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Home , Ulcer (dermatology)

Burn Carcinoma: Patients With Marjolin’s

George S. Midla, MPAS, MAED, PA-C, CP; Misty Carrillo, MLIS; and Reginald Richard, MS, PT

Marjolin’s ulcer is a malignant tumor often associated with thermal injuries. While this tumor has a long latency period, early identification and management of Marjolin’s ulcer is paramount to a good prognosis.

hermal injuries are common , tropical ulcers, frostbite, vacci- ties more often than upper extremi- in the battlefields of Afghani- nation sites, hidradenitis suppurativa, ties), 30% on the head and neck, stan and Iraq. As a result, med- gunshot wounds, puncture wounds, and 10% on the trunk. The flexor Tical training and treatment and dog bites.4,5,6 Marjolin’s ulcers are surfaces are also more prone to the for burns has advanced, improving usually slow to develop, appearing, development of these malignancies functional and cosmetic outcomes on average, 31 years after the injury.7 due to the constant trauma associated for burn survivors. However, despite Although very rare, reports have iden- with movement and a compromised these advances, serious complications tified tumors arising from scar tissue blood flow.3,11 Men are more likely from thermal injuries still occur and in < 1 year.8 Marjolin’s ulcers are clas- than women to develop the condition elude diagnosis. Marjolin’s ulcer is an sified as acute when development is at a ratio of 3 to 1.1,5 Burned areas example of a late, malignant compli- < 1 year and chronic when their oc- healed by secondary intention have cation of from burn sites, which currence is > 1 year postburn.2,8 been identified as a major risk fac- are at a risk of developing this aggres- Marjolin’s ulcer develops in about tor in the development of Marjolin’s sive carcinoma.1,2 Both patients and 2% of burn scars and accounts for ulcers. Wounds that are resurfaced providers need to be aware of Marjo- about 1% of all .8,9 Can- with a skin graft or flap are less likely lin’s ulcer in order to ensure effective cers arising from burn tissue dem- to become cancerous.12 Burns that screening, diagnosis, and treatment of onstrate different histologic trends have difficulty healing after initial these tumors. compared with other skin cancers. treatment should be observed care- Jean-Nicolas Marjolin described Nonmelanoma skin cancers in the fully for any , as these sites are the development of tumors in burn United States are 80% basal cell car- also more likely to produce Marjolin’s scars in a seminal report in 1828.3 cinoma (BCC) and 20% squamous ulcers.7 All treatments that promote Case reports eventually established cell carcinoma (SCC).10 A literature quick and suitable healing will lessen that the tumors Marjolin identified review by Kowal-Vern and Criswell the risk of the disease. were malignant. Marjolin’s ulcers examined 412 cases of Marjolin’s are most frequently associated with ulcers and found that 71% were SCC, PATHOLOGY thermal injuries but have also been 12% BCC, 6% malignant , The pathophysiology of carcinoma reported in discoid erythema- 5% sarcoma, 4% other neoplasms, development in burn scars is not tosus, pilonidal sinus, operative scars, 1% squamous-basal cell, and 1% known, although multiple theories chronic , chronic ve- squamous cell-melanoma.7 It has have been suggested. Toxins released nous ulcers, chronic fistulae, chronic been suggested that in Marjolin’s slowly over time, due to the unstable radiation dermatitis, , diabetic ulcer, SCC develops from loca- nature of the tissue, might contrib- tions that have full thickness burns, ute to malignant changes.13 Burn scar whereas BCC develops when a burn sensitivity to sunlight and chronic MAJ Midla is an associate professor of dermatol- leaves the sweat glands and hair fol- are also sus- ogy at the Interservice Physician Assistant Pro- 8 gram and a physician assistant at Brook Army licles intact. pected in the development of Marjo- Medical Center, Ms. Carrillo is a librarian at Stim- The most common sites for Mar- lin’s ulcer.8 The scar may be subjected son Library at the US Army Medical Department jolin ulcers are the extremities and to ongoing microtrauma as a result of Center and School, and Mr. Richard is a burn re- habilitation clinical research coordinator for the US scalp. The distribution pattern is 60% being elevated above the surround- Army Burn Center, all in Fort Sam Houston, Texas. on the extremities (lower extremi- ing skin, being unable to slide over

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been reported to be metastatic in 20% to 36% of cases.14 Regional lymph nodes are the most common site of metastasis, although other lo- cations may occur.12 It has been sug- gested that lymph-node dissection should be carried out only if they are palpable during an exam. How- ever, early metastasis may not afford palpable lymph nodes, and routine dissection may be warranted in this aggressive carcinoma.2,4,14,15 Sentinel lymph-node may also be used to correctly evaluate this condition. In this procedure, a tracer substance is injected into the at the site of the ; this substance is then fol- Figure 1. A 55-year-old male with previous burn to left lower leg at age 6 years. A well- lowed to the sentinel lymph node(s). differentiated SCC (Marjolin’s ulcer) of the inferior ulcer margin was identified after This procedure is minimally inva- previous were negative for carcinoma. sive and allows for correct staging.16 Radiotherapy has also been used in subcutaneous tissue, and having de- agnosis. The average latency period treatment but is considered contro- creased elasticity. All these conditions is 31 years, but there have been rare versial.2,5 may cause repeated micro-injuries, cases of earlier development.7 To ex- After surgical correction of a Mar- triggering the development of a car- clude previous conditions, the mini- jolin’s ulcer, a plan should be devel- cinoma.7,13 Continued pruritus of mum time to tumor development is 1 oped for home screening and regular the scar promotes repetitive trauma, month to 3 years postburn.5 visits to a provider to monitor for new which could lead to a malignant Marjolin’s ulcer should be ruled ulcers or metastases. If a new ulcer tumor. Decreased vascularity and a out if a patient describes the develop- develops, the should be surgi- depressed immunologic state in the ment of an ulcer within the boundar- cally removed, even if it has not been damaged tissue may also lead to a ies of a burn scar that increases in size, diagnosed as malignant.4 Overall sur- malignant development.12 Finally, he- persists, crusts, bleeds, or is painful. vival rates have been reported to be redity may also be a factor in the oc- Furthermore, prescribing antibiot- 52% at 5 years and 34% at 10 years.6 currence of Marjolin’s ulcer.7 ics and regular dressing changes for a burn scar ulcer will only delay diag- CONCLUSION IDENTIFICATION nosis and complicate treatment later The delay in the diagnosis of Marjo- Timely identification of Marjolin’s in the course of the disease. Multiple lin’s ulcers continues to be an obstacle ulcer is paramount to a good progno- punch biopsies should be taken from to the proper care and the positive sis. This aggressive carcinoma can be the tumor and at the outer edge to outcome of patients. A good outcome detected early only if there is a high confirm a diagnosis (Figure 1).5 Mag- requires a high index of suspicion, level of suspicion by both the clini- netic resonance imaging will provide familiarity with the risk factors, and cian and patient. To be diagnosed as a better understanding of the extent recognition of the early signs of the a Marjolin’s ulcer, the tumor must ap- of , neurovascular, and soft-tissue disease. The importance of the early pear within the boundaries of the scar involvement and may be indicated be- diagnosis of Marjolin’s ulcer cannot tissue, and there should be no pre- fore sugery.9 Once the tumor is iden- be overemphasized. Treatment with vious history of a tumor at the site. tified, a wide excision with a 2-cm a wide surgical excision and regular The cell types of the tumor and the margin should be performed.1,2 Re- visits to a provider for monitoring skin should be similar, and the time constructive surgery may be necessary should be included in the medical of tumor development postinjury for tumors that are extensive. plan. Finally, those returning from should be sufficient to support the di- This aggressive carcinoma has U.S. current conflicts with burn in-

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9. Ozercan IH, Okur MI, Coskun F, Yildirim AM. Ma- juries should be advised of the im- verse effects—before administering lignant fibrous histiocytoma and squamous car- portance of monitoring their skin for pharmacologic therapy to patients. cinoma derived from a burn scar. Acta Chir Belg. 2004;104(6):745-747. changes. l 10. Habif TP. Clinical Dermatology. 4th ed. China: Mosby REFERENCES Elsevier; 2010:747. 1. Chiang KH, Chou AS, Hsu YH, et al. Marjo- 11. Bloemsma GC, Lapid O. Marjolin’s ulcer in an am- Author disclosures lin’s ulcer: MR appearance. AJR Am J Roentgenol. putation stump. J Burn Care Res. 2008;29(6):1001- The authors report no actual or poten- 2006;186(3):819-820. 1003. 2. Sengul G, Hadi-Kadioglu H. Penetrating Marjolin’s 12. Xie E, Li A, Wang S, Kang S, Cheng G-X. Burn scar tial conflicts of interest with regard to ulcer of scalp involving bone, dura mater and brain carcinoma: Case reports and review of the literature. this article. caused by blunt trauma to the burned area. Neuro- The Euro-Mediterranean Council for Burns and cirugia (Astur). 2009;20(5):474-477. Fire Disasters-MBC website. http://www.medbc.com 3. Olaitan PB, Ogbonnaya IS. Marjolin’s ulcers on the /annals/review/vol_5/num_2/text/vol5n2p102.htm. Disclaimer thigh two years after burn. Ann Burns Fire Disasters. Accessed October 16, 2010. 2007;20(3):159-160. 13. Goldberg NS, Robinson JK, Peterson C. Gigantic The opinions expressed herein are those 4. Daya M, Balakrishan T. Advanced Marjolin’s ulcer malignant melanoma in a thermal burn scar. J Am of the authors and do not necessarily of the scalp in a 13-year-old boy treated by excision Acad Dermatol. 1985;12(5, pt 2):949-952. and free tissue transfer: Case report and review of 14. Cobey FC, Engrav LH, Klein MB, Isom CN, Byrd reflect those of Federal Practitioner, literature. Indian J Plast Surg. 2009;42(1):106-111. DR. Brief report: Sentinel lymph node dissection and Quadrant HealthCom Inc., the U.S. 5. Mohamed S, Abdullah B, Singh DA, Heng KS. CT burn scar carcinoma sentinel node and burn scar appearances of Marjolin’s ulcer in the left gluteal carcinoma. Burns. 2008;34(2):271-274. Government, or any of its agencies. region of a young man. Biomed Imaging Interv J. 15. Eastman AL, Erdman WA, Lindberg GM, Hunt This article may discuss unlabeled or 2006;2(3):e26. JL, Purdue GF, Fleming JB. Sentinel lymph node 6. Agale SV, Kulkarni DR, Valand AG, Zode RR, Grover biopsy identifies occult nodal metastases in pa- investigational use of certain drugs. S. Marjolin’s ulcer: A diagnostic dilemma. J Assoc tient with Marjolin’s ulcer. J Burn Care Rehabil. Please review complete prescribing in- Physicians India. 2009;57:593-594. 2004;25(3):241-245. 7. Kowal-Vern A, Criswell BK. Burn scar neoplasms: 16. Asuquo M, Ugare G, Ebughe G, Jibril P. Mar- formation for specific drugs or drug A literature review and statistical analysis. Burns. jolin’s ulcer: The importance of surgical manage- combinations—including indications, 2005;31(4):403-413. ment of chronic cutaneous ulcers. Int J Dermatol. 8. Kannan RY, Rauf GK. Acute burn scar basal cell car- 2007;46(suppl s2):29-32. contraindications, warnings, and ad- cinoma. Ann Plast Surg. 2010;64(3):321-322.

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