Systematic Review of Modern Case Series of Squamous Cell Cancer Arising in a Chronic Ulcer (Marjolin's Ulcer) of the Skin

Abstract

Purpose: Marjolin's ulcer is an aggressive cutaneous malignancy that arises in chronic nonhealing wounds. A review of modern series describing Marjolin's ulcer would be helpful in defining optimal management strategies and expected outcomes.

Methods: A systematic review was performed on October 18, 2018, by querying Medline and EMBASE. Key inclusion criteria were as follows: human studies, English language, published in 2000 or later, > 10 patients, and at least 80% of the patients having squamous cell carcinoma (SCC) histology.

Results: There were 599 patients in 14 case series from 10 countries; 82% of patients were from low-income and middle-income countries, and 48% were women. Overall, 65% of the ulcers were preceded by burns. Mean latency ranged from 11 years to 41 years (median, 28 years). Lower extremities were the most common site (62%). Differentiation was reported as well differentiated (64%), moderately differentiated (27%), or poorly differentiated (9%). Almost one third of cases were clinically node positive, though only 7% of all cases (24 of 334) were confirmed to be pathologically involved. Distant metastasis rates were reported in only 7 series, with median rate of 5% (range, 0%-27%). The main treatment modality was surgical excision (71%), followed by amputation (24%), primary radiotherapy (2%), and chemotherapy (< 1%). Outcomes data varied in content and quality. Mortality rates were 12%, 24%, and 37% in the three series reporting between 2 and 3 years of follow-up.

Conclusion: Marjolin's ulcer with SCC histology is an aggressive cancer with a notable potential for lymph node metastasis and distant metastasis. Comprehensive staging is recommended, with management optimally having a multidisciplinary context. Low- and middle-income countries are overrepresented in reports of Marjolin's ulcer, and there may be opportunities for prevention and early detection.

FIG 1

PRISMA flow diagram for identifying studies of modern case series of squamous cell cancer arising in a chronic ulcer (Marjolin's ulcer) of the skin.

FIG 2

Countries reporting Marjolin’s ulcer in identified case series. Reporting countries are colored light blue. Eight of ten were low-income or middle-income countries.

FIG A1

Search strategy for modern series of Marjolin’s ulcer.