Understanding Marjolin Ulcer in Chronic Burn Scars

The term Marjolin ulcer refers to an aggressive malignancy arising from chronic wounds, persistent sinuses, and old burn scars. Although thermal injuries cause the majority of these lesions, the malignant process develops exceptionally slowly. Indeed, clinicians frequently encounter latency intervals spanning two to four decades before carcinoma manifests. In this clinical setting, avascular scar tissue impairs local lymphatic drainage and hampers local immune surveillance. Consequently, repeated tissue breakdown, persistent cellular turnover, and continuous irritation trigger neoplastic transformation within unstable cicatrix margins. Histopathologically, approximately eighty percent of these malignant transformations present as cutaneous squamous cell carcinoma. However, specialists also identify basal cell carcinomas, malignant melanomas, and rare sarcomas in select cases. Because the surrounding scar tissue forms a dense, rigid barrier, tumors often remain undetected during their early phases. Furthermore, malignant cells eventually break through the fibrotic capsule, precipitating rapid regional spread and extensive local destruction. Therefore, healthcare providers must evaluate any long-standing scar that exhibits induration, bleeding, rapid growth, or spontaneous ulceration. Early detection significantly alters prognosis, as delayed recognition substantially worsens survival rates.

Clinical Case Presentation and Diagnostic Evaluation

A recent medical case highlighted a seventy-one-year-old male who presented with an ulcerated lesion in his left popliteal fossa. Specifically, the patient sustained severe thermal burns thirty-four years earlier and carried a persistent, fragile burn scar. Over several months, the scarred popliteal area underwent malignant degeneration, producing a painful and non-healing ulcerated wound. Additionally, the patient suffered from significant medical comorbidities, notably stage four chronic kidney disease and persistent hypertension. These underlying medical conditions severely limited therapeutic options and complicated the preoperative physiological optimization. Physical examination revealed an irregular, indurated ulcer with elevated edges surrounded by fibrotic scar tissue. Fortunately, regional palpation did not reveal palpable lymphadenopathy in the left inguinal basin. Clinicians subsequently performed an incisional punch biopsy from the active margin of the ulcer. Histopathology confirmed a moderately-to-well-differentiated squamous cell carcinoma without deep neurovascular invasion. Preoperative imaging further excluded regional nodal metastases and underlying osteomyelitis of the knee joint. Thus, the clinical team established a definitive diagnosis while actively considering the substantial perioperative risks associated with his advanced renal dysfunction.

Surgical Strategy and Multidisciplinary Decision-Making

Managing advanced malignant degeneration in medically compromised patients demands meticulous multidisciplinary coordination. Therefore, surgical oncologists, plastic surgeons, nephrologists, and anesthesiologists met to design a tailored therapeutic strategy. Radical operative clearance represents the primary curative modality for localized cutaneous malignancies. However, deep thermal contractures in the popliteal fossa lie directly over critical neurovascular structures, including the popliteal artery and tibial nerve. The surgical team planned a wide local excision incorporating a two-centimeter peripheral clear margin down to healthy deep fascia. Concurrently, nephrologists adjusted nephrotoxic medication protocols and managed perioperative fluid balances to prevent acute renal decompensation. Because general anesthesia carried heightened risks, anesthesiologists utilized a continuous regional peripheral nerve blockade. This targeted approach minimized systemic hemodynamic fluctuations while maintaining excellent intraoperative conditions. During the resection, surgeons carefully dissected the tumor bed off the popliteal neurovascular bundle without compromising oncological safety. Intraoperative frozen section analysis verified tumor-free peripheral and deep margins. Consequently, the surgical team achieved complete microscopic clearance while preserving critical lower limb motor function and arterial perfusion.

Reconstruction Techniques and Functional Outcomes

Reconstructing extensive soft tissue defects across major flexion creases presents substantial surgical challenges. Although surgeons frequently employ local rotational or microvascular free tissue transfers, this patient required a simpler, low-morbidity reconstructive solution. Specifically, his severe renal impairment and vascular vulnerability made prolonged microsurgical operative times excessively hazardous. Instead, the surgical team selected an individualized split-thickness punch skin grafting technique following wide excision. First, surgeons prepared a healthy, vascularized wound bed in the popliteal fossa using careful hemostasis. Subsequently, the team harvested split-thickness skin graft islands from the anterolateral thigh and placed them meticulously across the defect. Punch skin grafts provide exceptional adaptability, promote reliable drainage, and survive well over irregular recipient beds. Furthermore, this method minimizes donor site morbidity and reduces systemic anesthetic demands in fragile patients. Postoperatively, clinicians immobilized the left knee joint with a rigid posterior splint to prevent shearing forces. The skin grafts integrated completely within fourteen days, demonstrating total tissue adherence without graft necrosis. In addition, the patient began guided physical therapy, which successfully restored knee flexion and preserved functional ambulatory independence.

Long-Term Surveillance and Oncological Considerations

Because cutaneous malignancies originating in burn scars behave aggressively, comprehensive post-surgical surveillance remains indispensable. Marjolin carcinomas demonstrate significantly higher rates of regional recurrence and lymph node dissemination than ordinary cutaneous squamous cell carcinomas. Studies indicate regional metastatic rates ranging between twenty and thirty-five percent, particularly in lower extremity lesions. Therefore, patients require rigorous physical examinations every three months during the initial two years following surgical resection. During each outpatient visit, clinicians examine the local surgical site for nodularity and palpate regional inguinal nodal basins. Moreover, surveillance protocols should include periodic high-resolution ultrasonography to detect early subclinical nodal enlargement. For patients presenting with clinically suspicious lymph nodes, surgeons recommend fine-needle aspiration cytology followed by therapeutic lymph node dissection. Fortunately, this seventy-one-year-old patient showed no evidence of local tumor recurrence or regional metastasis during short-term postoperative follow-up. Nevertheless, physicians must continue regular reviews over five years to detect late recurrence promptly. Above all, patient education regarding scar inspection, sun avoidance, and immediate reporting of ulceration plays a vital role in preventing adverse oncological outcomes.

Frequently Asked Questions

Why do chronic burn scars undergo malignant degeneration into Marjolin ulcers?

Chronic burn scars create an avascular, rigid, and fibrotic microenvironment with impaired lymphatic drainage. Consequently, this tissue architecture shields developing neoplastic cells from normal host immune surveillance. Furthermore, recurrent mechanical trauma, prolonged tissue breakdown, and constant cellular regeneration stimulate persistent inflammatory cascades. Over decades, sustained oxidative stress and repeated mitotic cycles trigger genetic mutations in epidermal keratinocytes, ultimately resulting in aggressive squamous cell carcinoma.

What surgical margins are recommended when excising a suspected Marjolin ulcer?

Surgeons generally recommend achieving wide local margins measuring at least two centimeters from the visible clinical boundary. Additionally, the excision must extend deeply to uncompromised anatomical planes, including healthy deep investing fascia or periosteum. Because Marjolin malignancies exhibit infiltrative microscopic extensions within surrounding fibrotic scar tissue, conservative margins cause high local recurrence. Intraoperative frozen section analysis remains invaluable to confirm complete histological clearance before performing functional wound reconstruction.

How should clinicians monitor regional lymph nodes in post-burn scar cancer?

Clinicians must perform thorough clinical palpation of draining regional lymph node basins during every routine follow-up appointment. In addition, baseline and serial high-frequency lymph node ultrasonography provides high diagnostic accuracy for detecting early impalpable metastatic deposits. If imaging reveals suspicious nodal architecture, specialists should promptly perform ultrasound-guided fine-needle aspiration biopsy. Furthermore, surgeons reserve therapeutic lymphadenectomy for pathologically confirmed nodal involvement, whereas elective nodal dissection remains controversial in clinically node-negative presentations.

Disclaimer: This content is for informational and educational purposes only... Refer to the latest local and national guidelines for clinical practice.

References

Zhang Y et al. Surgical management of Marjolin's ulcer secondary to chronic burn scar: a case report. J Surg Case Rep. 2026 Oct undefined. doi: 10.1093/jscr/rjag1009. PMID: 42967179.

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Bazaliński D, Przybek-Mita J, Barańska B, Więch P. Marjolin's ulcer in chronic wounds: review of available literature. Contemp Oncol (Pozn). 2017;21(3):197-202.