Malignancy in chronic ulcers and scars of the leg (Marjolin’s ulcer): a study of 21 patients

Abstract

Objective. To study the imaging features of patients with chronic ulcers of the leg that were associated with malignancy. Design and patients. All patients who on biopsy were proven to have malignancy – the majority of which were squamous cell carcinoma – were included in a prospective study. Ulcers limited to the foot were ex cluded but ulcers of the leg which extended into the foot were included. Amputation was performed in all but two patients, due to pain, bleeding or tissue necrosis. Results. The etiology was multifac torial. The mean duration of the ul cers was 36 years including venous ulcers, extensive scarring of the leg secondary to infection, injury or burns. One ulcer was secondary to a snake bite. The remainder, usually in the upper part of the leg, had repeat ed episodes of blunt trauma or knife wounds, which were also complicat ed by infections which failed to heal or, if they healed, regularly recurred. Although arterial insufficiency was not primary in any patient, most were of advanced age and it may have been an element in some pa tients. Despite infection, osteomyeli tis was present in only one patient. The essential features were bone de struction, soft tissue mass and peri osteal reaction. The bone destruction was visible on the radiographs in all but one case. The soft tissue masses varied in size but in general were very large. The periosteal reaction varied in type but most commonly was lamellated. The classic undulat ing solid periosteal reaction of ve nous stasis was only occasionally present. The periosteal reaction was nonspecific in the majority of cases and did not aid in the diagnosis or etiology. MRI and CT studies were performed in six patients. These were helpful in defining the extent of bone destruction and periosteal reac tion but were not essential in man agement. Conclusion. Chronic ulcer present for decades that then undergoes ma lignant change is a disease of devel oping countries where patients only consult physicians when they have developed complications such as pain, bleeding or tissue necrosis. Chronic ulcers may require to be biopsied at regular intervals as ma lignant change in these ulcers is di rectly related to their duration.