Marjolin's ulcer of the foot caused by nonburn trauma

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.

"Hurricane-like" Presentation of a Recurrent Marjolin's Ulcer in a Young Female

Marjolin's ulcer (MU) with rapid progression and multiple distant metastases is rare. We report a case of an MU of the thigh developing in a postburn scar, which after successful R0 resection developed multiple bony and visceral metastasis to femur, vertebra, skull, lung, and liver within 3 months of excision. We highlight the "hurricane-like" recurrence in an MU, which is unusual for the metachronous disease. We stress that MUs, unlike conventional wisdom, need a thorough metastatic workup at presentation, and prognostication of a possible rapidly progressive course after surgery which may lead to grave prognosis and mortality.

Heel reconstruction for a Marjolin’s ulcer in a patient with multiple limb amputations: a case report

Coverage of the heel defects usually represents a challenge for the proper reconstructive requirements of the weight-bearing area of the foot. The presence of multiple limb amputation may represent a further concern for conventional free flap donor sites and the patient’s functional limitation, thus making reconstruction even more challenging. Amputee patients may be subjected to a higher risk of foot ulcerations and choosing the more appropriate reconstructive option in such patients is crucial. Here we describe the application of the medial plantar flap as a first-line option in a 66-year-old amputee patient with a squamous cell carcinoma arising from chronic ulceration on the left heel, that was successfully treated with limited functional limitations and excellent anatomical contour of the foot. Despite its use has been widely described for heel reconstruction, we believe that medial plantar flap would deserve greater relevance in the reconstructive scenario in such challenging cases.

Marjolin's ulcer of the forearm from 30-year-neglection of external fixator

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Marjolin’s ulcers are a rare form of malignancy that present at regions exposed to chronic inflammation.

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They are classically encountered in lower extremities more commonly than in the upper extremities.

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This disease should be suspected in every case of chronic ulcer, where histological studies of the lesion must be conducted.

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Treatment options vary according to local and regional factors.

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Early recognition and control of the disease allow for better control and relapse.

Background

Marjolin’s ulcers are a rare form of malignancy that present at regions exposed to chronic infection. They present with a clinical triad of nodularity, induration, and ulceration greater than 3 months.

Case report

We present herein, an extremely rare case of Marjolin’s ulcer of the forearm, secondary to osteomyelitis, resulting from a 30-year neglection of external fixator used to treat a war injury of the forearm.

Discussion

Marjolin’s ulcers are classically encountered in lower extremities at sites of burns, trauma or complicated wounds. In the upper extremity however, they are seldom mentioned in literature. The presence of risk factors raise the suspicion of the disease.

Conclusion

Marjolin’s ulcer is rare sequelae of chronic wound infection. Patients often present after a latency period with exacerbated pain, discharge, and exophytic mass. This disease should be suspected in every case of chronic ulcer, where histological studies of the lesion must be conducted to exclude or confirm the diagnosis.

Analysis of Factors Affecting Chronic Ulcers of Scalp Transforming Into Marjolin's Ulcer: A Single Center Experience

The Marjolin's ulcer (MU) is a rare malignant lesion, which is characterized by primary, chronic wound initially and formation of cancer after a certain incubation period eventually. Though few reports or a small case series about MU on the scalp have been published, special risk factors are still unknown about the formation of malignancy on the scalp with chronic ulcer. The aim of the article is to explore the risk factors. Seventy-four patients with the chronic ulcer were included in the study. In between, the chronic ulcer transformed into the MU on the scalp (tumor group) in 42 cases, while the chronic ulcer did not transform into the MU on the scalp (tumor-free group) in 32 cases as controlled group. We made a comparative study between the above two groups so as to find which risk factors were critical for cancer development. In tumor group, lymph node dissection was implemented if the lymph node metastasis was found. Artificial dura was used in eight cases when the dura was removed. Seven cases died. Two patients are currently undergoing follow-up. Other cases were without tumor detection from 1 to 7 years. When the comparative study between the above two groups, there is statistical significance about the influential factor: scar adherence to the skull (F = 5.602 P = .018). Scar adherence to the skull may be the most critical risk factor for cancer development for the scalp with chronic ulcer.

A review of 31 cases of Marjolin's ulcer on scalp: Is it necessary to preventively remove the scar?

We aimed to report the clinical features of squamous cell carcinoma (SCC) occurring on scalp scar tissue among a Chinese population, demonstrate its pathological progress, analyse the prognosis-related factors, and share our clinical experience of managing this rare disease in practice. A retrospective study was conducted at West China Hospital from January 2013 to January 2018 aiming to identify patients with a diagnosis of SCC or squamous atypical hyperplasia arising from scalp scars. Their medical records were reviewed, and related data were retrieved. Follow up was conducted, and informed consent was obtained by phone calls in June 2018. Of the 31 scalp Marjolin's ulcer (MU) patients, the average latency period and post-ulceration period were 42.9 years and 37.5 months, respectively. Among them, 30 patients (97%) were diagnosed with cancer more than 5 years after initial injury, and 25 patients (80.7%) experienced a pre-ulceration period longer than 20 years. A negative correlation between scalp MU's post-ulceration period and its pre-ulceration period was identified. Only burn scars caused post-ulceration periods of more than 24 months (7/19). Incomplete healing wounds experienced a significantly shorter latency period (P = 0.004) and longer post-ulceration period than others (P < 0.0001). However, the depth of tumour infiltration and complete tumour resection were the only two independent factors that significantly dictated patients' survival in this study. In conclusion, the scalp scaring tissue experienced a long-term stable period but would transform to malignancy rapidly and progressively once ulceration formed. The underlying malignant transformation mechanism remains unclear. Thus, we recommend scalp scarring tissue to be radically removed.

Rare Presentation of a Marjolin's Ulcer Secondary to a Post-Traumatic Injury

Marjolin's ulcer is a rare and aggressive cutaneous malignancy arising from previously traumatized skin, most commonly at the site of previous burns. We present a unique case of Marjolin's ulceration secondary to an orthopedic injury and a nonburn history of trauma. The patient had been involved in a motorcycle accident >20 years earlier. For 17 months, the patient had refused to acknowledge the severity of his disease state. He had refused the standard of care and opted for local wound care only until a minor fall caused a pathologic fracture, leading to an above the knee amputation. Road traffic incidents remain an uncommon cause of subsequent Marjolin's transformation in developed countries. As such, we present the case of a patient with a unique combination of a continued lack of compliance after diagnosis and the unusual cause of his initial trauma.

Nodular melanoma in trophic ulceration of a leprosy patient: a case study

Non-healing chronic trophic ulceration is very common in leprosy patients. Marjolin's ulcer consists of the malignant transformation of a chronic ulcerative lesion. Nodular melanoma developing from Marjolin's ulcer, caused by a trophic ulceration of a leprosy patient, is very rare with only a few cases reported in the literature. Due to the disguised presentation of these malignancies within trophic ulceration lesions in leprosy, neoplastic transformation is frequently overlooked, leading to misdiagnosed and delayed treatment. This paper reports a case of an 83-year-old man with lepromatous leprosy and chronic ulceration on the foot for 22 years. Over a period of 2 months, the ulcer enlarged, turned black, and became more painful. The patient underwent regional excision and immunotherapy after the diagnosis of malignant nodular melanoma. After 9 months follow-up, no metastasis was found.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

A Retrospective Study of Marjolin's Ulcer Over an Eleven Year Period

Background:

Marjolin's ulcer is a rare aggressive cutaneous malignancy occurring in previously occurred wounds. The most common aetiology is a burn wound involving extremities and squamous cell carcinoma is the most common variant.

Materials and Methods:

A retrospective analyses of medical records of patients treated in a single unit with a diagnosis of Marjolin's ulcer was performed.

Results:

During the study period, 14 patients were treated. Four patients had lymph node metastases and one had pulmonary metastases at the time of presentation. Seven patients underwent wide excision with reconstruction and seven underwent amputation or disarticulation because of advanced malignancy. During the follow up two patients developed local recurrence and one developed pulmonary metastases. Both the patients with pulmonary metastases had Marjolin's ulcer of trunk.

Conclusion:

Marjolin's ulcer occurs more commonly in the extremities. Distant metastases occur commonly in patients with ulcers on the of trunk.

Moderately differentiated squamous cell carcinoma of the palm: an extremely infrequent tumour

Squamous cell carcinoma of the palm is a very infrequent malignancy. Its unusual presentation can produce a delay in the final diagnosis with serious consequences as far as morbidity and mortality are concerned. This article summarises the case of a patient who was referred to our department presenting a squamous cell carcinoma on his left palm and a clinically positive axillar lymphadenopathy. He had previously been wrongly diagnosed on several occasions.

Marjolin's ulcer of the hallux

We report the case of a 51-year-old woman with malignant degeneration of a right hallux nail bed ulcer of 20 years' duration. Histologic examination confirmed the diagnostic features of Marjolin's ulcer, a well-defined but uncommon malignant ulcer that occurs in chronic wounds and cutaneous scars. In this report, we describe the clinical and histopathologic features and the differential diagnosis of this unusual lesion.

Marjolin's ulcer: a preventable malignancy arising from scars

BACKGROUND

Marjolin's ulcer (MU) is a rare malignancy arising from various forms of scars. This potentially fatal complication typically occurs after a certain latency period. This article attempts to reveal the importance of the latency period in the prevention and early treatment of the malignancy.

METHODS

A retrospective review of 17 MU patients who underwent surgical procedures between June of 2005 and December 2011 was conducted. Etiology of injuries, latency period, repeated ulceration, and outcomes were recorded. This observational report reveals characteristics of patients who develop MU.

RESULTS

An incidence of 0.7% of MU was found amongst patients complaining of existing scars in our study; burns and trauma were the most common etiology of MU. The mean latency period was 29 years (SD = 19) and the mean post-ulceration period was 7 years (SD = 9). Statistical analysis revealed a negative correlation between the age of patients at injury and the length of latency period (r = -0.8, P <0.01), as well as the lengths of pre-ulceration and post-ulceration periods (r = -0.7, P <0.01).

CONCLUSIONS

Patients experience different lengths of pre- and post-ulceration periods during the latency period. Younger patients tend to have a longer latency period. Skin breakdown on chronic scars and chronic unhealed ulcers are two main sources of MU. MU may be preventable with a close surveillance of the ulcer during the latency period.

[Marjolin's ulcer of the cheek developed on burn scar: a case report]

Marjolin ulcers are scar carcinomas most often arising in old burn injuries. They arise mostly in the extremities. We report medical history of a 50-year-old female suffering from a scar carcinoma on her right cheek which was histopathologically identified as a mean differentiated squamous cell carcinoma.

Marjolin's ulcers at a university teaching hospital in Northwestern Tanzania: a retrospective review of 56 cases

Background

Marjolin's ulcer is a rare but highly aggressive squamous cell cancer that is most often associated with chronic burn wounds. Although many individual case reports exist, no comprehensive evaluation of Marjolin's ulcer patients has been conducted in our setting. This study was conducted to describe the clinicopathological presentation and treatment outcome of this condition in our local setting and to identify predictors of outcome.

Methods

This was a retrospective study of histologically confirmed cases of Marjolin's ulcer seen at Bugando Medical Centre over a period of 10-years between January 2001 and December 2010. Data were retrieved from patients' files and analyzed using SPSS computer software version 15.0

Results

A total of 56 patients were studied. Male to female ratio was 2.1:1. Burn scars (89.3%) were the most common causative lesions of Marjolin's ulcer. The mean latent period between original injury and diagnosis of Marjolin's ulcer was 11.34 ± 6.14 years. Only 12.0% of the reported cases were grafted at the time of injury (P < 0.00). Most patients (48.2%) presented between one and five years of onset of illness. The lower limb (42.9%) was the most frequent site for Marjolin's ulcers. The median tumor size at presentation was 8 cm and the vast majority of patients (85.7%) presented with large tumors of ≥ 5 cm in diameter. Lymph node metastasis at the time of diagnosis was recorded in 32.1% of cases and distant metastasis accounted for 26.9% of cases. Squamous cell carcinoma (91.1%) was the most common histopathological type. Wide local excision was the most common surgical procedure performed in 80.8% of cases. Post-operative complication rate was 32.1% of which surgical site infection was the most common complication in 38.9% of patients. Local recurrence was noted in 33.3% of cases who were treated surgically. The mean length of hospital stay for in-patients was 7.9 ± 2.3 days. Mortality rate was 7.1%. According to multivariate logistic regression analysis, stage and grade of the tumor and presence of local recurrence were the main predictors of death (P < 0.001).

Conclusion

Marjolin's ulcers are not rare in our environment and commonly occur in burn scars that were not skin grafted and were left to heal secondarily. A high index of suspicion is required in the management of chronic non-healing ulcers and all suspected lesions should be biopsed. Early recognition and aggressive treatment of Marjolin's ulcers and close follow-up are urgently needed to improve outcomes in our environment.

A Comprehensive Review on Marjolin's Ulcers: Diagnosis and Treatment

Despite the misnomer, Marjolin's ulcers really reflect malignant degeneration arising within a pre-existing cicatrix or scar. In most instances, biopsied lesions demonstrate well-differentiated squamous cell tumors, although other epidermoid lesions are occasionally encountered. The lesions are rare and are most commonly found in the lower extremity, especially the heel and plantar foot. In light of the close association of these lesions with scarred tissues associated with various chronic lower-extremity wounds, those involved in health care delivery to these patients must be aware of Marjolin's ulcer, its manifestations and potential ramifications.

Marjolin ulcer: an overlooked entity

Marjolin ulcer is a well-defined, but uncommon malignant ulcer that occurs in chronic wounds and cutaneous scars. Jean-Nicolas Marjolin was credited with describing this phenomenon in 1828. This entity is frequently overlooked and therefore inadequately treated leading to a poor prognosis. The malignant transformation of an ulcer is most commonly associated with burn scars, but has been reported in many other types of chronic, non healing wounds such as traumatic wounds, venous stasis and chronic pressure ulcers, fistulas, lacerations and leprosy ulcers. Development of malignancy tends to be slow with an average time of approximately 25 years. Various theories concerning pathogenesis of Marjolin ulcer have been proposed. Well-differentiated squamous cell carcinoma (SCC) is the most common histological type of Marjolin ulcer. Biopsy with histopathologic interpretation remains the gold standard for the diagnosis, with radical surgical excision being the treatment of choice. A high index of suspicion should be held by any health care provider when evaluating a chronic, non healing wound. This is a case report of a Marjolin ulcer arising on the left buttock of a patient with a long-standing history of a traumatic wound.

Squamous cell carcinoma masquerading as a trophic ulcer in a patient with Hansen's disease

Nonhealing trophic ulcers in leprosy are a common phenomenon, but acute malignant transformations of the same are relatively rare. This study reports on a 35-year-old man previously treated for Hansen's disease with a squamous cell carcinoma involving the right foot with rapid lymphatic spread. He was being treated as a benign trophic ulcer for more than 12 months until he started developing huge inguinal lymph nodes and the ulcer rapidly increased in size. Squamous cell carcinomas are known to occur in ulcers of considerable duration but such rapid growth in such a short duration and rapid lymphatic spread is unusual in Marjolin's ulcer as the lymphatics are usually destroyed because of previous inflammation and scarring.

Marjolin's ulcers: theories, prognostic factors and their peculiarities in spina bifida patients

Background

Due to improved care, more and more children born with spina bifida in rural Kenya are surviving into adulthood. This improved survival has led to significant challenges in their lifestyles, especially the need to ensure pressure ulcer prevention and treatment. Malignant degeneration of pressure ulcers in spina bifida patients is very rare. The author describes the clinical presentation of two pressure ulcer carcinomas that are at variance from classical descriptions.

Materials and methods

An internet/Medline/PubMed search of English literature for theories on Marjolin's ulcer evolution and prognostic features of Marjolin's ulcers was performed.

A chart review of two young adults with spina bifida who had presented to the author's hospital between 2004 and August 2010 with chronic pressure ulcers found to be Marjolin's ulcers on histo-pathological examination was performed, and the clinical features are reported.

Results

The two ulcers appeared clinically benign: one was a deep ulcer, while the other was shallow; both had normal, benign-appearing edges, and a foul smelling discharge. The two ulcers were surrounded by induration and multiple communicating sinuses, with no evidence of chronic osteomyelitis. The internet search revealed a total of nine theories on Marjolin's ulcer development, as well as seven clinical and four histological prognostic features.

Discussion

The multifactorial theory, a coalescence of a number of proposed theories, best explains the evolution of Marjolin's ulcers. Poor prognostic features include pressure ulcer carcinomas, lesions and location in the lower limbs/trunks, all present in the two patients making their prognosis dim: this is despite the surgical margins being clear of tumor. Benign appearance, induration and presence of multiple communicating sinuses are features that have not been previously described as presenting features of pressure ulcers carcinomas.

Conclusion

There is need for spina bifida patients and their guardians/caretakers to receive a close follow-up throughout life; health education focused on pressure ulcer prevention as well as early treatment of pressure ulcers when they occur, will avert the development of Marjolin's ulcers, and save lives.

Malignant fibrous histiocytoma secondary to a traumatic hematoma

We present a case of malignant fibrous histiocytoma located in the region of the temple that corresponded to the main site of a traumatic hematoma. There are reports of malignant transformation triggered by different kinds of wounds, but the malignant transformation in a subcutaneous hematoma is rare. For chronic expanding hematoma, magnetic resonance imaging or biopsy is recommended in determining whether it is malignant, especially when the mass is growing rapidly.

Chronic ringworm infestation and Marjolin's ulcer, an association unknown in the literature

We report here a case of Marjolin’s ulcer developing in a long-standing, inadequately treated, chronic ringworm infestation of the lower limb. A 35-year-old female patient with a ten-year history of a chronic ringworm infestation had developed a nonhealing ulcer in an area of infestation on the right leg. A biopsy revealed well-differentiated squamous cell carcinoma associated with the ringworm infection. A below-knee amputation by an inguinal block dissection was performed. We conclude that proper and timely treatment of fungal infections of the skin is needed to allow for healing of dermal infections and thus the prevention of the disastrous consequences that recurrent mechanical trauma from scratching of the affected area, leading to occult malignancy, which may occur in a small number of patients.

Marjolin's ulcer: a preventable complication of burns?

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Discuss the clinical features of Marjolin's ulcer. 2. Identify the risk factors for the development of Marjolin's ulcer. 3. Develop a surgical management plan for the treatment of Marjolin's ulcer.

SUMMARY

Marjolin's ulcer is a rare and aggressive cutaneous malignancy that arises on previously traumatized and chronically inflamed skin, especially after burns. This clinical condition was first described by Marjolin in 1828. The term "Marjolin's ulcer" has been generally accepted to refer to a long-term malignant complication of the scars resulting from burns. However, vaccination, snake bites, osteomyelitis, pilonidal abscesses, pressure sores, and venous stasis may also induce this tumor. Clinically, reports suggest that atrophic and unstable scars tend to develop into cancer. Various etiological factors have been implicated in the condition, including toxins released from damaged tissues, immunologic factors, cocarcinogens, and miscellaneous factors such as irritation, poor lymphatic regeneration, antibodies, mutations, and local toxins. The incidence of burn scars undergoing malignant transformation has been reported to be 0.77 to 2 percent. All parts of the body can be affected, but the extremities and the scalp are most frequently affected. There are two variants: acute and chronic. In the former, the carcinoma occurs within 1 year of the injury. The chronic form is more frequent and malignancy tends to develop slowly, with an average time to malignant transformation of 35 years. Although many different cell types can be seen in these lesions, the major histological type is squamous cell carcinoma. Marjolin's ulcers are generally considered as very aggressive tumors with a higher rate of regional metastases; radical excision is the treatment of choice, but there is no consensus on lymph node dissection. Marjolin's ulcer can be insidious and often leads to a poor prognosis, and deaths from Marjolin's ulcer are not uncommon. Meticulous wound care is a crucial step in prevention of these lesions.

Basal cell carcinoma arising in a tattooed eyebrow

Malignant skin tumors, including squamous cell carcinoma and malignant melanoma, have occurred in tattoos. Seven documented cases of basal cell carcinoma associated with tattoos have also been reported in the medical literature. We encountered a patient with basal cell carcinoma in a tattooed eyebrow. We report on this case as the eighth reported case of a patient with basal cell carcinoma arising in a tattooed area.

Squamous cell carcinoma of the foot

BACKGROUND

Squamous cell carcinomas (SCC) of the foot are relatively common, but have been infrequently reported in the orthopaedic literature.

MATERIALS AND METHODS

Twelve patients with SCC of the foot treated at a single institution from 1998 to 2005 were studied retrospectively with regard to risk factors for the disease, treatment, and functional and oncologic outcomes. The mean duration of postoperative followup was 43 (range, 24 to 105) months.

RESULTS

Eight of the 12 patients had identifiable risk factors for SCC. Inadequate or inappropriate procedures had been previously performed in eight of the 12 cases, requiring more aggressive definitive treatment in at least four cases. Definitive operative treatment consisted of wide excision (4 patients), partial or complete toe amputation (4), partial foot amputation (3), and transtibial amputation (1). Two patients developed local recurrence of disease, and both ultimately required Syme amputations for local control. One patient with local recurrence died of metastatic disease and the other 11 patients are alive without evident disease. Musculoskeletal Tumor Society functional scores averaged 90 and were good or excellent in nine of the 11 surviving patients.

CONCLUSION

Squamous cell carcinomas of the foot are likely underreported and frequently subject to inappropriate initial treatment. Most patients have identifiable risk factors for SCC that can aid in formulating an appropriate differential diagnosis. Despite frequent suboptimal initial treatment, most patients are candidates for complete or partial limb salvage, with generally good oncologic and functional outcomes expected.

Early diagnosis is vital in the management of squamous cell carcinomas associated with chronic non healing ulcers: a case series and review of the literature

The association between chronic ulcers and squamous cell carcinomas (SCCs) is well established. Their clinical presentations, however, are varied, ranging from innocously appearing lesions to overtly exophytic growths. We present a series of cases with heterogeneous clinical presentations and different treatment outcomes. Case series - patient 1 was a 69-year-old man with an 18-month history of static non healing venous leg ulcer, but no sinister features, biopsy was performed to rule out Marjolin's transformation, histology revealed SCC and treatment was simple excision and skin grafting; patient 2 was a 73-year-old lady with an 18-month history of non healing ulcer (innocuous appearance) over distal interphalangeal joint of index finger, histology revealed SCC with deeper extension and treatment was amputation of distal half of finger; patient 3 was a 73-year-old lady with a 12-month history of non healing fungating leg ulcer with irregular borders and everted edges, histology revealed SCC (tumour eroding tibia and distant metastasis) and treatment was above-knee amputation, radiotherapy and palliation. Whilst SCC is amenable to simple excision in the early stages, delay in diagnosis could result in loss of the affected digit or limb; an SCC which has metastasised is also life threatening. Therefore, a low threshold to biopsy static non healing ulcers or ulcers in unusual sites should be adopted even in those not manifesting any evidence of malignancy.

[Intertoe space cutaneous epidermoid carcinoma]

BACKGROUND

Localisation of epidermoid carcinoma in the intertoe space is very rare. We report a case occurring in a setting of chronic intertoe intertrigo.

CASE

A 66 year-old woman presenting intertoe intertrigo for 30 years consulted for painful ulceration of the 3rd intertoe space of the left foot present for 4 years and refractory to antifungal treatment. The examination revealed ulceration with infiltrated edges occupying the entire 3rd intertoe space, with no satellite adenopathy. Histological examination of the skin biopsy sample revealed epidermoid carcinoma. Wide excision of the lesion was performed with a safety margin of 5 mm, with removal of the 3rd and 4th left toes. The outcome was favourable with no relapse after 12 months.

DISCUSSION

A single publication reported a series of 22 cases of intertoe epidermoid carcinoma in which the key aetiological feature of tumour was continual maceration. In this patient, maceration was maintained by a number of factors, including cultural factors: ritual ablutions performed 5 times daily, with no drying of the intertoe spaces, and domestic cleaning involving large quantities of water several times weekly.

Thirty-one cases of Marjolin's ulcer

Marjolin's ulcer is a rare and often aggressive cutaneous malignancy that arises in previously traumatized or chronically inflamed skin, particularly after burns. We reviewed 264 burns cases treated in our departments to assess the frequency and clinicopathological features of this malignant complication. We found 31 cases of Marjolin's ulcer and a further 14 cases of nonmalignant ulceration at previous burn sites. Eighteen Marjolin's ulcers were located on the extremities, six on the scalp, six on the trunk, and one on the nose. Most malignancies were squamous cell carcinomas. The average time lag between the burns and subsequent malignant ulceration was 19 years. Four of the malignant ulcers had spread to regional lymph nodes, but there were no distant metastases. This study emphasizes that Marjolin's ulcer should be considered as a significant postburn complication.

Wounds and malignancy

Due to the prevalence of skin cancers, health care practitioners involved with wound management are likely to encounter cutaneous malignancies as part of their practice. This article focuses on 2 ways in which malignancies and wounds are related: the malignant degeneration of chronic wounds into cancer and malignancies that present as chronic wounds. The most common scenario in which chronic wounds have been associated with the development of squamous cell carcinoma is in the presence of chronic osteomyelitis. However, wounds secondary to burns, trauma, radiotherapy, and diabetes are also at risk for malignant degeneration. It is often difficult to distinguish malignant transformations from primary malignant ulcers. Given the uncommon nature of degeneration of a chronic wound or a malignancy presenting as a chronic wound, some suggest that only suspicious wounds undergo biopsy. Primary malignancy should be considered if the ulcer has a relatively short duration and the patient does not have a history of prior radiotherapy. Until recently, amputation has been the treatment of choice for squamous cell carcinomas that arose within chronic wounds associated with chronic osteomyelitis; however, other reports have shown that other methods of ensuring complete local excision are also useful.

Marjolin's ulcer on the nose

Malignancies in scars are generally known as Marjolin's ulcer. The majority of these arise from burn injuries. Although Marjolin's ulcer consists of all kinds of skin cancer, squamous cell carcinoma is the main cancer type reported in the literature. The pathogenesis of this tumor is due to chronic irritation of the effected area and mostly involves the extremities and scalp area. This report presents an unusually located and rare type of Marjolin's ulcer: on the nose and baso-squamotic in type. A 54-year-old man, 33 years after burn, presented with an unhealed ulcer on his nose which had been present for 2 years. The case was managed by tumor excision and a naso-labial transposition flap. To our knowledge, this is the first report of Marjolin's ulcer developing on post-burned skin of the nose.

An unusual long-term complication of burn injury: malignant fibrous histiocytoma developed in chronic burn scar

Development of malignant tumors in chronic burn wounds is a well-known complication. These tumors are almost always squamous cell carcinomas, although other types of malignancies such as basal cell carcinoma, malignant melanoma and sarcomas can be seen rarely. There are only three previously reported cases of malignant fibrous histiocytoma developed in chronic burn scar in the literature. Two cases with malignant fibrous histiocytoma developed in chronic, badly treated burn wounds are presented. One of the tumors was multifocal and overexpression of the p53 gene was present. Both tumors were excised widely and skin grafted. Regional lymph node dissection was performed in one case. One of the patients died due to tumor recurrence and lymphatic metastases. These cases represent a very uncommon complication of burn injury and indicate the importance of the appropriate primary treatment of the burn wound.