Radical surgical treatment for Marjolin ulcer occurring after chronic osteomyelitis.

To the Editor: A 56-year-old man with a 40-year history of nonhealing osteomyelitis of the right leg presented with complaints of increasing pain. Previous treatment for the infection included unsuccessful surgical treatment and systemic antibiotic therapy. The lesion was ulcerative, with infiltration of the margins (Fig. 1). Bilateral chronic venous insufficiency was present. Local biopsy revealed the presence of a squamous cell carcinoma. Palpable lymph nodes were found in the groin. Excisional biopsy of the enlarged inguinal nodes revealed only reactional response. Computed tomography of the thorax revealed enlarged lymph nodes at the mediastinum. Mediastinoscopy was done, and biopsy did not show malignant cells. No abnormality was found on abdominal ultrasonography. The patient underwent a supracondylar leg amputation. Postoperative course was uneventful. There was no evidence of tumor recurrence one year after the procedure.

[FIGURE 1 OMITTED]

Marjolin ulcer is a malignant transformation of a chronic wound. Although there have been several reports of Marjolin ulcer complicating burn scars, (1) the occurrence of these tumors is an exceptional complication of osteomyelitis. (2)

The clinical course of Marjolin ulcer is aggressive and the diagnosis of these tumors may be challenging. Due to the rare occurrence of malignant transformation after osteomyelitis, treatment is not well established. In general, treatment follows the management principles of afterburn cancers. Even though surgical treatment may be accomplished by local excision, some physicians believe that radical treatment has become the standard of care. (3) Smith et al (4) performed amputation in all but one of their 21 patients. The only patient treated with local excision had local recurrence and ultimately underwent amputation. Hahn et al (1990) had a high recurrence rate with use of local excision, and the use of single radiotherapy was followed by a 2-year fatal course in all cases. (5)

We believe that the best treatment for Marjolin ulcer is early prevention with adequate treatment of all chronic wounds. Routine biopsy should be obtained from all nonhealing chronic ulcers.

Livia S. Smidt, MD

Luis Felipe S. Smidt, MS

Maria Bernadete F. Chedid, MD, PHD

Caren S. Bavaresco, MSC

Marcio F. Chedid, MD

Department of General Surgery Hospital de Clinicas, Federal University of Rio Grande do Sul Porto Alegre (RS), Brazil

References

1. Stankard CE, Cruse CW, Wells KE, et al. Chronic pressure ulcer carcinomas. Ann Plast Surg 1993;30:274-7.

2. Hensel KS, Ono CM, Doukas WC. Squamous cell carcinoma in chronic ulcerative lesions: a case report and literature review. Am J Orthop 1999;28:253-6.

3. Chlihi A, Bouchta A, Benbrahim A, et al. The Marjolin's ulcer, destiny of a unstable scar. About 54 cases of burn's sequelae. Ann Chir Plast Esthet 2002;47:291-7.

4. Smith J, Mello LF, Nogueira Neto NC, et al. Malignancy in chronic ulcers and scars of the leg (Marjolin's ulcer): a study of 21 patients. Skeletal Radiol 2001;30:331-7.

5. Hahn SB, Kim DJ, Jeon CH. Clinical study of Marjolin's ulcer: Yonsei Med J 1990;31:234-41.

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