Marjolin's ulcer. This entity was first described in 1828 by Marjolin, who diagnosed non-healing ulcers developing in burn scars. Later, Dupuytren found these ulcers to be malignant in nature.1 Today, the term Marjolin's ulcer is used to describe a cancer arising from any site of chronic inflammation. Ninety percent of Marjolin's ulcers develop from burn scars. Other sites include stasis ulcers, decubitus ulcers, granuloma inguinale, syphilitic lesions, and smallpox vaccination scars. They also may occur in sinus tracts from hidradenitis suppurativa, acne conglobata, or osteomyelitis.1
Marjolin's ulcers occur most often on the extremities and in wounds that have been present for 30 years or more.2 Clinically, they exhibit exuberant granulation tissue that spills over their well-defined margins onto the surrounding tissue. Histologic examination is consistent with squamous cell carcinoma in 95 percent of cases, although basal cell carcinoma, melanoma, and sarcomas also may be present.3
Marjolin's ulcers have a particularly aggressive course with higher rates of recurrence and overall metastasis compared with other forms of squamous cell carcinoma. The five-year survival rate is 30 percent. There is limited evidence on what percentage of treatment-resistant, non-healing ulcers reveal malignancy. Thus, experts recommend biopsy (i.e., wedge-shaped biopsy of the borders or multiple punch biopsies) of any non-healing ulcer resistant to standard intervention to rule out malignancy. Once diagnosed, wide excision followed by skin grafting is recommended. Although autologous skin grafting remains the gold standard, bioengineered skin substitutes such as cultured autologous and allogeneic keratinocyte grafts, composites, cellular and acellular matrices, and living skin substitutes also have been shown to stimulate healing by acting as an occlusive dressing while releasing tissue growth factors and cytokines. Elective lymph node dissection has been suggested because of the high rate of metastasis. Finally, amputation may be recommended for recurrent disease, or when a Marjolin's ulcer is associated with underlying osteomyelitis.The etiology for the malignant transformation is unclear. One suggestion is that previously traumatized skin may be more susceptible to mutation, and that fibrotic and avascular scar tissue may interfere with immune surveillance, resulting in the inability of circulating lymphocytes to reach and destroy neoplastic cells.
The differential diagnosis is broad and may include any non-healing ulcer such as venous stasis ulcers, diabetic ulcers, arterial ulcers, or pyoderma gangrenosum.