Review Question - QID 107583

This patient presents with a previous wound that has been repeatedly healing and breaking down over the last 20 years. New features of ulceration and elevated edges most likely represent a marjolin ulcer, conversion of this chronic wound to squamous cell carcinoma.

Marjolin ulcers occur after long term damage to the skin that prevents complete healing. These usually occur in cases with damage to the skin with acute (such as gunshot wounds and burns) or chronic (such as damage due to peripheral neuropathy in diabetes or venous congestion in the lower extremities) precipitating events. The transition of an old wound to a wound that starts ulcerating, bleeding, and growing more rapidly may be indications of transition to squamous cell carcinoma.

Pekarek et al. discuss the diagnosis and management of marjolin ulcers. They state that though these normally present 10 years or more after the initial wound, some cases have been documented as soon as 6 weeks after the initial wound. They also state that despite no official guidelines for treatment, most cases are treated with wide excision and skin grafting or amputation proximal to the wound.

Challa et al. note that though these ulcers normally occur post-open wounds, etiologies such as underlying osteomyelitis can cause marjolin ulcers in diabetic patients who may be immunocompromised. In their restrospective review, they conclude that marjolin ulcers occur more commonly on the extremities, but when they occur on the trunk, they are more likely to be diagnosed with distant metastases.

Figure A shows the biopsy of a marjolin's ulcer. It reveals squamous cells with keratin pearls surrounded by cells with areas of high nucleus to cytoplasm ratio. This is significant for squamous cell carcinoma.

Incorrect Answers
Answer 1: Basal cell carcinoma is the most common type of skin cancer and typically occurs above the lips and presents with rolled edges.
Answer 3: A melanoma is typically hyperpigmented and presents with ABCDEs (asymmmetry, irregular border, nonuniform color, increasing diameter, evolving shape/color).
Answer 4: Actinic keratosis is a lesion which occurs in elderly patients in sun exposed lesions and can progress to squamous cell carcinoma but is not associated with chronic wounds.
Answer 5: Seborrheic keratosis is often described as a "stuck on" hyperpigmented lesion which does not progress to squamous cell carcinoma.