SCC in Chronic Wound or Scar | Latency Decades | Biopsy Every Non-Healing Lesion
MOST COMMONLY USED CLASSIFICATIONS
Critical Must-Knows
- Marjolin's ulcer is squamous cell carcinoma (SCC) arising in a chronic wound, scar, sinus or ulcer (most commonly old burn)
- Latency from original injury averages two to four decades in burn scars; osteomyelitis sinus tends to have shorter latency
- Any chronic wound that fails to heal, develops raised everted edges, foul discharge, bleeding, or pain after long quiescence needs biopsy
- Treatment is wide local excision (2-4 cm margins) or amputation for deep bone / joint involvement, plus nodal staging
- Nodal metastasis is more common than in de novo SCC (20-40 percent at diagnosis) - sentinel node biopsy is increasingly used
- Five-year survival is worse than de novo SCC and depends on stage, grade, depth, and nodal status
Clinical Pearls
- "The ulcer that has been stable for 20 years and suddenly changes is a Marjolin's until proven otherwise
- "Biopsy the edge, not the floor, of a chronic ulcer - the floor is granulation tissue and gives false negatives
- "Osteomyelitis sinus with a Marjolin is a classic viva - squamous epithelium grows down the sinus tract
- "Lower limb is the single most common site because burns and chronic osteomyelitis are concentrated there
- "Always check the regional lymph nodes clinically and radiologically at presentation
Clinical Imaging
Imaging and clinical photographs of Marjolin's ulcer are critical for recognising the change in a chronic wound. In a fully built topic page this section hosts verified web-sourced and AI-generated MedicalImage components illustrating: chronic non-healing burn-scar ulceration with raised everted edges, fungating tumour arising within an old burn, osteomyelitis sinus with malignant change, and the typical wide local excision defect with split-skin graft coverage.
Until the topic image manifest is populated this section is left as a placeholder. Captions for each image MUST be written only after visually verifying the image with the Read tool - never trust source metadata.
Critical Marjolin's Ulcer Exam Points
Definition
Malignant transformation in a chronic wound, scar, sinus or ulcer - 75-95 percent are squamous cell carcinoma, the remainder include basal cell carcinoma, melanoma, sarcoma and Merkel cell carcinoma. Originally described by Marjolin (1828) observing tumour change in old burn scars.
Latency
Average 20-40 years in burn scars, often less in chronic osteomyelitis sinus (commonly 10-20 years). Acute Marjolin (under 1 year from injury) exists but is rarer and behaves more aggressively. The longer the scar has been stable, the more sinister is a new change.
Biopsy of Non-Healing Wound
Any chronic wound that fails to heal, or any stable scar that ulcerates, bleeds, becomes painful or develops a mass, must be biopsied. Take a punch or wedge biopsy from the edge including both abnormal and adjacent normal tissue. Floor biopsies are often false negative (granulation tissue).
Treatment and Prognosis
Wide local excision (2-4 cm margins) down to deep fascia for soft-tissue disease; amputation for deep bone / joint / extensive limb involvement. Sentinel lymph node biopsy is increasingly standard because nodal metastasis is 20-40 percent at presentation. Five-year survival is worse than de novo SCC.
Quick Decision Guide
| Presentation | Diagnosis | Treatment | Key Pearl |
|---|---|---|---|
| Stable burn scar for 25 years, new ulceration, raised edge, foul discharge | Edge biopsy showing well- to moderately-differentiated SCC | Wide local excision 2-4 cm margin, SLNB if feasible, nodal surveillance | Latency is the giveaway - any change after decades is suspicious |
| Chronic osteomyelitis sinus for 15 years, increased discharge, fungating mass at sinus mouth | Edge / sinus-tract biopsy showing SCC arising from tract epithelium | Amputation often required; wide excision only if small and distal | Sinus epithelium undergoes malignant change - biopsy any suspicious sinus |
| Enlarging ulcer with heaped-up everted edges, bleeding, regional lymphadenopathy | Edge biopsy + staging CT chest/abdomen + ultrasound or CT of regional nodes | Wide excision + therapeutic lymph node dissection if nodes positive | Up to 40 percent have nodal disease at presentation - examine nodes every time |
| Patient with non-healing venous or pressure ulcer, multiple failed skin grafts | Edge biopsy - multiple samples if heterogeneous, request second opinion if benign but suspicious | Excision of ulcer with appropriate reconstruction (graft or flap) | Long-standing leg ulcers are the second most common source after burn scars |
CHANGEMarjolin's - the warning signs in a chronic wound
| C | Crusting or bleeding New bleeding from a previously dry, stable scar |
| H | Heaped-up edges Raised, everted, rolled margins |
| A | Atypical pain Pain after years of being painless |
| N | New discharge Foul, bloody or purulent discharge from sinus or ulcer |
| G | Growth / mass A new nodule or fungating lesion in the wound |
| E | Enlargement Failure to heal, progressive enlargement despite dressings |
| C | Crusting or bleeding New bleeding from a previously dry, stable scar | A | Atypical pain Pain after years of being painless | G | Growth / mass A new nodule or fungating lesion in the wound |
| H | Heaped-up edges Raised, everted, rolled margins | N | New discharge Foul, bloody or purulent discharge from sinus or ulcer | E | Enlargement Failure to heal, progressive enlargement despite dressings |
Hook:Any CHANGE in a chronic wound is a Marjolin's until biopsy proves otherwise!
BURNSSAetiology of Marjolin's Ulcer
| B | Burn scars The classic cause - usually 20-40 years post-injury, often unstable or grafted scars |
| U | Ulcers (venous, pressure, diabetic) Long-standing leg and foot ulcers, especially in elderly or immobile patients |
| R | Radiation dermatitis Post-radiotherapy chronic skin change, often after head and neck or breast treatment |
| N | Non-healing traumatic wounds Chronic sinuses, fistulae, surgical scars that have never healed |
| S | Sinus of chronic osteomyelitis Epithelialised sinus tract - squamous epithelium replaces granulation |
| S | Skin conditions (vaccination, lupus, dystrophic epidermolysis) Rare - chronic scarring dermatoses or vaccination scars |
| B | Burn scars The classic cause - usually 20-40 years post-injury, often unstable or grafted scars | R | Radiation dermatitis Post-radiotherapy chronic skin change, often after head and neck or breast treatment | S | Sinus of chronic osteomyelitis Epithelialised sinus tract - squamous epithelium replaces granulation |
| U | Ulcers (venous, pressure, diabetic) Long-standing leg and foot ulcers, especially in elderly or immobile patients | N | Non-healing traumatic wounds Chronic sinuses, fistulae, surgical scars that have never healed | S | Skin conditions (vaccination, lupus, dystrophic epidermolysis) Rare - chronic scarring dermatoses or vaccination scars |
Hook:BURNSS - the mnemonic for the diverse causes of Marjolin's ulcer.
EXCISESurgical Management Steps
| E | Edge biopsy first Confirm SCC and grade before definitive surgery |
| X | X-ray + cross-sectional staging MRI of limb, CT chest for distant disease |
| C | Consider sentinel node biopsy 20-40 percent nodal spread - stage the nodal basin |
| I | Incise 2-4 cm margin Wide local excision down to deep fascia (or bone if involved) |
| S | Set reconstruction plan Skin graft, fasciocutaneous or free flap, or amputation |
| E | Examine nodes at every follow-up Recurrence often nodal - ultrasound surveillance 2-5 years |
| E | Edge biopsy first Confirm SCC and grade before definitive surgery | C | Consider sentinel node biopsy 20-40 percent nodal spread - stage the nodal basin | S | Set reconstruction plan Skin graft, fasciocutaneous or free flap, or amputation |
| X | X-ray + cross-sectional staging MRI of limb, CT chest for distant disease | I | Incise 2-4 cm margin Wide local excision down to deep fascia (or bone if involved) | E | Examine nodes at every follow-up Recurrence often nodal - ultrasound surveillance 2-5 years |
Hook:EXCISE - confirm, stage, cut wide, reconstruct, and follow the nodes.
Overview and Epidemiology
Why This Matters
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.
Key Facts
- 75-95 percent of Marjolin's ulcers are squamous cell carcinoma
- Latency averages 20-40 years in burn scars; less in osteomyelitis sinus
- Lower limb is the single most common site (40-60 percent of cases)
- Nodal metastasis at presentation in 20-40 percent (vs less than 5 percent for de novo SCC)
- Second primary SCC may develop in 10-20 percent of patients - lifelong skin surveillance is required
Patient Groups
- Burn survivors in low- and middle-income countries where childhood burns were managed conservatively
- Patients with chronic osteomyelitis - long-standing draining sinus, often decades
- Elderly patients with chronic venous or pressure ulcers
- Patients with previous radiotherapy - radiation-induced chronic skin change
- Patients with chronic fistulae or surgical scars that have never epithelialised properly
Epidemiology Pearl
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.
Pathophysiology
Two Pathways to Malignant Change
Two mechanistic pathways are described. (1) The chronic-inflammation / scar-niche model - persistent wound healing, repeated epithelial injury, free-radical damage, local immunosuppression and bacterial colonisation produce cumulative DNA damage in a setting of impaired immune surveillance; this is the dominant model for burn-scar and osteomyelitis-sinus Marjolin's. (2) The direct malignant transformation of unstable scar epithelium, which is histologically supported by dysplasia at the wound edge adjacent to frank carcinoma in many specimens.
Cellular Events
Chronic wound environment:
- Repeated epithelial injury and repair
- Sustained cytokine release (TNF-alpha, IL-6)
- Local immunosuppression by regulatory T cells
- Free-radical and bacterial toxin exposure
- Hypoxia and lactate accumulation
Genetic events:
- p53 mutation in a high proportion of cases
- Loss of p16 and other cell-cycle regulators
- UV-signature mutations in sun-exposed sites
- Field change: dysplasia extends beyond visible tumour
Why It Is More Aggressive Than De Novo SCC
Tumour biology:
- Often higher grade at diagnosis
- Deep invasion by the time diagnosis is made
- High rate of perineural and lymphovascular invasion
- Frequently poorly circumscribed at the deep margin
Patient biology:
- Older, more comorbidities
- Often poor nutrition and chronic disease
- May not have presented early because the wound was long-standing
- Reconstructive options limited by surrounding scar
Net effect: lower survival than de novo SCC of equivalent stage.
Pathology Pearl
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.
Classification and Types
Classification by Timing of Malignant Change
| Type | Latency | Behaviour | Prognosis |
|---|---|---|---|
| Acute Marjolin | Less than 1 year from original wound | Aggressive, often high grade, deep invasion | Worse than chronic form |
| Chronic Marjolin (typical) | Over 1 year - usually decades after burn | Variable grade, often well-differentiated | Guarded - depends on stage, depth, nodal status |
| Primary (de novo) SCC in chronic wound | Arises in long-standing wound, no preceding scar | Behaviour similar to de novo SCC | Better than typical Marjolin's |
Acute Marjolin's is uncommon and is typically described in acute burns that fail to heal and then turn malignant within months. Chronic Marjolin's is the textbook variant.
Clinical Assessment
History
- Original injury: Mechanism, age at injury, healing course, treatments received
- Time since original wound: Latency in years (decades typical for burn scar)
- Change in wound: New bleeding, pain, discharge, mass, foul smell, failure to heal
- Previous treatments: Skin grafts, dressings, surgery, dressings compliance
- Systemic: Weight loss, night sweats, anorexia, bone pain (suggests metastasis)
- Past radiotherapy, immune suppression, smoking
Examination
- Inspect the wound: Size, depth, edges (raised / everted / rolled), floor (granulation / necrotic / fungating)
- Surrounding skin: Satellite nodules, dysplastic change, old scar quality
- Palpate the wound: Induration, fixation to deep structures, bone involvement
- Regional lymph nodes: Inguinal, axillary, popliteal, epitrochlear, cervical depending on site
- Distal neurovascular status: Especially before any amputation decision
- Distant sites: Lung auscultation, abdominal exam for hepatomegaly
Biopsy the EDGE, not the Floor
Technique: A punch biopsy (4 mm) or wedge biopsy should be taken from the edge of the lesion including both abnormal and adjacent normal-appearing tissue. Floor biopsies are often false negative because the floor is granulation tissue, slough, or necrotic debris without diagnostic epithelium.
Multiple biopsies should be taken for large or heterogeneous lesions - the most suspicious (raised, indurated, painful) area should be sampled. Discuss the clinical suspicion explicitly with the pathologist so that multiple levels and immunohistochemistry are considered.
Differential Diagnosis of a Non-Healing Ulcer in Old Scar
| Condition | Discriminating feature | Key test |
|---|---|---|
| Marjolin's ulcer (SCC in scar) | Raised everted edges, new pain, bleeding, mass in old burn scar | Edge biopsy showing SCC with adjacent dysplasia |
| Chronic infection / osteomyelitis | Discharge, sinus, no mass; improves with antibiotics | CRP, ESR, MRI, deep swab; biopsy if no improvement |
| Hypertrophic scar or keloid | No ulceration, pruritic, raised but soft; responds to steroid | Clinical diagnosis; biopsy if atypical |
| Pyoderma gangrenosum | Violaceous undermined edge, often in IBD / arthritis | Biopsy (exclude malignancy), clinical pattern |
| Vasculitic ulcer (RA, SLE) | Multiple ulcers, systemic features, abnormal serology | ANA, ANCA, biopsy of ulcer edge including vessel |
| Arterial / venous insufficiency ulcer | Classical site (medial gaiter area for venous), Doppler changes | ABI, venous Doppler, biopsy if non-healing after revascularisation |
Examination Pearl
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.
Investigations
Staging Pathway
Edge biopsy with 4 mm punch or wedge including normal-appearing skin
Multiple samples for heterogeneous or large lesions (at least 2-3 from the most suspicious areas)
Pathology request: clinical context (Marjolin's suspected), specify SCC versus other, ask for depth of invasion, grade, lymphovascular and perineural invasion, margins if excisional
Immunohistochemistry: useful if poorly differentiated; consider p16, p53, Merkel cell polyomavirus
Indication: assess depth, soft-tissue extension, bone involvement, sinus tract
Findings: enhancing soft-tissue mass, possible bone marrow oedema, cortical breach, sinus tract
Use: guides surgical margin and reconstruction; identifies invasion of neurovascular bundle or joint
Ultrasound of regional nodes: first-line; can guide fine-needle aspiration of suspicious nodes
CT or MRI of nodal basin: for deep nodes (pelvis, retroperitoneum) or when ultrasound is equivocal
Sentinel lymph node biopsy: increasingly used because of high rate of microscopic nodal disease, but evidence is mixed for SCC; consider in high-grade, deep, large lesions
Indication: high-grade lesions, large primary, clinically positive nodes, or systemic symptoms
Sites: lung (most common distant site), liver, bone
PET-CT: increasingly used in advanced or recurrent disease; identifies occult metastatic disease
Imaging Pearl
Plain radiographs of the limb are often obtained to look for bony involvement (chronic osteomyelitis, cortical breach, pathological fracture) and as a baseline for future comparison. They do not exclude early marrow involvement - MRI is the local staging study of choice, and CT chest is the standard distant staging study for any high-risk tumour.
Investigations - Why and When
| Investigation | Purpose | When to use |
|---|---|---|
| Edge biopsy | Confirm SCC, grade, depth, invasion | Mandatory in every suspected case |
| MRI limb | Local staging - depth, bone, sinus | All confirmed cases pre-excision |
| Ultrasound nodes | Nodal staging - first line | All confirmed cases |
| Sentinel node biopsy | Micrometastasis detection | Consider in high-grade, deep, large lesions |
| CT chest | Lung metastasis | High grade, large tumour, positive nodes, recurrent disease |
| PET-CT | Occult metastatic disease | Recurrent, advanced, equivocal cross-sectional imaging |
Management Algorithm
Wide Local Excision (2-4 cm Margin) for Localised Soft-Tissue Disease
Goal: complete oncological resection with adequate margins, then reconstruct the defect
Wide Excision Protocol
Confirm diagnosis: edge biopsy, grade, depth on MRI
Multidisciplinary review: oncology, plastic surgery, radiology, pathology
Reconstruction plan: skin graft, local flap, free flap, or amputation
Consent: recurrence risk, nodal disease, amputation, flap failure
Margin: 2-4 cm of clinically normal tissue around the lesion (some centres accept 2 cm in low-grade small lesions)
Depth: down to and including deep fascia; include periosteum or paratenon if close to bone or tendon
Specimen orientation: sutures or ink to mark margins; intra-operative frozen section of peripheral and deep margins if available
Reconstruction: split-skin graft for shallow defects, fasciocutaneous flap for deep defects, free flap for extensive defects around joints
Wound care: graft check at day 5, flap monitoring for 48-72 hours
Mobilisation: dependent on reconstruction; limb elevation, splint as needed
Histology review: confirm clear margins; re-excise if close or involved margin
Wound check at 1, 3, 6 months, then 6-monthly to 5 years
Nodal ultrasound at each visit if SLNB negative or not done
Annual CT chest for high-grade or node-positive disease
Patient education: report new bleeding, mass, pain, lymph node swelling urgently
Margin Pearl
The recommended margin is 2-4 cm of clinically normal skin and deep fascia because of the field-change effect - dysplasia often extends well beyond the visible tumour. Margins greater than 1 cm give significantly better local control than narrower margins in this disease. A close or involved margin mandates re-excision or amputation depending on the residual anatomy.
Complications
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Local recurrence | 20-50 percent at 5 years | Close / positive margin, deep invasion, high grade | Re-excision or amputation; adjuvant radiotherapy |
| Regional nodal metastasis | 20-40 percent at diagnosis, additional 10-20 percent at follow-up | Tumour depth greater than 4-5 mm, high grade, lymphovascular invasion | Therapeutic dissection; adjuvant radiotherapy |
| Distant metastasis (lung, bone, liver) | 10-30 percent overall, more with positive nodes | Node-positive disease, high grade, recurrent primary | Systemic therapy; palliative radiotherapy; surgical resection of isolated metastasis |
| Wound complications / flap failure | 10-30 percent after wide excision with reconstruction | Poor surrounding skin, infection, irradiated field | Debridement, regraft, salvage flap, or amputation |
| Amputation stump problems | Common - phantom pain, skin breakdown, neuroma | Poor soft-tissue cover, neuroma at nerve end, diabetes | Stump revision, neuroma excision, prosthetic adjustment |
| Second primary SCC | 10-20 percent over lifetime | Field change in chronic wound skin, sun exposure, immune suppression | Lifelong skin surveillance, biopsy any new lesion |
Late Recurrence Demands Lifelong Follow-Up
Marjolin's ulcer is one of the few cutaneous malignancies that can recur 10-20 years after apparently successful treatment. A healed scar that changes again must be re-biopsied and treated as a new Marjolin's until proven otherwise. Patients should be educated at discharge to seek urgent review for any new bleeding, mass, pain, nodal swelling, or non-healing in the scar - even decades later.
Outcomes and Prognosis
Prognosis by Stage and Nodal Status
| Factor | 5-year survival | Notes |
|---|---|---|
| Node-negative, localised | 70-90 percent | Wide excision with clear margins - best outcome |
| Node-positive, resected | 40-60 percent | Therapeutic dissection plus adjuvant radiotherapy |
| Distant metastasis at diagnosis | Less than 20 percent | Systemic therapy; palliative radiotherapy |
| Recurrent tumour after previous excision | 30-50 percent | Amputation often required; aggressive multimodality therapy |
Prognostic Factors
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.
Marjolin's Ulcer Versus De Novo Cutaneous SCC
| Feature | Marjolin's ulcer | De novo SCC |
|---|---|---|
| Latency | Decades from original wound | Years of cumulative sun damage |
| Nodal metastasis at diagnosis | 20-40 percent | Less than 5 percent |
| Histological grade | Often higher grade | Variable, often well-differentiated |
| Depth at diagnosis | Often deep by the time of biopsy | Usually superficial at diagnosis |
| 5-year survival (matched stage) | Worse than de novo SCC | Better than Marjolin's |
Evidence Base and Key Trials
Burn Scar Neoplasms: A Literature Review and Statistical Analysis
- Comprehensive literature review and statistical analysis establishing that burn-scar carcinoma is overwhelmingly squamous cell carcinoma, with mean latency from burn to malignant change commonly exceeding two decades
- Lower extremity is the single most common site, reflecting the concentration of burn injuries in this region
- Nodal metastasis at presentation is substantially more common than in de novo cutaneous SCC, dominating prognosis
- Wide local excision with adequate margins is the cornerstone of treatment, with amputation reserved for deep or extensive disease
Marjolin Ulcer: A Comprehensive Review
- Comprehensive review confirming that the lower extremity is the most common site because of the concentration of burn and chronic-wound pathology there
- Biopsy of any non-healing wound, including the edge of long-standing burn-scar ulceration, is the diagnostic step that cannot be omitted
- Wide local excision with adequate margins is the mainstay; sentinel lymph node biopsy is suggested as a staging adjunct in high-risk lesions, though level of evidence remains lower than for melanoma
- Recurrence and nodal failure after apparently curative surgery can occur more than 5 years out - justifying prolonged surveillance
Marjolin's Ulcer Associated with Chronic Osteomyelitis
- SCC can arise in the epithelialised sinus tract of chronic osteomyelitis, often after decades of drainage
- Lower limb is the most common site, with tibial osteomyelitis sinus the classic scenario
- Amputation is often required because the sinus communicates directly with bone, precluding limb-sparing wide excision
- Biopsy of the sinus mouth and tract is diagnostic; standard imaging underestimates the deep extent of disease
Marjolin Ulcer: Clinical Experience with 34 Patients over 15 Years
- Retrospective clinical experience of 34 Marjolin's ulcer patients over 15 years confirms burn scar as the most common aetiology, with lower extremity predominance
- Median latency from original injury to malignant change is in the order of decades, with shorter latency in chronic osteomyelitis sinus and radiation-induced cases
- Regional lymph node metastasis is substantially more common than in de novo SCC and is the dominant prognostic factor
- Amputation was required in a substantial proportion of cases with bone or extensive soft-tissue involvement; wide local excision with adequate margins is otherwise the standard
Burn Scar Carcinoma
- Retrospective series of burn-scar carcinoma (Marjolin's ulcer) across multiple anatomical sites confirms that lower extremity is the most common site and that long latency is the rule
- Wide local excision with adequate margins achieved local control in the majority of node-negative patients
- Positive nodal status at diagnosis and recurrent primary disease were the dominant predictors of poor survival
- Reconstruction with skin graft or local flap was feasible in most cases; free flap was required for extensive defects
Staging for Cutaneous Squamous Cell Carcinoma as a Predictor of Sentinel Lymph Node Biopsy Results: Meta-Analysis of American Joint Committee on Cancer Criteria and a Proposed Alternative System
- Meta-analysis of AJCC staging criteria as predictors of sentinel lymph node biopsy results in cutaneous SCC - including high-risk lesions such as Marjolin's ulcer
- Positive sentinel node identifies patients at significantly higher risk of recurrence and disease-specific death
- High-risk features that justify SLNB include tumour depth greater than 4-5 mm, high grade, and perineural or lymphovascular invasion
- The authors propose an alternative staging system with improved predictive performance for SLNB positivity, supporting wider SLNB use in high-risk cutaneous SCC including Marjolin's ulcer
Exam Viva Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Scenario 1: Burn-Scar Ulcer with New Bleeding
"A 58-year-old man presents with a 6-month history of increasing pain, malodorous discharge and intermittent bleeding from a chronic ulcer on the anterolateral aspect of his right lower leg. The ulcer sits within an extensive burn scar he sustained at age 6 in a house fire. Examination shows a 4 cm ulcer with heaped-up everted edges and a friable floor; the surrounding scar is unstable. There is palpable ipsilateral inguinal lymphadenopathy. An X-ray of the tibia is normal. What is your diagnostic and management approach?"
Scenario 2: Chronic Tibial Osteomyelitis Sinus with New Mass
"A 64-year-old man with a 22-year history of post-traumatic chronic osteomyelitis of the left tibia presents with a 4-month history of increased purulent discharge from his medial sinus and a 2 cm fungating mass at the sinus mouth. He has had no fevers and his inflammatory markers are normal. X-rays show a chronic sclerotic tibia with a thick corticated cloaca. MRI demonstrates a soft-tissue mass continuous with the sinus tract, no abscess, and no marrow oedema. What is your differential, and how do you confirm and manage this?"
MCQ Practice Points
Definition Question
Q: What is Marjolin's ulcer? A: Squamous cell carcinoma (most common) or other malignancy arising within a chronic wound, scar, sinus or ulcer, typically decades after the original injury. Originally described by Marjolin in 1828 from malignant change in old burn scars.
Latency Question
Q: What is the typical latency between the original wound and malignant change in burn-scar Marjolin's? A: Decades, averaging 20-40 years. Acute Marjolin's (latency under 1 year) is rare and more aggressive. Osteomyelitis-sinus Marjolin's typically has a shorter latency of 10-20 years.
Biopsy Question
Q: Where should the biopsy be taken from in a suspected Marjolin's ulcer? A: The edge of the ulcer, including the transition between abnormal and adjacent normal-appearing skin. Floor biopsies are unreliable because the floor is granulation tissue. Multiple biopsies should be taken for large or heterogeneous lesions.
Histology Question
Q: What is the most common histological type of Marjolin's ulcer? A: Squamous cell carcinoma, accounting for 75-95 percent of cases. Less common types include basal cell carcinoma, melanoma, sarcoma, and Merkel cell carcinoma.
Treatment Question
Q: What is the recommended surgical margin for wide local excision of a Marjolin's ulcer? A: 2-4 cm of clinically normal skin and underlying deep fascia. Margins less than 2 cm are associated with higher local recurrence because of the field-change effect. Amputation is indicated for deep bone or joint involvement.
Nodal Question
Q: What is the rate of regional nodal metastasis at presentation in Marjolin's ulcer compared with de novo cutaneous SCC? A: Up to 20-40 percent in Marjolin's ulcer, compared with less than 5 percent for de novo cutaneous SCC. This high rate drives the recommendation to stage regional nodes with ultrasound and consider sentinel node biopsy in high-risk lesions.
Prognosis Question
Q: What is the most important prognostic factor in Marjolin's ulcer? A: Nodal status at diagnosis. Other adverse factors include deep invasion (greater than 4-5 mm), high grade, lymphovascular and perineural invasion, recurrent tumour, bone involvement, and immunocompromise.
Guidelines, Registries & Global Practice
Global Epidemiology
- Lower-limb burn scars in patients from low- and middle-income countries are the dominant source; incidence reflects regional burn-care history
- Chronic osteomyelitis sinus is a consistent source in all regions, particularly post-traumatic tibial disease
- Venous and pressure ulcers are an increasing source in ageing populations globally
- Radiation-induced chronic skin change is concentrated in patients treated for head and neck, breast, and pelvic malignancy
Practice Variation by Resource Setting
- High-resource centres: MRI, sentinel node biopsy with dual tracer, free-flap reconstruction routinely available
- Limited-resource settings: wide local excision with split-skin graft remains the workhorse; SLNB is not universally available
- Burnscar surveillance programmes: established in some high-income systems; opportunistic in many regions - any clinic visit is a chance to inspect an old burn scar
- Reconstructive options: free flap reconstructive surgery for extensive defects is concentrated in tertiary centres
Society and Reference Guidance (Side by Side)
| Source | Diagnosis emphasis | Treatment emphasis | Follow-up |
|---|---|---|---|
| NCCN (US) - cutaneous SCC guideline | Edge biopsy for any non-healing ulcer or changing scar; MRI for deep lesions | Wide local excision 2 cm minimum margin for low-risk; 4 cm for high-risk; consider SLNB | 3-6 monthly for 2 years, 6-12 monthly to 5 years, then annual lifelong |
| BAD / British Association of Dermatologists | Biopsies of any lesion that has changed within a scar; multidisciplinary review for high-risk | Complete excision with 2-4 cm margin; nodal staging with ultrasound and SLNB for high-risk | Regular review for 5 years minimum; patient education on self-examination |
| ESMO / European consensus | Biopsy confirmation essential; cross-sectional imaging for advanced disease | Wide excision with adequate margins; nodal dissection for positive nodes | Multidisciplinary follow-up; adjuvant radiotherapy for high-risk nodal disease |
| ISAPS / plastic surgery societies | High index of suspicion in chronic burn and osteomyelitis wounds | Wide excision and reconstructive ladder; amputation for unresectable disease | Lifelong scar surveillance and patient education |
Registry and Evidence Note
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.
Documentation Essentials (Globally Applicable)
Record in every suspected case:
- Date and mechanism of original wound
- Latency since original wound in years
- Description of recent change (bleeding, pain, discharge, mass)
- Site, size, edge characteristics of the lesion
- Palpation of regional lymph nodes with size and character
- Biopsy site, type, and pathology result
- Multidisciplinary team discussion outcome and treatment plan
A missed or delayed diagnosis of Marjolin's ulcer is a recognised source of complaints and medico-legal claims. Always document the biopsy site and result for any non-healing wound that you have seen in clinic.
Controversies & Areas of Uncertainty
Role of sentinel lymph node biopsy
Sentinel node biopsy is widely used in melanoma and increasingly used in high-risk cutaneous SCC, including Marjolin's. However, no randomised trial has yet shown a survival benefit of SLNB-guided management in cutaneous SCC. The pragmatic view: offer SLNB in high-risk lesions (deep, high grade, large, lymphovascular invasion) and act on the result within a multidisciplinary framework. The clinical question is unresolved.
Optimal margin width
The 2-4 cm margin range reflects consensus rather than randomised comparison. Smaller margins (1 cm) have been used for low-risk cutaneous SCC, but in Marjolin's the field-change effect argues for wider margins where reconstructive anatomy allows. The exact minimum is unknown.
Limb-sparing surgery versus amputation
For advanced disease with bone or joint involvement, the question of when to amputate is judgemental. Modern free-flap techniques can extend limb-sparing options, but at the cost of long surgery, prolonged rehabilitation, and risk of flap failure. The decision is shared with the patient and is not protocol-driven.
Adjuvant radiotherapy after wide excision
Adjuvant radiotherapy is accepted for node-positive disease and for close or involved surgical margins. Its role in node-negative, margin-negative, high-grade primaries is debated. Emerging evidence suggests benefit in selected high-risk features (perineural invasion, lymphovascular invasion, depth greater than 4-5 mm), but this is not yet a universal recommendation.
Systemic therapy for advanced disease
Historically, systemic therapy for advanced SCC had limited efficacy. Immune checkpoint inhibitors (PD-1 inhibitors) and EGFR inhibitors (cetuximab) have shown activity in advanced cutaneous SCC, but their role in Marjolin's ulcer specifically is not yet defined. Trials are ongoing.
Surveillance intensity and duration
Most recurrences occur in the first 2-3 years, but late recurrence (over 10 years) is well described. Lifelong annual review with low threshold for re-biopsy is the prudent approach, although this is not universally implemented and is a topic of resource-allocation debate.
MARJOLIN'S ULCER
Clinical summary
Definition and Histology
- •Malignant transformation in a chronic wound, scar, sinus or ulcer (most often SCC, 75-95 percent)
- •Originally described by Marjolin in 1828 in old burn scars; term now covers all aetiologies
- •Less common types: basal cell carcinoma, melanoma, sarcoma, Merkel cell carcinoma
- •Field change - dysplasia often extends beyond the visible tumour
Aetiology - BURNSS Mnemonic
- •Burn scars (classic, latency 20-40 years)
- •Ulcers (venous, pressure, diabetic) - common in elderly
- •Radiation-induced chronic dermatitis (10-30 years latency)
- •Non-healing traumatic wounds, fistulae, surgical scars
- •Sinus of chronic osteomyelitis (epithelium grows down the tract)
Warning Signs in a Chronic Wound - CHANGE
- •Crusting or bleeding from a previously stable scar
- •Heaped-up everted edges
- •Atypical new pain in a previously painless scar
- •New foul or bloody discharge
- •Growth or mass within the wound
Diagnosis
- •Biopsy the EDGE of the ulcer (punch or wedge), not the floor - floor is granulation tissue and gives false negatives
- •Multiple biopsies for large or heterogeneous lesions
- •MRI of the limb for local staging (depth, bone, sinus)
- •Ultrasound of regional nodes with FNA of suspicious nodes
- •CT chest for distant staging in high-grade or node-positive disease
Treatment
- •Wide local excision with 2-4 cm margins down to deep fascia
- •Amputation for bone, joint or extensive deep disease - it is a legitimate curative option, not a failure
- •Sentinel node biopsy for high-risk lesions (deep, high grade, large)
- •Therapeutic lymph node dissection for clinically positive nodes
- •Adjuvant radiotherapy for close / involved margins or high-risk nodal disease
Prognosis
- •Worse than de novo cutaneous SCC at matched stage
- •Nodal status is the dominant prognostic factor
- •5-year survival: 70-90 percent node-negative, 40-60 percent node-positive, under 20 percent distant metastasis
- •Local recurrence 20-50 percent at 5 years; late recurrence (over 10 years) is well recognised
- •Second primary SCC in 10-20 percent - lifelong skin surveillance required