Marjolin's ulcer: a preventable malignancy arising from scars

Abstract

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.

Figure 1

Comparison of the concepts of MU, burn scar carcinoma, and scar tissue carcinoma. The intersection between MU and burn scar carcinoma represents the etiology and pathological outcome in common. SCC = squamous cell carcinoma; BCC = basal cell carcinoma.

Figure 2

Various paths to malignancy during the latency period. Ulcer formation is a key step between initial injury and final malignant transformation.

Figure 3

Relationship between the age of patients at initial injury and the length of the latency period.

Figure 4

Relationship between the pre- and post-ulceration periods.

Figure 5

Anterolateral thigh (ALT) flap reconstruction. (A) A 56-year-old male MU patient burned his left leg at the age of 29. (B) Preoperative design of a reverse-flow ALT flap. (C) Reverse-flow ALT flap measured 20 cm × 10 cm, was elevated during operation. (D) Area of ulceration widely excised and reconstructed with ALT flap three years postoperatively.

Figure 6

Superior gluteal artery perforator (SGAP) flap reconstruction. (A) A 68-year-old male gluteal MU patient injured at the age of 58. (B) Preoperative design of bilateral inferior gluteal artery perforator flaps. (C) Area of ulceration widely excised and covered with good results.

Figure 7

Anterolateral thigh (ALT) flap reconstruction. (A) A 35-year-old female MU patient had her scalp burned at the age of 6. (B) Anterior and lateral views of the patient, one year after wide excision and reconstruction with ALT flap.