What is the best course of treatment for a 57-year-old male patient with a chronic non-healed indurated ulcer with rolled elevated margins at the posterolateral side of the knee, suspected to be Marjolin's ulcer, 20 years after a thermal burn?

Management of Marjolin's Ulcer in a Post-Burn Patient

Wide local excision with flap reconstruction is the recommended treatment for this patient with a suspected Marjolin's ulcer on the posterolateral side of the knee.

Clinical Assessment and Diagnosis

This 57-year-old male presents with classic features of Marjolin's ulcer:

• History of thermal burn 20 years ago
• Chronic non-healing ulcer
• Indurated ulcer with rolled elevated margins
• Location at posterolateral side of the knee
• No clinically detected lymphadenopathy

These features strongly suggest malignant transformation of the chronic burn scar, most likely into squamous cell carcinoma (SCC), which is the most common histological type of Marjolin's ulcer 1.

Treatment Algorithm

Step 1: Confirm Diagnosis

• Perform an incisional biopsy to confirm malignancy before definitive treatment
• This is essential as Marjolin's ulcers are frequently overlooked and inadequately treated 1

Step 2: Staging Workup

• Perform baseline imaging (chest radiograph, CT and/or PET/CT) to evaluate for metastatic disease 2
• Ultrasound examination of regional lymph nodes (inguinal in this case)

Step 3: Definitive Treatment

For this patient with no detected lymphadenopathy:

1. Wide local excision with flap reconstruction is the optimal first-line treatment

   • Ensures complete removal of the malignancy with adequate margins
   • Provides appropriate soft tissue coverage for the knee joint area
   • Aligns with guideline recommendations for surgical excision with negative margins 2

2. Sentinel lymph node biopsy (SLNB) should be considered despite clinically negative nodes

   • Research shows SLNB can identify occult nodal metastases in up to 80% of cases 3
   • This is particularly important as 30.23% of SCC Marjolin's ulcers exhibit sentinel lymph node metastasis 4

Step 4: Further Management Based on Pathology Results

If SLNB is positive:

• Complete lymph node dissection (inguinal in this case) is indicated 4
• Consider adjuvant radiotherapy 5

If deep invasion or aggressive features are found:

• More radical surgery may be necessary in cases of advanced disease 4

Rationale for Treatment Selection

Option A (Wide local excision with flap reconstruction) is superior because:

• It provides definitive treatment for the primary lesion
• It ensures adequate soft tissue coverage for the knee joint area
• It allows for proper oncological margins while preserving limb function
• It aligns with guideline recommendations for surgical management of malignant skin lesions 2

Option B would be insufficient as initial management without first confirming lymph node involvement.

Option C would be overly aggressive without evidence of lymph node metastasis and could lead to unnecessary morbidity.

Important Considerations

• Marjolin's ulcers are aggressive in nature with high metastatic potential compared to primary cutaneous malignancies 4
• The knee location requires careful reconstruction to maintain function
• Scar tissue may act as a barrier for tumors; releasing this barrier without adequate margins could permit tumor spread 5
• Long-term follow-up is essential as recurrence rates are high

Pitfalls to Avoid

• Underestimating the malignant potential of chronic ulcers in burn scars
• Inadequate surgical margins leading to recurrence
• Neglecting lymph node evaluation despite clinically negative nodes
• Delayed diagnosis and treatment, which significantly worsen prognosis 1
• Failing to obtain proper tissue diagnosis before definitive treatment

Wide local excision with flap reconstruction represents the optimal balance between oncological control and functional preservation for this patient with a suspected Marjolin's ulcer at the posterolateral knee.