When should a Marjolin ulcer be biopsied?

When to Biopsy Marjolin Ulcer

Any non-healing wound or chronic ulcer with suspicious features should be biopsied immediately to rule out Marjolin ulcer, as early diagnosis significantly improves mortality and morbidity outcomes. 1

Clinical Indications for Biopsy

Mandatory Biopsy Situations

• Non-healing wounds lasting longer than 4 weeks 1
• Rapidly growing wounds, especially those with exuberant granulation tissue 1
• Deep, punched-out ulcers with raised or rolled edges 1
• Areas of hyperkeratosis surrounded by a shoulder of raised skin 1
• Wounds with altered sensation (tingling or increased pain) 1
• Any chronic wound with suspicious changes in appearance, size, or symptoms 1, 2

High-Risk Scenarios Requiring Heightened Vigilance

• Long-standing burn scars (most common precursor) 3, 4
• Chronic wounds in patients with:
  • Previous trauma sites 3
  • Venous stasis ulcers 3
  • Pressure ulcers 5
  • Chronic fistulas 3, 6

Biopsy Technique

Recommended Approach

• Punch biopsy, shave biopsy, or excisional biopsy depending on lesion characteristics 1
• Ensure adequate size and depth to provide sufficient tissue for accurate diagnosis 1
• For suspicious ulcers, biopsy should include:
  • Base of the ulcer
  • Edges of the ulcer (particularly important) 1
  • Multiple biopsies if the lesion has different morphological characteristics 1

Pre-Biopsy Considerations

• Perform blood tests before biopsy to exclude contraindications 1:
  • Full blood count
  • Coagulation studies
  • Fasting blood glucose

Diagnostic Evaluation

Histopathological Assessment

• Well-differentiated squamous cell carcinoma is the most common histological type 3
• Request specific histopathological assessment for:
  • Tumor grade
  • Depth of invasion
  • Margins 1

Post-Biopsy Management

• If initial biopsy is inadequate for accurate diagnosis, repeat biopsy should be performed 1
• For confirmed Marjolin ulcer, complete staging workup is necessary to guide treatment 1

Special Considerations

Acute vs. Chronic Marjolin Ulcer

• Acute Marjolin ulcers develop within 12 months of injury 2
• Chronic Marjolin ulcers develop after 12 months (average 35.9 years in extremity lesions) 4
• Both types require the same aggressive diagnostic approach 2

Pitfalls to Avoid

• Delaying biopsy of suspicious chronic wounds (leads to poor prognosis) 3
• Inadequate sampling (can miss malignant areas) 1
• Misdiagnosing as simple inflammatory changes 5
• Failing to consider Marjolin ulcer in acute wounds (can occur in wounds less than 12 months old) 2

Conclusion

Marjolin ulcers are aggressive malignancies with high metastatic potential (40.3% regional lymph node metastasis reported in one series) 4. The high mortality rate associated with delayed diagnosis necessitates early biopsy of any suspicious chronic wound. Remember that any non-healing wound, regardless of duration, should be considered for biopsy to rule out malignant transformation.