Image of the Month—Diagnosis

Abstract

Marjolin Ulcer C linical suspicion led to an incisional biopsy, the specimen of which demonstrated a verrucous squamous cell carcinoma. Inguinal lymph nodes were not palpable. The patient was taken to the operating room for wide local excision and skin grafting. Further histopathologic examination of the excised lesion revealed a moderately differentiated squamous cell carcinoma measuring 11ϫ6.5 cm with a depth of 15 mm and clear excisional margins. The patient made an uneventful recovery. The patient was closely followed up and at 15 months remained free of recurrence. Marjolin ulcer is a malignant change in a longstanding ulcer and/or scar tissue. Commonly, these lesions are treated as chronic ulcers or infections, leading to delayed diagnosis and resulting in the need for more extensive surgery and increased risk of metastasis. 1 Suspicion of malignant change should be raised with crusting, ulceration of scar tissue, increase in pain or size of the ulcer, and bleeding. 2 Marjolin ulcers have a 1% to 2% incidence in all burns but can also develop from previously traumatized and scarred tissue of other etiologies. 3 The malignant transformation has no predilection for race but is more predominant in the late 50s, with a typical lag time after injury of 20 to 40 years. 4 Malignant transformation presents as squamous cell carcinoma in 75% to 96% of the cases. Other neoplasms, such as basal cell carcinomas, melanoma, osteogenic sarcoma, fibrosarcoma, and liposarcoma, have been reported. 5,6 Grades of differentiation vary and are described as well differentiated (35%), moderately differentiated (55%), and poorly differentiated (10%). 7