Clinicopathological evaluation of Marjolin ulcers over two decades

Synchronous carcinoma and sarcoma in a burn scar: a treatment conundrum

Marjolijn's ulcer is a malignant ulcer in a burn scar. Types of malignancy are squamous cell carcinoma, basal cell carcinoma and malignant melanoma. Soft tissue sarcoma case reports indicate only one type of cancer. We present a patient in her 60s with a 10-year-old burn scar developing a biopsy-proven squamous cell carcinoma on the lateral aspect of the left thigh with metastatic superficial inguinal node. A wide excision and grafting of ulcer with ilioinguinal dissection done on left side. On the 12th postoperative day 2, subcutaneous swellings adjacent to the grafted area developed, on biopsy revealed to be pleomorphic sarcoma. PET CT scan revealed tumour deposits in the muscles of the left lower limb, liver and lung. There are no case reports of synchronous carcinoma and sarcoma in a burn scar. The case is reported for its rarity and the decision-making dilemma.

Sestrin2 in cancer: a foe or a friend?

Sestrin2 is a conserved antioxidant, metabolism regulator, and downstream of P53. Sestrin2 can suppress oxidative stress and inflammation, thereby preventing the development and progression of cancer. However, Sestrin2 attenuates severe oxidative stress by activating nuclear factor erythroid 2-related factor 2 (Nrf2), thereby enhancing cancer cells survival and chemoresistance. Sestrin2 inhibits endoplasmic reticulum stress and activates autophagy and apoptosis in cancer cells. Attenuation of endoplasmic reticulum stress and augmentation of autophagy hinders cancer development but can either expedite or impede cancer progression under specific conditions. Furthermore, Sestrin2 can vigorously inhibit oncogenic signaling pathways through downregulation of mammalian target of rapamycin complex 1 (mTORC1) and hypoxia-inducible factor 1-alpha (HIF-1α). Conversely, Sestrin2 decreases the cytotoxic activity of T cells and natural killer cells which helps tumor cells immune evasion. Sestrin2 can enhance tumor cells viability in stress conditions such as glucose or glutamine deficiency. Cancer cells can also upregulate Sestrin2 during chemotherapy or radiotherapy to attenuate severe oxidative stress and ER stress, augment autophagy and resist the treatment. Recent studies unveiled that Sestrin2 is involved in the development and progression of several types of human cancer. The effect of Sestrin2 may differ depending on the type of tumor, for instance, several studies revealed that Sestrin2 protects against colorectal cancer, whereas results are controversial regarding lung cancer. Furthermore, Sestrin2 expression correlates with metastasis and survival in several types of human cancer such as colorectal cancer, lung cancer, and hepatocellular carcinoma. Targeted therapy for Sestrin2 or regulation of its expression by new techniques such as non-coding RNAs delivery and vector systems may improve cancer chemotherapy and overcome chemoresistance, metastasis and immune evasion that should be investigated by future trials.

When Benign Becomes Cancer: Malignant Degeneration of Chronic Inflammation

Chronic inflammation, long implicated in the genesis of malignancy, is now understood to underlie an estimated 25% of all cancers. The most pertinent malignancies, to the plastic surgeon, associated with the degeneration of chronic inflammation include Marjolin's ulcer, breast implant-associated large cell lymphoma, radiation-induced sarcoma, and Kaposi's sarcoma. The cellular and genetic damage incurred by a prolonged inflammatory reaction is controlled by an increasingly understood cytokinetic system. Advances in understanding the chronic inflammatory cascade have yielded new therapeutics and therapeutic targets.

Systematic Review of Modern Case Series of Squamous Cell Cancer Arising in a Chronic Ulcer (Marjolin's Ulcer) of the Skin

PURPOSE

Marjolin's ulcer is an aggressive cutaneous malignancy that arises in chronic nonhealing wounds. A review of modern series describing Marjolin's ulcer would be helpful in defining optimal management strategies and expected outcomes.

METHODS

A systematic review was performed on October 18, 2018, by querying Medline and EMBASE. Key inclusion criteria were as follows: human studies, English language, published in 2000 or later, > 10 patients, and at least 80% of the patients having squamous cell carcinoma (SCC) histology.

RESULTS

There were 599 patients in 14 case series from 10 countries; 82% of patients were from low-income and middle-income countries, and 48% were women. Overall, 65% of the ulcers were preceded by burns. Mean latency ranged from 11 years to 41 years (median, 28 years). Lower extremities were the most common site (62%). Differentiation was reported as well differentiated (64%), moderately differentiated (27%), or poorly differentiated (9%). Almost one third of cases were clinically node positive, though only 7% of all cases (24 of 334) were confirmed to be pathologically involved. Distant metastasis rates were reported in only 7 series, with median rate of 5% (range, 0%-27%). The main treatment modality was surgical excision (71%), followed by amputation (24%), primary radiotherapy (2%), and chemotherapy (< 1%). Outcomes data varied in content and quality. Mortality rates were 12%, 24%, and 37% in the three series reporting between 2 and 3 years of follow-up.

CONCLUSION

Marjolin's ulcer with SCC histology is an aggressive cancer with a notable potential for lymph node metastasis and distant metastasis. Comprehensive staging is recommended, with management optimally having a multidisciplinary context. Low- and middle-income countries are overrepresented in reports of Marjolin’s ulcer, and there may be opportunities for prevention and early detection.

Characteristics of Marjolin's Ulcers in 21st Century: A Retrospective Study, Systematic Review, and Surgical Guideline Recommendation

Marjolin's ulcer is rare and aggressive malignancy. The objective was to conduct a review of Marjolin's ulcer cases to gain a better understanding and its management. A retrospective study of patients with Marjolin's ulcers at our hospital between 2010 and 2019 was conducted. For the systematic review, the electronic database of the National Library of Medicine was searched and articles published between 2000 and 2019 were included. A total of 14 patients were included in the retrospective study. Twelve patients were male. The mean age was 59.71 years. The latency period was 27.78 years. The most common malignancy was squamous cell carcinoma, and 71.43% had developed on the lower extremities. Well-differentiated squamous cell carcinomas occurred in 38.46% of the cases Rates of lymphovascular and perineural invasion were 30.77 and 23.08%, respectively. Results from the literature search yielded 80 case reports (91 cases) and 42 retrospective reviews (1216 cases). Most cases were male and the most common location was lower extremities. The latency period for the acute and chronic periods was 2.75 months and 20.75 years, respectively. The most common malignancy was squamous cell carcinoma (92.27% in the retrospective reviews) and 59.98% of the cases exhibited well-differentiation. Rates of regional lymph node involvement and distant metastases were 10.20 and 12.09%, respectively. Marjolin's ulcer in 21st century is not so rare. The most common is well differentiated squamous cell carcinoma. Early flap surgery or skin grafts for chronic ulcers or burn scars are recommended to reduce risk. Guideline for surgical management is established.

Melanoma Marjolin's ulcer in the hand: A case report

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Marjolin’s ulcer is usually misdiagnosed.

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Some theories try to explain the mechanisms of malignant degeneration.

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Melanoma is rare and aggressive and, once suspected, a biopsy must be done.

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Deep second and third degree burns must be debrided and covered by a skin graft.

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Early diagnosis, treatment and vigilance are the keys to success and survival.

Introduction

Burn scars have the potential to malignant transformation, creating an identity named Marjolin’s ulcer. This term refers to any scar in a traumatized skin that degenerates into a skin cancer. The majority of them are derived from burns that were not grafted, appearing several years later. The most frequent type is squamous cell carcinoma with few cases of melanoma described in the literature. This last one accounts for a poor prognosis.

Case presentation

Female, 74 years old, presents to our department with a malignant melanoma arising from a thermal burn scar in the right thenar eminence 14 years after the initial injury. The lesion was excised and the defect covered by a full thickness skin graft. At 6 months post-operatively there are no signs of locoregional recurrence or systemic dissemination.

Discussion

Malignant melanoma arising from a burn scar is extremely rare and the pathogenesis is unknown. Many theories try to explain this low incidence and the factors that contribute to degenerative changes of melanocytes in the affected skin.

Conclusion

Health professionals must consider this pathology when evaluating a burn scar or a chronic wound, performing a biopsy when suspicion is high. An early diagnosis, a prompt surgical intervention and a greater vigilance are the keys to success and survival.

Marjolin's Tumor Complicating Chronic Periprosthetic Infection of a Total Knee Arthroplasty

Marjolin's tumor is a term used to describe a malignancy developing in the setting of a chronic wound, infection, or other tissue subject to chronic inflammatory changes. These malignancies usually present after many years of chronicity, and can range from lower grade basal cell carcinomas to high-grade sarcomas. We present the case of a squamous cell carcinoma that developed within a chronic periprosthetic infection of a total knee arthroplasty of 7 years duration. The intra-articular location, association with an orthopaedic implant, and brief latency period are all unique features of this case.