, 53.3±1.2 years). The mean latency period was 28.8±1.7 years. The most common initial injury of the patients was flame burns, followed by skin masses, trauma, skin ulcerations caused by repeated scratching/friction, and scalding. The age at onset of initial injury or disease in patients had a significantly negative correlation with the latency period (P<0.01). The most common lesion locations were the lower limbs (42.1%), followed by the head, face and neck (34.5%). Of the 140 patients, 46 cases (32.9%) had bone invasion, 33 cases (23.6%) had lymph node enlargement and only 5 cases (3.6%) had lymph node metastasis. The skull was the bone that was most susceptible to Marjolin's ulcer invasion. The prevalence of bone invasion in patients with head, face and neck lesions was significantly higher than that in patients with lesions in other locations (P<0.01). The surgical methods applied were skin grafting, local flap repair, amputation and island flap repair. In the 65 cases who underwent follow-up, recurrence mainly occurred within 1 year after surgery. In conclusion, Marjolin's ulcer mainly occurred in males and was a scar carcinoma after a flame burn in most cases. Autologous skin grafting and local skin flap repair were the major repair methods. The peak period of recurrence was within one year after surgery and patients should receive regular follow-ups.

Comprehensive Analysis of Long Noncoding RNAs and Messenger RNAs Expression Profiles in Patients with Marjolin Ulcer

Background

Marjolin ulcer (MU) is an aggressive cutaneous malignancy. Typically, MU occurs over a period of time in post-burn and/or post-traumatic lesions and scars. However, the pathogenesis of scar carcinogenesis and MU development remains to be elucidated. The present study aimed to investigate the long noncoding RNA (lncRNA) and messenger RNA (mRNA) expression profiling in MU, which could provide new information on the potential molecular mechanisms of MU development.

Material/Methods

The lncRNA microarray analysis was conducted in normal skin, scar, and MU tissue, and quantitative real-time PCR experiment was carried out to validate the reliability of the microarray data. Furthermore, a series of integrative bioinformatic approaches were applied to decipher the function of differentially expressed lncRNAs.

Results

A total of 7130 lncRNAs and 9867 mRNAs were differentially expressed among normal skin, scar, and MU tissues. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway analysis demonstrated that these aberrantly expressed transcripts were mainly involved in cell cycle, immune response, and the p53 signaling pathway. Series Test of Cluster analysis indicated certain dysregulated lncRNAs were expressed with a gradually increasing or decreasing trend and might participated in malignant transformation of scar tissue postburn. Co-expression analysis showed 5 selected lncRNAs might regulate cell proliferation through the p53 signaling pathway. Finally, the competing endogenous RNA (ceRNA) network indicated that lncRNA uc001oou.3 might be implicated in ceRNA mechanism during MU development.

Conclusions

Taken together, our study implied the aberrant expression of lncRNAs may play an important role in the pathogenesis and development of MU, and the exact mechanism warrants further investigation.

Would Marjolin see it coming? Two unusual cases of squamous cell carcinoma

•

Aggressive behavior of SCC in young patients is uncommon.

•

Diagnosed a year after first signs of the lesion; One previously diagnosed as an abscess, the other as necrotizing fasciitis.

•

These delayed diagnoses might be a contributing factor to the tumor aggressiveness.

•

Hence, a tissue diagnosis is necessary to rule out malignancy in chronic lesions, taking Marjolin’s ulcer into account.

Introduction

Cutaneous squamous cell carcinoma (SCC) is a common skin cancer, second in incidence only to basal cell carcinoma (BCC). The incidence of SCC increases significantly with age; thus, it is rarely diagnosed in young patients. In this paper, we present two cases of young patients who presented clinically with purulent lesions that were later diagnosed as large primary SCCs.

Materials and methods

A review of the medical records of two patients who were admitted to the department of plastic surgery with a final clinical diagnosis of cutaneous SCC was conducted. Information of the review included history, physical examination, laboratory tests, imaging studies and histology. A literature review was also conducted and discussed.

Results

Two female patients under the age of 45 presented with large, purulent lesions that were initially clinically suggestive of an infectious etiology. The lesions were surgically treated by incision and drainage without sending tissue samples to pathology. Biopsies of the lesions were performed to obtain a tissue diagnosis due to recurrence approximately one year after the initial treatment. Histological evaluation revealed well differentiated squamous cell carcinomas. Surgical intervention with wide excision with adjuvant chemotherapy was recommended based on biopsy and CT scan results.

Discussion

Aggressive behavior of SCC in young patients is uncommon. The patients in this report were diagnosed only one year after the first sign of the lesion. One patient was first diagnosed with an abscess, and the other with necrotizing fasciitis. The delayed diagnosis of SCC in these two patients is a potential contributing factor to the aggressiveness of the tumors. Therefore, it is imperative to perform skin biopsies of chronic or persistent purulent lesions to rule out malignancies including Marjolin’s ulcer.

Conclusion

Aggressive SCC should be suspected in cases of persistent and relapsing purulent lesions in all patients.

Marjolin's ulcer in chronic wounds - review of available literature

Marjolin's ulcer is a rare, aggressive skin cancer developing in scar tissue, chronic ulcers and areas affected by inflammations. Its incidence is estimated to range from 1% to 2% of all burn scars. It most frequently takes the form of squamous cell carcinoma which sometimes is diagnosed during examination of lesions developing in scars and hard-to-heal chronic wounds (pressure sores, leg ulcers). Therapeutic management of Marjolin's ulcer requires well-designed treatment plan to ensure optimal medical care and good quality of life for the patient. The high risk of metastases and damage to the structure of vitally important organs determines the need for early diagnosis and prompt surgical intervention with supplementary therapy. The purpose of the study was to examine etiopathogenesis of Marjolin's ulcer and principles of its treatment. The authors focused on the aspect of malignant degeneration in chronic wounds (leg ulcers, pressure sores) as a very rare, aggressive form of Marjolin's ulcer. A review of the available literature on the issue of Marjolin ulcers was conducted using the key words; Marjolin ulcers, pressure sore, chronic wound. Malignant degeneration in chronic wounds is a very rare aggressive form of Marjolin ulcer. Increased oncological alertness should be displayed by nursing and medical personnel taking care of patients with chronic wounds.

Acute Marjolin's Ulcer in a Postauricular Scar after Mastoidectomy

Background. Marjolin's ulcer is a rare, aggressive cutaneous malignancy that arises primarily in burn scars but can occur in other types of scars. Squamous cell carcinoma is the most common variant, and while malignant degeneration usually takes a long time, it can develop acutely. Case Report. a 30-year-old man who developed Marjolin's ulcer acutely in a right postauricular scar after mastoidectomy and the incision and drainage of a mastoid abscess. To the best of our knowledge, this report is the first to describe a Marjolin's ulcer in a postauricular surgical scar. However, it has been reported in others areas in the head and neck. Conclusion. Marjolin's ulcer is most commonly observed after postburn scars, but it may be observed after any type of scars, as our patient developed an SCC with a postsurgical scar. Early diagnosis is essential, and a biopsy should be performed on any nonhealing wound or chronic wound that undergoes a sudden change. Tissue samples should be taken from both the centre and the margins of the wound.

Glasses: Hiding or causing skin cancer?

This article evaluates malignant transformation of lesions presenting in the periocular skin under the eye spectacle nose pad. A non-comparative retrospective chart review of clinical features and pathological findings of patients presenting with periocular malignancies in the exact vicinity where the nose pads of their eye spectacles rested was completed. The study took place in one tertiary oculoplastic referral center between 2007-2013. Ten patients were included, six of whom were male. All subjects wore eye spectacles while awake for at least 15 years, and had an evident suspicious lesion in the exact area that coincided with the resting place of the nose pad. The mean age was 73.5 years (range 65-85 years) and all patients had the lesion present for at least one year. Most cases were squamous skin malignancies (five squamous cell carcinomas [SCC], 2 intra-epidermal carcinomas [IEC], while 3 basal cell carcinomas [BCC]). Treatment involved surgical excision of the lesion with frozen section for margin control and reconstruction with a myocutaneous flap. Periocular malignancies of the inferior medial canthal area, where the nose pad of eye spectacle places pressure, can be easily missed or misdiagnosed. Marjolin ulcers (MU) classically present as an aggressive SCC in area of chronic inflammation, which has been previously correlated to constant pressure, repetitive trauma, or non-healing wounds in other areas of the body. We propose that the traumatic chronic pressure in the infero-medial canthal region from long-term eye spectacle nose pad use, may induce poor lymphatic regeneration leading to an immune system deficiency that predisposes this skin to a malignant transformation. The presence of chronic eye spectacle nose pads also prevents proper and timely detection of such malignancies. Complete excision of these lesions with margin control, adequate follow-up for possible recurrence, and surveillance for new lesions on the patient's contralateral side, is crucial for adequate management.

From Wheelchair to Cane: Elective Transtibial Amputations in a Patient with Spina Bifida

Spina bifida is associated with foot deformities, which may lead to foot ulcers, osteomyelitis, and limb amputation. Calcanectomy and Symes amputations have been reported successful in spina bifida. There is lack of evidence for transtibial amputations. This case describes a 27-yr-old woman with L4 level spina bifida who underwent bilateral transtibial amputations. She ambulated with bilateral ankle foot orthoses and canes until age 22. At age 22, she had bilateral foot reconstructive surgeries complicated by nonunion, ulcerations, and osteomyelitis. She was using a wheelchair by age 25. She had elective bilateral transtibial amputations at age 27 for progressive osteomyelitis. Four weeks after amputations, she was fit with bilateral prostheses. On completion of 2 mos of rehabilitation, she ambulated with a cane. This case demonstrates good functional outcomes after transtibial amputations in a young spina bifida patient. Prosthetic fitting should be considered for similar, previously high functioning spina bifida patients with transtibial amputation(s).

A Retrospective Study of Marjolin's Ulcer Over an Eleven Year Period

Background:

Marjolin's ulcer is a rare aggressive cutaneous malignancy occurring in previously occurred wounds. The most common aetiology is a burn wound involving extremities and squamous cell carcinoma is the most common variant.

Materials and Methods:

A retrospective analyses of medical records of patients treated in a single unit with a diagnosis of Marjolin's ulcer was performed.

Results:

During the study period, 14 patients were treated. Four patients had lymph node metastases and one had pulmonary metastases at the time of presentation. Seven patients underwent wide excision with reconstruction and seven underwent amputation or disarticulation because of advanced malignancy. During the follow up two patients developed local recurrence and one developed pulmonary metastases. Both the patients with pulmonary metastases had Marjolin's ulcer of trunk.

Conclusion:

Marjolin's ulcer occurs more commonly in the extremities. Distant metastases occur commonly in patients with ulcers on the of trunk.

Palliative reconstructive surgery: contextualizing palliation in resource-poor settings

Introduction. Palliative care in Kenya and the larger Sub-Saharan Africa is considered a preserve of hospices, where these exist. Surgical training does not arm the surgeon with the skills needed to deal with the care of palliative patients. Resource constraints demand that the surgeon be multidiscipline trained so as to be able to adequately address the needs of a growing population of patients that could benefit from surgical palliation. Patients and Methods. The author describes his experience in the management of a series of 31 palliative care patients, aged 8 to 82 years. There were a total of nine known or presumed mortalities in the first year following surgery; 17 patients experienced an improved quality of life for at least 6 months after surgery. Fourteen of these were disease-free at 6 months. Conclusion. Palliative reconstructive surgery is indicated in a select number of patients. Although cure is not the primary intent of palliative surgery, the potential benefits of an improved quality of life and the possibility of cure should encourage a more proactive role for the surgeon. The need for palliative care can be expected to increase significantly in Africa, with the estimated fourfold increase of cancer patients over the next 50 years.

Marjolin's ulcer: a preventable malignancy arising from scars

BACKGROUND

Marjolin's ulcer (MU) is a rare malignancy arising from various forms of scars. This potentially fatal complication typically occurs after a certain latency period. This article attempts to reveal the importance of the latency period in the prevention and early treatment of the malignancy.

METHODS

A retrospective review of 17 MU patients who underwent surgical procedures between June of 2005 and December 2011 was conducted. Etiology of injuries, latency period, repeated ulceration, and outcomes were recorded. This observational report reveals characteristics of patients who develop MU.

RESULTS

An incidence of 0.7% of MU was found amongst patients complaining of existing scars in our study; burns and trauma were the most common etiology of MU. The mean latency period was 29 years (SD = 19) and the mean post-ulceration period was 7 years (SD = 9). Statistical analysis revealed a negative correlation between the age of patients at injury and the length of latency period (r = -0.8, P <0.01), as well as the lengths of pre-ulceration and post-ulceration periods (r = -0.7, P <0.01).

CONCLUSIONS

Patients experience different lengths of pre- and post-ulceration periods during the latency period. Younger patients tend to have a longer latency period. Skin breakdown on chronic scars and chronic unhealed ulcers are two main sources of MU. MU may be preventable with a close surveillance of the ulcer during the latency period.

Melanoma arising in chronic ulceration associated with lymphoedema

Chronic ulceration can be complicated by development of a malignancy. The most frequent associated malignances are squamous cell carcinoma and basal cell carcinoma, although melanoma, leiomyosarcoma and adenocarcinoma are less commonly seen. Chronic lymphoedema may also predispose to development of some malignancies, including lymphangiosarcoma, squamous cell carcinoma and Kaposi's sarcoma. Here, we report the case of a 77-year-old man with primary lymphoedema, who developed melanoma in a chronic foot ulcer of 60 years' duration. The patient underwent wide excision for the melanoma, and remains free from metastases at 1-year follow up.

Marjolin's ulcers at a university teaching hospital in Northwestern Tanzania: a retrospective review of 56 cases

Background

Marjolin's ulcer is a rare but highly aggressive squamous cell cancer that is most often associated with chronic burn wounds. Although many individual case reports exist, no comprehensive evaluation of Marjolin's ulcer patients has been conducted in our setting. This study was conducted to describe the clinicopathological presentation and treatment outcome of this condition in our local setting and to identify predictors of outcome.

Methods

This was a retrospective study of histologically confirmed cases of Marjolin's ulcer seen at Bugando Medical Centre over a period of 10-years between January 2001 and December 2010. Data were retrieved from patients' files and analyzed using SPSS computer software version 15.0

Results

A total of 56 patients were studied. Male to female ratio was 2.1:1. Burn scars (89.3%) were the most common causative lesions of Marjolin's ulcer. The mean latent period between original injury and diagnosis of Marjolin's ulcer was 11.34 ± 6.14 years. Only 12.0% of the reported cases were grafted at the time of injury (P < 0.00). Most patients (48.2%) presented between one and five years of onset of illness. The lower limb (42.9%) was the most frequent site for Marjolin's ulcers. The median tumor size at presentation was 8 cm and the vast majority of patients (85.7%) presented with large tumors of ≥ 5 cm in diameter. Lymph node metastasis at the time of diagnosis was recorded in 32.1% of cases and distant metastasis accounted for 26.9% of cases. Squamous cell carcinoma (91.1%) was the most common histopathological type. Wide local excision was the most common surgical procedure performed in 80.8% of cases. Post-operative complication rate was 32.1% of which surgical site infection was the most common complication in 38.9% of patients. Local recurrence was noted in 33.3% of cases who were treated surgically. The mean length of hospital stay for in-patients was 7.9 ± 2.3 days. Mortality rate was 7.1%. According to multivariate logistic regression analysis, stage and grade of the tumor and presence of local recurrence were the main predictors of death (P < 0.001).

Conclusion

Marjolin's ulcers are not rare in our environment and commonly occur in burn scars that were not skin grafted and were left to heal secondarily. A high index of suspicion is required in the management of chronic non-healing ulcers and all suspected lesions should be biopsed. Early recognition and aggressive treatment of Marjolin's ulcers and close follow-up are urgently needed to improve outcomes in our environment.

Squamous cell carcinoma (Marjolin's ulcer) in an orocutaneous fistula of a large mandibular ameloblastoma: a case report

Introduction

Ameloblastomas are rare lesions constituting 1% of all jaw tumors. Oral squamous cell carcinomas are common lesions; these constitute about 90% of all oral cancers. Concurrent tumors consisting of ameloblastoma and squamous cell carcinoma are extremely rare.

Case presentation

This case report describes a 35-year-old African man who presented with a large mandibular tumor with an orocutaneous fistula that was found to be an ameloblastoma on histopathological examination, with concurrent squamous cell carcinoma histology within the fistula. This presentation was consistent with a Marjolin's ulcer within an ameloblastoma.

Conclusion

Ameloblastomas and Marjolin's ulcers require different management strategies. Careful histopathological examination of surgical specimens is key to patient outcome, as treatment of these patients depends on an accurate diagnosis.