Marjolin's Ulcer

Marjolin's ulcer is the classic orthopaedic oncology viva topic because it tests the candidate's understanding that chronic wounds can undergo malignant change, that biopsy is mandatory for any non-healing ulcer, and that treatment is wider than for de novo SCC because the biological behaviour is more aggressive. Lower-limb burns, chronic osteomyelitis sinuses, and venous ulcers are the typical sources seen in fracture-clinic and sarcoma-unit practice worldwide.

The single biggest risk factor is time since burn injury. Patients with burns sustained in childhood (especially in regions with limited acute burn care) are now reaching the latency window in middle age, and incidence of Marjolin's is expected to rise in these populations. Vigilance in this group is cost-effective - a single targeted biopsy can change management.

On histology the tumour is most often well- to moderately-differentiated SCC, with keratin pearls, intercellular bridges and invasive nests. The diagnosis is made when SCC is identified arising from - or directly adjacent to - the chronic wound epithelium. The dysplasia-carcinoma sequence is often visible at the wound edge, with adjacent carcinoma in situ.

The histology table lists angiosarcoma "in chronic lymphoedematous tissue" - this is Stewart-Treves syndrome, the classic exam counterpart to Marjolin's ulcer and a favourite "compare and contrast" question:

• What it is: a cutaneous angiosarcoma arising in chronically lymphoedematous tissue, not an SCC. The classic setting is the arm years after axillary dissection and radiotherapy for breast cancer (post-mastectomy lymphoedema), but it also occurs in chronic primary or filarial lymphoedema of the limb.
• Latency: typically about 10 years of chronic lymphoedema before malignant change.
• Appearance: multiple violaceous/red-blue macules, nodules or plaques in the swollen limb that coalesce - quite unlike the rolled-edge ulcer of Marjolin's; biopsy shows angiosarcoma (CD31/CD34/ERG positive endothelial markers).
• Behaviour and treatment: aggressive, early haematogenous (lung) metastasis and a poor prognosis; treatment is radical excision/amputation often with chemotherapy/radiotherapy, but outcomes are worse than Marjolin's SCC.

Exam point: contrast the two chronic-tissue transformations - Marjolin's = SCC in a chronic scar/wound/sinus (rolled-edge ulcer, decades latency, nodal spread) versus Stewart-Treves = angiosarcoma in chronic lymphoedema (violaceous nodules, ~10-year latency, early lung metastasis, worse prognosis).

Always compare the contralateral limb and assess the regional lymph nodes at the same consultation. A Marjolin's on the lower leg that has travelled to the popliteal or inguinal nodes is a different operation to one that is node-negative. Document the nodal status and use ultrasound or cross-sectional imaging if the nodes are clinically equivocal.

The prognosis tables below talk about "stage" and "matched stage", but the topic never says how a Marjolin's/cutaneous SCC is staged - here is the framework examiners expect:

• AJCC 8th edition T-stage (head and neck cutaneous SCC): T1 tumour under 2 cm; T2 2 cm up to under 4 cm; T3 4 cm or more, OR minor bone erosion, OR perineural invasion, OR deep invasion (beyond subcutaneous fat or over 6 mm deep); T4 gross cortical bone/marrow or skull-base invasion. N and M follow standard TNM (nodal disease being the dominant driver in Marjolin's).
• The Brigham and Women's Hospital (BWH) alternative T-stage was designed because AJCC poorly separates high-risk cutaneous SCC. It counts four high-risk factors: tumour 2 cm or more, poorly differentiated, perineural invasion 0.1 mm or larger, and invasion beyond the subcutaneous fat (excluding bone, which upstages to T3). T1 = 0 factors, T2a = 1, T2b = 2-3, T3 = 4 factors or bone invasion. BWH T2b/T3 stratify the patients who actually metastasise and die far better than AJCC - most poor outcomes cluster there.
• Why it matters in Marjolin's: these tumours are typically deep, often poorly differentiated and large at diagnosis, so they cluster in the high-risk (BWH T2b/T3) groups - which is precisely the population in whom SLNB, adjuvant radiotherapy and close surveillance are justified.

Exam point: stage cutaneous SCC by AJCC 8th T1-T4 (size/depth/PNI/bone), but quote the BWH system (high-risk factors: size 2 cm+, poor differentiation, PNI 0.1 mm+, invasion beyond fat) as the better predictor of metastasis and death - Marjolin's lesions cluster in its high-risk T2b/T3 groups.

Favourable: small, well-differentiated, node-negative, no lymphovascular invasion, clear margins, immunocompetent host, no bone involvement, no perineural invasion.

Unfavourable: deep invasion (greater than 4-5 mm), high grade, lymphovascular invasion, perineural invasion, positive nodes, bone / joint involvement, recurrent tumour, immunocompromised host, latent period under 1 year (acute Marjolin), older age and comorbidities.

Worse than de novo SCC: even stage-for-stage, Marjolin's carries a lower survival than primary cutaneous SCC because of higher grade, deeper invasion at presentation, and more frequent nodal disease.

There is no dedicated Marjolin's ulcer registry. Evidence comes from single-centre retrospective series, narrative reviews, and case reports rather than randomised trials, because the disease is uncommon and clinically heterogeneous. The dominant national registry evidence in adjacent areas - cutaneous SCC registries, burn registries, and sarcoma registries - supports the principles of biopsy-driven diagnosis, wide margin excision, and nodal staging, but does not provide high-level evidence for specific surgical techniques.