Management of Marjolin's Ulcer
Radical surgical excision with wide margins (2-5 cm) is the definitive treatment for Marjolin's ulcer, and any chronic wound that fails to heal or shows suspicious changes warrants immediate biopsy to rule out malignant transformation. 1, 2
Diagnostic Approach
Biopsy is mandatory for any chronic wound showing the following features 3, 4:
- Non-healing despite appropriate wound care
- Changes in wound appearance (raised edges, friable tissue, bleeding)
- Development in burn scars, pressure ulcers, venous stasis ulcers, or traumatic wounds
- Average latency period of 25-35 years from initial injury, though acute variants can occur within 1 year 3, 1
The most common histological finding is well-differentiated squamous cell carcinoma, which occurs in the majority of cases 3, 1, 2
Surgical Management
Wide local excision is the cornerstone of treatment 1, 2:
- Excision margins of 2-5 cm beyond visible tumor to ensure complete removal 1
- Immediate reconstruction with skin grafting or flap coverage after excision 1, 2
- Regional lymph node dissection should be performed if nodes are clinically involved or imaging suggests metastases 5, 1
Critical Surgical Principle
Do not perform simple excision or debridement of suspicious chronic wounds - the scar tissue may act as a barrier containing the tumor, and releasing this barrier without adequate margins permits aggressive tumor spread 5. This underscores why radical excision with wide margins is essential from the outset.
Adjuvant Therapy
A combined aggressive approach is necessary for advanced disease 5:
- Postoperative radiotherapy for cases with positive margins, lymph node involvement, or high-risk features 5
- Chemotherapy may be considered in metastatic disease 5
- Amputation should be considered for extensive extremity involvement where limb-sparing surgery cannot achieve adequate margins 5, 1
Prognosis and Follow-up
Marjolin's ulcers are highly aggressive with poor prognosis 1, 2:
- Higher rates of regional metastases compared to primary squamous cell carcinoma 1
- Mortality is significant, particularly in advanced cases 1, 2
- Early detection and aggressive surgical management yield the best outcomes 2
Prevention Strategy
Meticulous wound care is crucial for prevention 1:
- Aggressive early treatment of burn wounds with excision of eschar 1
- Proper management of chronic wounds (pressure ulcers, venous stasis ulcers) 4
- High index of suspicion - any chronic wound present for years should be monitored closely for malignant changes 3, 4
Common Pitfalls to Avoid
- Never delay biopsy of a non-healing chronic wound - the insidious nature of Marjolin's ulcer often leads to late diagnosis and poor outcomes 1
- Avoid inadequate surgical margins - simple excision or debridement is insufficient and may worsen prognosis 5
- Do not underestimate the aggressive nature - these tumors metastasize more frequently than typical cutaneous squamous cell carcinomas 1
- Recognize that any body location can be affected, though extremities and scalp are most common 1, 2