Multimodality Management in Locoregionally Extensive Marjolin’s Ulcer

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Dr Sandipta Mitra discusses her case report featuring a patient presenting with Marjolin's ulcer 20 years after sustaining a burn to the scalp. Read the full paper here.

Transcript:

Sandipta Mitra, MS, MRCS, DNB:
I am Dr Sandipta, I am working at the All India Institute of Medical Sciences, New Delhi, in the department of Otorhinolaryngology and Head and Neck Surgery. So today I am going to talk about my paper which is on the Multimodality Management of a Loco-Regionally Extensive Marjolin’s Ulcer.

Our paper is a report on a case of Marjolin’s ulcer, which is an aggressive malignancy of the skin. This patient of ours is a young patient of 20 years old who presented to us with history stating that he sustained a flame injury over his scalp when he was 3 months old. So following the diagnosis, he was treated conservatively back then. He was apparently well for about 20 years, after which he developed a non-healing ulcer over the same site, which was then diagnosed to be a Marjolin’s ulcer. 

He underwent a surgery, followed by an adjuvant mold brachytherapy. He was apparently well for 2 months, after which he came back with a parotid nodal metastasis, which was PET-positive along with multiple other PET-positive lymph nodes, which were bilateral cervical, supraclavicular, suboccipital, as well as mesenteric. So, he was started on concurrent chemoradiation. So, and he was being followed up very stringently after that.

But just after a gap of 1 month, he came back with extensive ulceration of that left parotid region, which was biopsy proven to be a moderately differentiated squamous cell carcinoma. And then he underwent a radical parotidectomy along with neck dissection with appropriate reconstruction with a local regional flap, and he was being followed up every month. At about 6 months of follow-up, he came back to us with extensive local regional recurrence and along with axillary lymphadenopathy. 

The point that we want to make here is that Marjolin’s ulcer is a very aggressive form of cutaneous squamous cell carcinoma, as we well know. So, the most striking feature about this report is that our patient, despite adequate treatment, which was timed appropriately, had a very stringent follow-up, but he came back to us with multiple recurrences with very short treatment-free intervals and finally systemic metastases. So, all of this points towards an extremely aggressive nature of the disease that we're dealing with at hand despite multimodality treatment. So that is what we wanted to emphasize through this report. 

Well, I would say that the patient was under a very strict follow-up, all the treatment modalities were timed perfectly, but then still he came back to us with this very, very aggressive disease, so that is what basically is the nature of the disease that we have at hand, so that was very, very striking to us, I would say.

Well, the inherent aggressiveness of this disease and its propensity of its systemic spread. So, this prompted us to think about any systemic targetable agents, like we have in recurrent metastatic squamous cell carcinoma, such as the PD-1 inhibitors. So the future research should be directed towards such agents, which could better handle the disease, the very aggressiveness of the disease which we are dealing with. So, I believe that's what our future research should be directed at. 

I would just say whenever a patient of Marjolin’s ulcer probably walks into my clinic, I would counsel him about the nature of the disease with a very guarded prognosis, the options available, and that he has to be under a very strict follow-up, and probably counsel him regarding these systemic options that are coming up nowadays.