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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