How to manage burn wounds with a high risk of malignancy?

Management of Burn Wounds with Malignancy Risk

For chronic burn wounds suspected of malignant transformation (Marjolin's ulcer), perform immediate biopsy and proceed with aggressive wide local excision followed by reconstruction with free tissue transfer or regional flap rather than skin grafting, as these lesions behave aggressively once they break free of the scar. 1

Recognition and Diagnosis

High-Risk Features Requiring Biopsy

• Any chronic burn wound or scar that fails to heal, particularly after a latency period averaging 29-31 years, should be biopsied to rule out malignant transformation 1, 2
• Suspect Marjolin's ulcer when patients present with itchy, painful ulceroproliferative masses in old burn scars, especially those causing new symptoms like discomfort or difficulty with movement 3
• The extremities (particularly lower extremities) are the most common sites, followed by the scalp, though any anatomic location including the perineum can be affected 2, 3
• Most cases present in patients over age 50, though no age is immune to this complication 2

Pathologic Spectrum

• Histologic findings in suspected chronic burn wounds include: 21% chronic ulcer, 21% pseudoepitheliomatous hyperplasia, and 58% frank malignancy (predominantly squamous cell carcinoma, occasionally leiomyosarcoma or basosquamous carcinoma) 1, 2
• Pseudoepitheliomatous hyperplasia, which is difficult to distinguish from squamous cell carcinoma and represents a transitional state toward malignancy, should be treated as aggressively as confirmed malignancy 1

Surgical Management

Definitive Treatment Approach

• Perform aggressive wide local excision with adequate margins rather than conservative debridement, as Marjolin's ulcers become increasingly aggressive once they escape the confines of the scar tissue 1
• Reconstruction should utilize free tissue transfer or regional flap transposition for definitive coverage, not split-thickness skin grafting, which is inadequate for these lesions 1
• For confirmed malignancy, individualize surgical planning based on tumor grade, with low-grade malignancy and well-planned surgery offering the best prognosis 2

Adjuvant Therapy

• Adjuvant radiotherapy should be incorporated into the treatment plan alongside surgical excision for optimal outcomes 2
• The management course may need modification based on factors beyond surgical excision alone, particularly in cases with higher-grade malignancy 2

Follow-Up and Surveillance

Monitoring for Recurrence

• Close surveillance for early signs of disease recurrence is paramount, as locoregional recurrence or lymph node metastasis occurs in approximately 42% of cases (8 of 19 patients in one series) 2
• Recurrence typically manifests as lymph node enlargement and/or locoregional metastasis, often within the first year after intervention 2
• Mortality is high among recurrent cases, with 75% (6 of 8) dying within one year of recurrence detection 2

Prevention Strategies

Primary Prevention

• Proper initial wound care and early surgical management of burns, including timely excision and grafting, are essential to prevent chronic scar formation that predisposes to malignant transformation 3
• Regular surveillance of chronic burn scars, particularly those persisting beyond 20-30 years, can facilitate early detection 1, 2

Critical Caveats

Important Distinctions

• While Marjolin's ulcer is a severe complication requiring aggressive management, population-based epidemiological data shows that burn injuries in general do not increase the overall risk of skin cancer (SIR 0.88 for both squamous cell carcinoma and melanoma), even with 20-39 years of follow-up 4
• The malignant transformation rate of burn scars into Marjolin's ulcer is less than 2%, making this a rare but serious complication when it occurs 3
• The key distinction is between acute/healed burns (which carry no increased cancer risk) versus chronic non-healing burn wounds or unstable scars (which have significant malignancy potential) 1, 4

Prognostic Factors

• Best outcomes are associated with: early accurate diagnosis, low-grade malignancy, well-planned individualized surgery, and adjuvant radiotherapy 2
• Delayed treatment due to inadequate medical care, limited healthcare access, or societal stigma (particularly for burns in sensitive areas) leads to worse outcomes through chronic scar contracture and eventual malignant transformation 2, 3