Discussion: Marjolin ulcer was first described as malignant tumor forming over burn injuries by DaCosta [1]. Marjolin ulcer is now known as a tumor arising from chronic wounds and ulcers, with an incidence of 1.3% to 2.2%. The incidence rate is dependent on the chronicity of the pre-existing lesion. The mean latency period for the development of Marjolin ulcer is approximately 40 years; however, a few cases have been reported up to 65 years [2]. Patients tend to have late presentations in developing countries, so the incidence is increasing in these countries [3]. Malignant transformation is explained by chronic irritation, traumatic epithelial element implantation, heredity, immunologic privileged site, co-carcinogen, ultraviolet rays, initiation and promotion, and environmental and genetic interaction [4]. However, there is no exact causation factor for malignant transformation. Some believe that there is traumatic displacement of living epithelial tissue into the dermis, leading to a foreign body response and deranged regenerative process, ultimately resulting in carcinoma [5]. Squamous cell carcinoma is the most common histological type; however, basal cell carcinomas, melanomas, and sarcomas may also be found [6]. The gold standard for the diagnosis of Marjolin ulcer is biopsy and should be performed in any suspicious lesions that have not healed in three months[7,8]. Squamous cell carcinomas are mostly associated with regional lymph node metastasis [9,10]; however, in our case, regional lymph nodes were not palpable, and ultrasonography showed no features of inguinal and popliteal lymphadenopathy\sout . Distant metastasis mostly occurs in the lungs, liver, and bone tissues [10, 11]. Wide local excision, lymph node evaluation, and examination for distant metastasis should be addressed for squamous cell carcinoma [12]. Different treatment modalities have been advocated; however, we practice wide local excision, block dissection of the regional nodes, amputation in advanced lesions of limbs, radiotherapy, and chemotherapy given either as neo or adjuvant therapy depending upon the case [13]. The necessity for amputation in pseudo-epitheliomatous involving lower extremity field hyperplasia treatment was put forward by Johnson and Kempson [14]. Regional lymph node dissection is indicated when nodes are clinically palpable in squamous cell carcinoma, but for malignant melanoma, sentinel lymph node biopsy should be performed regardless of the presence of enlarged lymph nodes [15]. Lesions on the face, scalp, hands, feet, areolae, and other areas where improved cosmesis is desired can be managed with Mohs surgery [16,17]. For advanced-stage disease when wide local excision and Mohs surgery are not possible, amputation is the mainstay of treatment [18]. Patients with poor prognostic factors or distant metastasis are managed with radiotherapy and chemotherapy in the form of four courses of (Methotrexate, Bleomycin, and Cisplatinum)[19,20]. \sout Conclusion: Chronic wounds or ulcers rarely undergo malignant transformation\sout . Squamous cell carcinoma is the most common histological variant and can have local as well as distant metastasis. Wide local excision with regional lymph node assessment and distant metastasis work\sout up is advocated for squamous cell carcinoma. Amputation, as in our case, is indicated when wide local excision or Mohs surgery could not be done. Chemotherapy and radiotherapy are indicated for patients with poor prognostic factors and advanced disease with distant metastasis
Consent Statement:
Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.
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