When Malignant Degeneration Occurs With Chronic Wounds

Chronic wounds of the lower extremity are all too common. Despite our best efforts, some wounds take months or even years to heal fully. In refractory or unusual cases, one should not rule out malignancy.

Although rare, malignant degeneration can occur with chronic wounds. These wounds are called Marjolin’s ulcers after the French anatomist and surgeon Jean-Nicolas Marjolin. Marjolin’s ulcer is a highly virulent, malignant skin lesion that develops in a chronic ulcer or scar that has been misdiagnosed as benign.¹ Neoplastic transformation most often occurs in burn scars, traumatic scars, venous stasis ulcers, osteomyelitis and pressure sores.^1,2

The overall incidence of Marjolin’s ulcer is low with only 1.7 to 2 percent of all chronic ulcers undergoing malignant degeneration.^3,4 Marjolin’s ulcers occur three times more frequently in men than women, and typically arise within the fifth decade of life.^4,5 These ulcers may be visible anywhere throughout the body but tend to affect the limbs 85 percent of the time.¹ A markedly worse prognosis is associated with lesions found on the lower extremity and trunk in comparison to those on the upper extremity, head or neck.⁵

Squamous cell carcinoma is most commonly visible upon biopsy of these wounds with Marjolin’s ulcers accounting for 2 to 5 percent of all squamous cell carcinoma cases.¹ Basal cell carcinoma may also be present in Marjolin’s ulcers but it is less common.¹ One should consider Marjolin’s ulcers to be malignant. The five-year survival rate is 30 percent.⁶ These lesions are aggressive in nature with the local recurrence rate and the metastatic potential being high.^1,5 Authors have documented spread to regional lymph nodes.⁷ A retrospective study by Combemale and colleagues identified 80 patients with 85 leg ulcer tumors.⁷ Of the 85 tumors, 88 percent were of venous origin. The study authors found the overall death rate was 32 percent, which increased to 66 percent when lymph nodes were involved. Twenty-nine of the patient in the study had to undergo a leg amputation.

The exact pathogenesis of malignant degeneration is unknown although it is likely related to longstanding inflammation and irritation of the affected area.⁵

Early diagnosis of Marjolin’s ulcers is critical.⁵ One should consider obtaining a biopsy for any wound that demonstrates an increase in size, increased bleeding, increased pain, a change in color or texture, or failure to respond to standard intervention. Biopsy technique may include single or multiple punch biopsies, or excisional biopsy when possible.⁶

The treatment of choice for a Marjolin’s ulcer is wide surgical excision and obtaining 2 cm clear margins.¹ Skin grafting may or may not be required depending on the size to the ulcer. The treating physician should examine regional lymph nodes for lymphadenopathy. In the presence of lymphadenopathy, one should make an appropriate referral for evaluation by a surgical oncologist. Due to the high local recurrence rate and risk of metastases with these ulcers, clinicians should closely follow these patients. Any new lesions appearing on the lower extremity should have a biopsy and exam for malignant histological features.¹

References

1. Drozdowski PH. Marjolin's ulcer: A non-frequent manifestation of a carcinomatous transformation in a chronic wound–Description of three cases and literature review. Polish Ann Med. 2013; 20(2):135-140.
2. Kerr-Valentic MA, Samimi K, Rohlen BH, et al. Marjolin's ulcer: modern analysis of an ancient problem. Plast Reconstr Surg. 2009; 123(1):184-191.
3. Trent JT, Kirsner RS. Wounds and malignancy. Adv Skin Wound Care. 2003; 16(1):31-34.
4. Çelik E, Fýndýk H, Uzunismail A. Early arising Marjolin's ulcer: report of three cases. Br J Plast Surg. 2005; 58(1):122-124.
5. Aydoğdu E, Yildirim S, Aköz T. Is surgery an effective and adequate treatment in advanced Marjolin's ulcer? Burns. 2005; 31(4):421-431.
6. Stanford R, Lowell D, Raju R, Arya S. Marjolin's ulcer of the leg secondary to nonhealing chronic venous stasis ulcer. J Foot Ankle Surg. 2012; 51(4):475-478.
7. Combemale P, Bousquet M, Kanitakis J, et al. Malignant transformation of leg ulcers: a retrospective study of 85 cases. J Eur Acad Dermatol Venereol. 2007; 21(7):935-941.