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Date posted: May 1, 2012

Dr Rajneesh Kumar Sharma MD (Hom)

Marjolin’s Ulcer
Synonyms and related keywords: decubitus ulcer, bed sore, pressure sore, nonhealing wound, non-healing wound, wound healing complication, wound-healing complication, pressure ischemia, paraplegia, quadriplegia, spina bifida, immobilization, multiple sclerosis, MS, Marjolin ulcers, pressure sore reconstruction, flap procedures, chronic wound, pressure sore carcinoma.

Definition
Marjolin initially described malignant transformation of a chronic scar from a burn wound. But presently, the term Marjolin ulcer has been used interchangeably for malignant transformation of any chronic wound, including pressure sores, osteomyelitis, venous stasis ulcers, urethral fistulas, anal fistulas, and other traumatic wounds. This malignant transformation is, histologically, a well-differentiated squamous cell carcinoma.

Squamous cell carcinoma (SCC)
This is a malignant tumour of the epidermis or its appendages.

Incidence
Less common than basal cell carcinoma.

Age
Usually in later life with increasing incidence after 60.

Sex
7 Male : 3 Female

Pathophysiology
It can occur anywhere but more usually occurs in a pre-existing skin lesion, or as a result of previous irradiation. It is also common in those with scleroderma pigmentosum when lesions appear in early adulthood.

Predisposing factors:

  • Sunlight exposure
  • long-standing chronic granulomas e.g. syphilis, lupus vulgaris, leprosy
  • Chronic ulcers
  • Osteomyelitis
  • Hydradenitis suppuritiva
  • Long-standing venous ulcers
  • Old burn scars
  • A SCC developing in a chronic ulcer is called a Marjolin’s ulcer.

MACROSCOPIC :Nodule or ulcer. The latter has an everted edge.

MICROSCOPIC :Tumours of epidermal keratinocytes characterised by invasive nests of cells with variable central keratinisation and horn cell formation. These ‘onion-like’ clusters of cells are often called ‘epithelial pearls’.
There is no peripheral palisading as seen in Basal Cell Carcinoma (BCC).
Cells are pleomorphic, varying from well-differentiated with vesicular nuclei and prominent nucleoli to anaplastic. Most tumours invade as adherent strands and metastases usually have the same pattern.

CLINICAL FEATURES
History
A lesion in a region commonly exposed to the sun e.g. backs of hands and forearms, face ( in males especially the lips and pinna).
Lump or bleeding ulcer
Increasing size, usually present for few months
May be painful (if deeper structures are involved)
May be several lesions

Examination
Position- Anywhere, usually exposed skin or skin exposed to chemicals or irritation
Colour- Everted edge usually a dark red-brown colour due to its vascularity
Temperature- Normal
Tenderness- Usually non-tender
Shape- Begin as small nodules, the center of which becomes necrotic as size increases, progressing to a circular ulcer
Edge- Everted edges (as it grows over normal skin)
Relations to surrounding structures- depends on extent of malignant infiltration
Regional lymph nodes- often enlarged but not always due to metastases. About 1/3 due to infection.
State of local tissues- may be oedematous. Subcutaneous spread may be along nerves causing neuritis. Involvement of blood vessels- may cause thrombosis.
There are often multiple types of skin lesions in the same patient e.g. BCC, SCC and melanomas
There are often signs of sunlight damage in the adjacent skin:

Signs of sunlight damage-
Elastotic degeneration of the dermis
Keratosis
Irregular pigmentation
Telangiectasia
Leucoplakia
Fissuring of the lips
Induration is the first sign of malignancy.
Regional lymphadenopathy occurs because of infection or from metastases.

DIAGNOSIS
Clinically and by biopsy.

DIFFERENTIAL DIAGNOSIS
Basal cell carcinoma
Keratoacanthoma
Melanoma
Solar keratosis
Pyogenic granuloma
Infected seborrhoeic wart

Case History
Patient’s name-  XX
Male- 45 years
Occupation- Farming.

Chief complaints-
Weakness and weariness.
No hope of recovery.
H/O burn at right upper arm.
Chronic ulcer at the site of burning.
Burning pains at the site, worse with pressure.
Always sleepy. Yawning, even during sleep.
Can not rest because it aggravates the pain.
H/O injury to the burnt area, which caused abrasion that, turned into ulceration.
H/O gum abscess.
H/O nasal polyp.

Biopsy-
Sufdarjang Hospital New Delhi, vide pathology no. 10763/ 16- 12- 2003/ well differentiated squamous cell carcinoma, Marjolin’s Ulcer.

Rubrics-
SLEEP – SLEEPINESS – evening
GENERALS – CANCEROUS affections – sarcoma
GENERALS – WEARINESS
GENERALS – PRESSURE – agg.
GENERALS – INJURIES (including blows, bruises, falls) – bones; fractures of
SLEEP – YAWNING
NOSE – POLYPUS
GENERALS – REST – agg.
MOUTH – ABSCESS of Gums
NOSE – EPISTAXIS

Repertorization : hecla hep. phos. sil. merc. alum. am-c. calc. lach. lyc. nit-ac. petr.

Further quarries-
Thirst for small quantities of water.
Dryness of mouth.
Restlessness.
Disgust for medicine.

18-12-2003
Hekla lava 200 one dose stat
SL x 7 days.

27-12-2003
Burning pain markedly diminished.
No thirst.
Hekla lava 200 one dose stat
SL x 7 days.

07-01-2004
Much better in all respects.
SL x 25 days.

12-02-2004
Much better in all respects.

Biopsy- Safdarjang Hospital, New Delhi, vide path. No. 797 \ 28.01.04- Histopathological picture reveals squamous cell reaching just up to the deeper resected margin. Lateral resected margins are free of tumour.
Sac lac x 40 days.

30-04-2003
Much better.
Same treatment continued…..
(All the investigation reports available if required)

Dr. Rajneesh Kumar Sharma MD (Hom)
Homoeo Cure & Resaerch Centre
NH 74- Moradabad Road
Kashipur (Uttaranchal)

Comments

3 Responses so far.

  1. Note:
    Hekla lava crude nowadays is not available, as lava has stopped errupting from the volcanoes in hekla.

  2. dr mustafa hakimji says:

    Good case to learn.

  3. Muhammad Ali says:

    Dear Sir, I want to know that How long the Heckla lava takes to cure oral Cancer ( Carcinoma).. and is Hecla lava 3x tabs are suitalbe for this disease..

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