Review Question - QID 106379

The clinical presentation and biopsy result describe a squamous cell carcinoma occurring in an area of chronic inflammation, a phenomenon known as a Marjolin's ulcer.

Marjolin's ulcer is a term used to describe a locally-aggressive squamous cell carcinoma arising from an area of chronically inflamed skin. It presents as a slow-growing mass with the classic "heaped up" edges in the context of chronic ulcers, burns, osteomyelitis, and radiation scars. Diagnosis is achieved by wedge biopsy of both the center and the edge of the ulcer with histologic findings characteristic of squamous cell carcinoma. This cancer is locally-aggressive and generally requires wide excision with 1 cm margins, although topical therapy is occasionally used for small ulcers with reported success.

Firnhaber reviews the diagnosis and treatment of basal cell and squamous cell carcinoma, noting that non-melanoma skin cancer is the most common cancer in the United States. The author advises that basal cell carcinoma most often appears as a pearly-white, dome-shaped papule with prominent telangectasias, whereas squamous cell carcinoma often presents as a firm, smooth, hyperkeratotic plaque with central ulceration. Diagnosis is achieved by biopsy and treatment through surgical excision or cryotherapy and topical agents for smaller tumors. Follow-up is recommended in all cases due to the high risk of recurrence.

Yu et al. review the management of Marjolin's ulcers. The authors stress the need to regularly monitor scars for the formation of a tumor so that it can be treated in its early stages. They performed a retrospective review of 17 patients with Marjolin's ulcer and found that the mean latency period was 29 years, with shorter latency periods occurring in more elderly patients.

Figure A is a clinical photograph demonstrating a Marjolin's ulcer on the plantar aspect of the right foot secondary to a chronic wound. Note the "heaped up" edges. Illustration A is an artist's rendering of the differing appearance of squamous cell carcinoma and basal cell carcinoma.

Incorrect Answers:
Answers 1 and 3: Melanoma and basal cell carcinoma do not commonly arise from chronic wounds.
Answer 4: This patient is at risk for osteomyelitis secondary to his chronic plantar wound, but it would not be diagnosed on the basis of these biopsy results.
Answer 5: Plantar fasciitis refers to painful inflammation of the plantar fascia of the foot.