Malignancy transformation of chronic osteomyelitis: description of 6 cases of Marjolin’s ulcers

Latent Chronic Osteomyelitis Presenting Decades After Initial Trauma: A Case Report and Literature Review

Osteomyelitis is an inflammatory bone process secondary to infection, and often presents as a chronic, recurrent illness, posing diagnostic and treatment challenges. It is frequently the result of previous inadequate treatment or undiagnosed acute infection. Clinical suspicion, thorough evaluation, laboratory studies, and advanced imaging modalities such as magnetic resonance imaging (MRI) and computed tomography (CT) play crucial roles in diagnosis. Treatment typically entails a combination of antibiotics and surgical debridement to eliminate infection and facilitate bone healing. In this report, we present a rare case involving a 64-year-old male who presented with new-onset pain in the right femur decades after experiencing a complicated femur fracture and forearm crush injury. Imaging studies revealed evidence of chronic osteomyelitis, leading to a diagnosis of latent infection. The patient underwent a comprehensive evaluation, including clinical examination, imaging studies, laboratory tests, and bone biopsy, confirming the diagnosis. This case of latent osteomyelitis highlights the clinical presentation, diagnostic modalities, and treatment strategies employed in managing this challenging condition.

Squamous Cell Carcinoma Arising from Chronic Osteomyelitis in the Extremities: Treatment Approach and Oncological Outcomes-A Systematic Review of the Literature

Aims

In chronic osteomyelitis-derived squamous cell carcinoma, what are the demographic and clinical variables, risk factors associated with worse outcomes, and results of treatment modalities used?

Methods

A systematic review was performed using PubMed and EMBASE. Articles were evaluated for inclusion and exclusion criteria, and for quality analysis. PRISMA guidelines were applied. Demographic and clinical data and therapeutic approaches were presented narratively and in descriptive statistics registered at PROSPERO.

Results

Most patients were male (40/49), trauma was the most common etiology (27/36), and about half of all SCC were in the tibia (25/48). Amputation was the main definitive treatment (42/47). Adjuvant treatments were not analyzed. Well-differentiated SCC accounted for 58.3% (21/36) of all tumors. Bone invasion was described in 82.8% (24/29); recurrence, in 7.7% (3/39); and metastasis, in 7.7% (3/39). Recurrence and metastasis occurred more frequently when bone invasion was present (p = 0.578 and p = 0.646, respectively). SCC with lymph node involvement showed a higher tendency to metastasize (p = 0.377). Compared with limb salvage, amputation was associated with a tendency for less recurrence (p = 0.312) and longer survival (p = 0.219).

Conclusions

COM-derived SCC mostly occurs after trauma and is usually located in the tibia. Bone invasion is common, and patients predominantly undergo amputation. This treatment is associated with a trend toward higher survival, compared to limb salvage.

Squamous cell carcinoma complicating chronic osteomyelitis: A systematic review and case series

INTRODUCTION

Squamous cell carcinoma (SCC) is a rare but serious complication of chronic osteomyelitis. This study aimed to determine an optimum approach to diagnosis and management.

METHODS

A systematic review was performed using Medline, Embase, CINAHL and Web of Science, from 1999-present. Additional cases, meeting the eligibility criteria, were added from our hospital database. Patient demographics (age, gender, co-morbidities), osteomyelitis diagnosis (location, duration), diagnosis of SCC (method, imaging, extent of disease) and management (amputation versus wide local excision versus palliation) as well as outcome at one and five years were collected.

RESULTS

Nineteen studies involving 106 patients met strict inclusion criteria. All published studies were case reports or case series. Chronic osteomyelitis had been present for a mean of 31 years (range 3-67) prior to SCC diagnosis. SCC was most commonly treated by amputation (81%). A poorer outcome occurred in those with metastatic disease (p = 0.006 at one year; p = 0.032 at five years), an incidental diagnosis at surgery for osteomyelitis (p = 0.052; p = 0.021) and SCC after pelvic osteomyelitis (p < 0.001; p = 0.002).

CONCLUSIONS

SCC should be suspected in all cases of chronic osteomyelitis with skin changes, particularly if the duration of sinus drainage exceeds 3 years. Histological biopsy for malignancy should be taken in all suspected cases, as well as routinely during excision of osteomyelitis when chronic skin changes are present. Staging computed tomography (CT) scanning is recommended to guide adjunctive therapy. Amputation, where possible, may be considered as the definitive surgical management, after discussion with the patient.

Current Trends in Management of Marjolin's Ulcer: A Systematic Review

Marjolin's ulcer (MU) is a rare, aggressive entity with frequent delay in diagnosis for a variety of regions. Although well described and classically taught in medical school, aspects of its treatment remain ill-defined and controversial. A systematic review was performed according to PRISMA guidelines to identify studies discussing patients who underwent surgical treatment of MU. A total of 31 papers, reporting on 1016 patients, were included. Burns were the most common etiology of malignant degeneration (68%), followed by trauma. The lower extremity was most affected (51%) and Squamous Cell Carcinoma (SCC) was found in 94% of cases, with the majority being well differentiated. Basal cell carcinoma and melenoma composed a minority of cases. Melanoma occurred more frequently in previously skin grafted wounds and had a higher rate of metastases than SCC. Most patients did not have associated regional or distant metastases present at diagnosis. Wide local excision (71%) was performed in most cases, unless amputation was indicated for severe disease or bone involvement. Lymphadenectomy and sentinel lymph node biopsy were variably reported, with conflicting evidence on the efficacy. Lymphadenectomy was most commonly indicated for known lymph node involvement. In cases of metastatic disease chemotherapy and radiation were used in conjunction with surgical treatment. Despite numerous articles on this topic, controversy remains in the management of MU. Early diagnosis of suspicious chronic wounds and prompt surgical intervention remains imperative to its treatment.

Clinical characteristics, treatment, and prognosis of squamous cell carcinoma arising from extremity chronic osteomyelitis: a synthesis analysis of one hundred and seventy six reported cases

PURPOSE

Squamous cell carcinoma (SCC) arising from extremity chronic osteomyelitis (COM) has not been well-understood due to its low prevalence. This study aimed to synthesize the cases recently published to clarify their clinical characteristics, treatment, and prognosis.

METHODS

PubMed, Embase, and Cochrane Library databases were searched for English literature reporting cases diagnosed of SCC originating from extremity COM between January 1, 1990, and September 30, 2019. The National Institutes of Health (NIH) assessment tool was used to evaluate the quality of reports included, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to summarize the quality of available evidence. The data synthesized for analysis were clinical features, treatment strategy, and incidences of local recurrence, metastasis, all-cause, and SCC-related deaths. In addition, potential factors that might have influenced treatment efficacy and prognosis of SCC were also investigated.

RESULTS

Included for this analysis were 60 studies of 176 patients (a male-to-female ratio of 6.7). COM mostly occurred following trauma (73%), the tibia was the most frequent site (61%), and a sinus tract was the most common symptom (61%). The mean duration from COM to SCC was 27 years. Positive rate of pathogen culture was 90%, with 73% being polymicrobial. Limb amputation was performed in 80.5% of the patients. Incidences of local recurrence, metastasis after treatment, all-cause, and SCC-related mortalities were 16.7%, 12%, 31.1%, and 12.6%, respectively. Patients with local lymphadenopathy at diagnosis had significantly higher risks of local recurrence (P = 0.01), SCC-related (P = 0.02), and all-cause deaths (P = 0.01) than those without. Patients with moderately-to-poorly differentiated SCC types had significantly higher risks of local recurrence (P = 0.01) and all-cause death (P = 0.02) than those with a well-differentiated type.

CONCLUSIONS

SCC arising from extremity COM favoured males and the tibia. Although limb amputation was the mainstay of treatment, the overall incidences of local recurrence, metastasis, and SCC-related death exceeded 10%. Patients with local lymphadenopathy at diagnosis of SCC and those with moderately-to-poorly differentiated SCC types should be followed up closely.

TRIAL REGISTRATION

CRD42020154221.