a power point presentation on marjolin's ulcer

1. Marjolin’s ulcer
Dr Okpako Isaac Oghenero
Senior Registrar plastic and Reconstructive surgery
University of Abuja Teaching Hospital
Gwagwalada
21/04/24

2. Outline
• Introduction
• Definition
• Historical perspective
• Epidemiology
• Statement of surgical importance
• Risk factors
• Pathogenesis
• Theories of development of marjolin’s ulcer
• Clinical types
• Clinical features
• Investigations
• Treatment
• Prevention
• Prognosis
• Current trend
• Conclusion
• References

3. Introduction
• Definition
• Marjolin’s ulcers are malignant
cutaneous ulcers arising from
areas of chronic irritation

4. Introduction - Historical perspective
• in AD 100, Celcius was the first to observe malignant transformation in burn
scars.
• In 1828, Jean Nicholas Marjolin, a French surgeon, described two simple leg
ulcers with warty changes as 'Ulcer canchroides', this was published in an article
in the French Dictionaire de Medicine, at that time he did not recognize the
malignant nature of the ulcer
• A more detailed description of these lesions was later made by Dupuytren.
• Byron and Smith in 1844 and 1850 respectively confirm these conditions as
carcinomas. They described cancers arising in burn scars, scars from flogging as
well as other forms of trauma
• However it was Da Costa that first use the term 'Marjolin's ulcer' in 1903 to
describe ulcer arising from simple leg ulcers

5. Introduction - EPIDEMIOLOGY
• Occurs predominantly in middle aged group with a report average age
group of 53 to 59 years
• Onset at 44 years in India (Sisrat and Shrikhande)
• Average onset in south Eastern Nigeria 44.1 years (Asuquo etal)
• Male greater than female 2-3:1

6. Introduction - Statement of surgical importance
• A good knowledge of marjolin
ulcer is necessary in prevention
early detection and appropriate
management of the condition

7. Risk factors
• Chronic leg ulcers
• Burn scars
• Osteomyelits sinuses
• Pressure sore
• Urinary fistulas
• Pilonidal sinuses
• Gumata
• radiation scars
• Scars from flogging

8. Pathogenesis
• Ewing formulated a set of criteria to establish the relationship between trauma
and development of cancers and this was adapted by treves and park in burns
scar
• The cancer must arise within the boundaries of the scar or wound.
• Incontrovertible evidence of trauma or the pre-existing ulcer as evidenced by the wound
or scar.
• The absence of any precursory or similar neoplasm on the site of the trauma/wound prior
to the development of the cancer
• The histologic variety of the cancer must be compatible with the tissues found in the site
of the trauma or scar/wound
• The interval time between the trauma/ulcer and the onset of the cancer must be
appropriate.
• A period of one month has been proposed as the minimum acceptable time
between the trauma/ulcer and the onset of the cancer

9. Classification
• Acute
• Usually within one year latency period
• Chronic
• Latency period last for more than a year

10. Parts of the body commonly affected
• Lower limbs 40%
• Head and neck region 30%
• Upper extremities 20%
• Trunk 10%

11. Theories of development of marjolin’s ulcers
• These theories tries to explain the evolution of marjolin’s ulcer however
non fully explains all aspect of the development
• Virchow theory of chronic irritation
• Friedwald and Rouse co-carcinogenic theory
• Treves and Pack toxin theory
• Ribet's theory of epithelial element implantation
• Castillo and Goldsmith immunologically privillaged site theory
• Hereditary theory
• Environmental and genetic interaction theory
• Multifactorial theory

12. Theories of development of marjolin’s ulcers
• Theory of chronic irritation
• This theory explains that with chronic irritation and repeated tissue injuries attempts at healing
becomes increasing difficult resulting in unstable epithelium which eventually loss contact inhibition and
undergoes malignant changes
• Co-carcinogeneic theory
• This theory proposes an initator and promoter phase- where the initiator phase developes a dormant
neoplastic cells which when acted upon by the promoter forms marjolins ulcer and in the case of burn
the burn injury may be the initator while actinic radiation or some other agents such as chronic
irritation may serves as the promoter in the formation of marjolins ulcer

13. Theories of development of marjolin’s ulcers
• Toxin theory
• This theory suggest that as a result of tissue damage, toxins are released
which result in a nutritional deficiency at the cellular level. This compromises
the ability of the cells to effect tissue repairs following carcinogenic insults
with attendant accumulation of mutated DNA and subsequent malignant
changes
• Epithelial element implantation
• This theory postulates that epithelial cells implanted into the dermis during
injury undergoes a disordered regenerative process leading to carcinomatous
changes

14. Theories of development of marjolin’s ulcers
• Immunologically privileged site theory
• This theory states that due to poor lymphatic flow to scar tissue immunosurvelance
is impaired making it difficult for the body to mount effective antigen-antibody
response to proto-oncogens or tumour within the scar this allows the tumour to
escape early recognition by the host
• Hereditary theories
• This theory states that the genetic composition of the host is susceptible to
development of the disease this is supported by the findings of p53 and Ras genes
in patient with marjolins ulcer

15. Theories of development of marjolin’s ulcers
• Environmental and genetic interaction theory
• This theory explains that the evolution of acute Marjolin's ulcers, occurs
because the genetic makeup of the individual is more susceptible to the
environmental insult, resulting in a short latent period.
• Multifactorial theory
• This proposes that a combination of the above theories will best explain the
process of evolution of Marjolin's ulcer

16. Clinical Types
• Flat indurated, infiltrative,
ulcerative marjolin’s ulcer.
(poorer prognosis)
• The less frequent exophytic
papillary form

17. Clinical features
• Symptoms
• Latent period of at least 4 weeks post excision or one year post injury
average of about 20 to 40 years
• Presence of an ulcer or a scar
• Dull aching pain
• Change in the nature of discharge if present and this may change to
offensive smell and sometimes hemorrhagic

18. Clinical features
• Signs
• Tenderness
• Ulcer usually begins at the edge of the scar which may show some warty changes with
some elevation
• Occasionally there is appearance of a mass within the scar or ulcer
• The base becomes increasing indurated and granular often with necrotic floor and
blood clot
• Healing may occur in some areas where sloughing has occurred thus presenting a
deceptively innocuous appearance
• Progression of the ulcer to involve deeper tissues
• It is also important to note that all the signs of malignant transformation must not
necessarily be present to draw a suspicion of Marjolin's ulcer

19. Spread
• Direct invasion mainly and
• in the late stage by lymphatic spread

20. Diagnosis
• To confirm diagnosis
• Histology (from the edge and as well as the center)- excision / incision
• Forms
• Squamous cell carcinoma
• Basal cell carcinoma
• Malignant melanoma
• Fibrosarcoma
• Liposarcoma
• Occasionally more than one histologic type can be found e.g basosquamous Ca

21. Diagnosis
• To know extent of disease
• Plain radiographs
• CT scan
• MRI
• Typical features seen on imaging are soft tissue mass, bony destructions and periosteal
reaction
• To prepare patient for surgery
• FBC
• E/U/Cr
• LFT

22. Treatment
• Surgery
• Excision biopsy
• A margin of 2cm is generally
recommended
• Skin grafting and flap
• Excision biopsy +/_ lymph node
dissection
• Amputation

23. Treatment
• Radiotherapy
• Though the tumors show poor response to radiotherapy due to their
poor vascularity it can be used for palliation
• Chemotherapy
• Intra-arterial perfusion with methotrexate however due to the poor
vascularity response is mostly poor however Novick et al reported
improved outcome and recommended it as a useful adjunct

24. Prevention
• Primary
• prevention of burn wound and ulcers
• Secondary
• Early and prompt treatment of burn wound and ulcers
• Early skin grafting
• Tertiary
• Prevention/ reduction of sun exposure to scars
• Early excision

25. Current trend
• Prevention of marjolin’s ulcer

26. Prognosis
• Location – lower limbs are more likely to have worse prognosis
• Latent period – a short latent period has worse prognosis
• Histologic types – SCC has worse prognosis
• Tumor size > 2cm
• Grade of tumor – poorly differentiated tumor has poor prognosis
• Tumor with little/ no peritumoral T lymphocyte infiltration has poor prognosis
• Metastasis – has poor prognosis
• Tumor from pressure sore

27. Conclusion
• Marjolin’s ulcers are malignant cutaneous ulcers arising from areas of
chronic inflammation
• Prevention is a better option

32. •Thank you

33. References
• Kingsley O.O, Otene I. C. Marjolin’s Ulcers: A Review The Nigerian Health Journal, Vol. 11, No 4, October - December, 2011
• Treves N, Pack GT: The development of cancer in burn scars. Surg Gynecol Obstet 1930, 51:749-782. st2. Marjolin JN. Ulcers.
Dictionaire de Medicine. Vol.21, 1 ed. Paris: Bechet Jeune, 1828: 46
• Applebaum J, Burrows WM, Greenway HJ. Acute Marjolin's ulcer. J Assoc Mil Dermatol 1985;11: 57-61
• Nancarrow JD. Cicartrical cancer in South-West England: a regional plastic surgery unit's experience over a 20 tear period. Br J Surg.
1983:70;205-208
• Cruickshank AH, Connel EM, Miller DG. Malignancy in scars, chronic ulcers and sinuses. J Clin Pathol 1963;16:573-80
• Smith J, Mello LF, Nogueira Neto NC, et al. Malignancy in chronic ulcers and scars of the leg (Marjolin's ulcer): a study of 21 patients.
Skeletal Radiol 2001;30(6):331-7.
• Castillo J, Goldsmith HS. Burn scar carcinoma. Cancer J. Clin. 1968;18:140-142
• Sisrat MV, Shrikhande SS. Histochemical studies on squamous cell carcinomas of the skin arising in burn scars with special reference to
histogenesis. Indian J. Cancer. 1967;3:157-169
• Novick M, Gard DA, Hardy SB, Spira M. Burn scar carcinoma: A review and analysis of 46 cases. The Journal of Trauma. 1977;10:809-
817.
• Engler HS: Cancer arising in scars of old burns. J Med Assoc Ga 1968; 57:145 11. Nthumba PM. Marjolin's ulcers in sub Saharan Africa.
World J Surg. 2010;34:
• Asuquo ME Ikpeme IA, Bassey EE, Ebughe G. Squamous Cell Carcinoma in South-Eastern Equatorial Rain Forest in Calabar, Nigeria.
• Stauffer H: Zeistschr Krebsforsch . 1929;28:418Eplasty. 2009; 9: e53