Is medical management available for a patient with Marjolin's ulcer?

Medical Management for Marjolin's Ulcer

No, there is no effective medical management for Marjolin's ulcer—radical surgical excision is the only definitive treatment and must be performed urgently. 1, 2, 3

Why Surgery is Mandatory

Marjolin's ulcer is an aggressive squamous cell carcinoma arising in chronic wounds, burn scars, or chronically inflamed tissue, and it behaves far more aggressively than conventional squamous cell carcinoma. 1, 2, 3 The malignancy typically develops slowly over an average of 25-35 years after the initial injury, but once established, it demonstrates:

• High metastatic potential: Regional lymph node metastasis occurs in 40.3% of patients and lung metastasis develops in 41.9% during follow-up 1
• Poor prognosis: The 5-year survival rate is only 42.9% for upper extremity lesions and 58.3% for lower extremity lesions 1
• Aggressive local behavior: The tumor is considered more virulent than standard squamous cell carcinoma, particularly when located on extremities 1, 3

The Surgical Approach Required

Wide local excision with adequate margins is the treatment of choice and must be performed as soon as the diagnosis is confirmed. 2, 3, 4 The surgical strategy should include:

• Wide excision with safe margins as the primary intervention 4
• Regional lymph node dissection in 21% of cases, particularly when clinical or radiographic evidence of nodal involvement exists 1
• Amputation combined with lymph node dissection in 6.4% of advanced cases where limb-sparing surgery is not feasible 1
• Biopsy with histopathologic interpretation remains the gold standard for diagnosis and must be obtained before definitive surgery 2

Why Medical Management Fails

The evidence is clear that surgical excision alone is often inadequate in advanced disease, and there is no role for primary medical management. 4 The scar tissue acts as a barrier that initially contains the tumor, but once this barrier is breached or the tumor becomes established, aggressive surgical intervention is required. 4

An aggressive combined approach is essential in early stages with high success rates, but results are generally unsuccessful in advanced disease regardless of treatment modality. 4 This combined approach includes:

• Excision with safe margins 4
• Lymphatic dissection when indicated 4
• Postoperative radiotherapy 4
• Chemotherapy as adjuvant therapy 4
• Amputation if anatomically necessary 4

Critical Prognostic Factors

Three factors directly affect survival and must guide surgical planning: 1

1. Presence of metastasis (most important)
2. High histologic grade
3. Tumor size (increasingly recognized as crucial)

The mean survival for the entire patient population is only 4.55 years, with estimated mean time of survival calculated at 7.76 years. 1

Key Clinical Pitfall

Any chronic, non-healing wound must be biopsied to exclude Marjolin's ulcer—this diagnosis is frequently overlooked and inadequately treated, leading to poor prognosis. 2 Deaths from Marjolin's ulcer are not uncommon, and the condition can be insidious in presentation. 3 Healthcare providers must maintain a high index of suspicion when evaluating any chronic wound, particularly those with a history of burns, trauma, pressure ulcers, or venous stasis. 2, 5

Meticulous wound care and early surgical intervention for unstable or atrophic scars is the only preventive strategy. 3