A Power Point Presentation on Marjolin's ulcer.pptx

a power point presentation on marjolin's ulcer

1. Marjolin’s ulcer Dr Okpako Isaac Oghenero Senior Registrar plastic and Reconstructive surgery University of Abuja Teaching Hospital Gwagwalada 21/04/24

2. O utline Introduction Definition Historical perspective Epidemiology Statement of surgical importance Risk factors Pathogenesis Theories of development of marjolin’s ulcer Clinical types Clinical features Investigations Treatment Prevention Prognosis Current trend Conclusion References

3. Introduction Definition Marjolin’s ulcers are malignant cutaneous ulcers arising from areas of chronic irritation

4. Introduction - Historical perspective in AD 100, Celcius was the first to observe malignant transformation in burn scars. In 1828, Jean Nicholas Marjolin , a French surgeon, described two simple leg ulcers with warty changes as 'Ulcer canchroides ', this was published in an article in the French Dictionaire de Medicine, at that time he did not recognize the malignant nature of the ulcer A more detailed description of these lesions was later made by Dupuytren . Byron and Smith in 1844 and 1850 respectively confirm these conditions as carcinomas. They described cancers arising in burn scars, scars from flogging as well as other forms of trauma However it was Da Costa that first use the term ' Marjolin's ulcer' in 1903 to describe ulcer arising from simple leg ulcers

5. Introduction - EPIDEMIOLOGY Occurs predominantly in middle aged group with a report average age group of 53 to 59 years Onset at 44 years in India ( Sisrat and Shrikhande ) Average onset in south Eastern Nigeria 44.1 years ( Asuquo etal ) Male greater than female 2-3:1

6. Introduction - Statement of surgical importance A good knowledge of marjolin ulcer is necessary in prevention early detection and appropriate management of the condition

7. Risk factors Chronic leg ulcers Burn scars Osteomyelits sinuses Pressure sore Urinary fistulas Pilonidal sinuses Gumata radiation scars Scars from flogging

8. Pathogenesis Ewing formulated a set of criteria to establish the relationship between trauma and development of cancers and this was adapted by treves and park in burns scar The cancer must arise within the boundaries of the scar or wound. Incontrovertible evidence of trauma or the pre-existing ulcer as evidenced by the wound or scar. The absence of any precursory or similar neoplasm on the site of the trauma/wound prior to the development of the cancer The histologic variety of the cancer must be compatible with the tissues found in the site of the trauma or scar/wound The interval time between the trauma/ulcer and the onset of the cancer must be appropriate. A period of one month has been proposed as the minimum acceptable time between the trauma/ulcer and the onset of the cancer

9. Classification Acute Usually within one year latency period Chronic Latency period last for more than a year

10. Parts of the body commonly affected Lower limbs 40% Head and neck region 30% Upper extremities 20% Trunk 10%

11. Theories of development of marjolin’s ulcers These theories tries to explain the evolution of marjolin’s ulcer however non fully explains all aspect of the development Virchow theory of chronic irritation Friedwald and Rouse co-carcinogenic theory Treves and Pack toxin theory Ribet's theory of epithelial element implantation Castillo and Goldsmith immunologically privillaged site theory H ereditary theory E nvironmental and genetic interaction theory M ultifactorial theory

12. Theories of development of marjolin’s ulcers T heory of chronic irritation This theory explains that with chronic irritation and repeated tissue injuries attempts at healing becomes increasing difficult resulting in unstable epithelium which eventually loss contact inhibition and undergoes malignant changes Co- carcinogeneic theory This theory proposes an initator and promoter phase- where the initiator phase developes a dormant neoplastic cells which when acted upon by the promoter forms marjolins ulcer and in the case of burn the burn injury may be the initator while actinic radiation or some other agents such as chronic irritation may serves as the promoter in the formation of marjolins ulcer

13. Theories of development of marjolin’s ulcers Toxin theory This theory suggest that as a result of tissue damage, toxins are released which result in a nutritional deficiency at the cellular level. This compromises the ability of the cells to effect tissue repairs following carcinogenic insults with attendant accumulation of mutated DNA and subsequent malignant changes E pithelial element implantation This theory postulates that epithelial cells implanted into the dermis during injury undergoes a disordered regenerative process leading to carcinomatous changes

14. Theories of development of marjolin’s ulcers I mmunologically privileged site theory This theory states that due to poor lymphatic flow to scar tissue immunosurvelance is impaired making it difficult for the body to mount effective antigen-antibody response to proto- oncogens or tumour within the scar this allows the tumour to escape early recognition by the host Hereditary theories This theory states that the genetic composition of the host is susceptible to development of the disease this is supported by the findings of p53 and Ras genes in patient with marjolins ulcer

15. Theories of development of marjolin’s ulcers E nvironmental and genetic interaction theory This theory explains that the evolution of acute Marjolin's ulcers, occurs because the genetic makeup of the individual is more susceptible to the environmental insult, resulting in a short latent period. Multifactorial theory This proposes that a combination of the above theories will best explain the process of evolution of Marjolin's ulcer

16. Clinical T ypes Flat indurated, infiltrative, ulcerative marjolin’s ulcer. (poorer prognosis) The less frequent exophytic papillary form

17. Clinical features Symptoms Latent period of at least 4 weeks post excision or one year post injury average of about 20 to 40 years Presence of an ulcer or a scar Dull aching pain Change in the nature of discharge if present and this may change to offensive smell and sometimes hemorrhagic

18. Clinical features Signs Tenderness Ulcer usually begins at the edge of the scar which may show some warty changes with some elevation Occasionally there is appearance of a mass within the scar or ulcer The base becomes increasing indurated and granular often with necrotic floor and blood clot Healing may occur in some areas where sloughing has occurred thus presenting a deceptively innocuous appearance Progression of the ulcer to involve deeper tissues It is also important to note that all the signs of malignant transformation must not necessarily be present to draw a suspicion of Marjolin's ulcer

19. Spread Direct invasion mainly and in the late stage by lymphatic spread

20. Diagnosis To confirm diagnosis Histology (from the edge and as well as the center)- excision / incision Forms Squamous cell carcinoma Basal cell carcinoma Malignant melanoma Fibrosarcoma Liposarcoma Occasionally more than one histologic type can be found e.g basosquamous Ca

21. Diagnosis To know extent of disease Plain radiographs CT scan MRI Typical features seen on imaging are soft tissue mass, bony destructions and periosteal reaction To prepare patient for surgery FBC E/U/Cr LFT

22. Treatment Surgery Excision biopsy A margin of 2cm is generally recommended Skin grafting and flap Excision biopsy +/_ lymph node dissection Amputation

23. Treatment Radiotherapy Though the tumors show poor response to radiotherapy due to their poor vascularity it can be used for palliation Chemotherapy Intra-arterial perfusion with methotrexate however due to the poor vascularity response is mostly poor however Novick et al reported improved outcome and recommended it as a useful adjunct

24. P revention Primary prevention of burn wound and ulcers Secondary Early and prompt treatment of burn wound and ulcers Early skin grafting Tertiary Prevention/ reduction of sun exposure to scars Early excision

25. Current trend Prevention of marjolin’s ulcer

26. Prognosis Location – lower limbs are more likely to have worse prognosis Latent period – a short latent period has worse prognosis Histologic types – SCC has worse prognosis Tumor size > 2cm Grade of tumor – poorly differentiated tumor has poor prognosis Tumor with little/ no peritumoral T lymphocyte infiltration has poor prognosis Metastasis – has poor prognosis Tumor from pressure sore

27. Conclusion Marjolin’s ulcers are malignant cutaneous ulcers arising from areas of chronic inflammation Prevention is a better option

28. Thank you

29. References Kingsley O.O, Otene I. C. Marjolin’s Ulcers: A Review The Nigerian Health Journal, Vol. 11, No 4, October - December, 2011 Treves N, Pack GT: The development of cancer in burn scars. Surg Gynecol Obstet 1930, 51:749-782. st2. Marjolin JN. Ulcers. Dictionaire de Medicine. Vol.21, 1 ed. Paris: Bechet Jeune , 1828: 46 Applebaum J, Burrows WM, Greenway HJ. Acute Marjolin's ulcer. J Assoc Mil Dermatol 1985;11: 57-61 Nancarrow JD. Cicartrical cancer in South-West England: a regional plastic surgery unit's experience over a 20 tear period. Br J Surg. 1983:70;205-208 Cruickshank AH, Connel EM, Miller DG. Malignancy in scars, chronic ulcers and sinuses. J Clin Pathol 1963;16:573-80 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(6):331-7. Castillo J, Goldsmith HS. Burn scar carcinoma. Cancer J. Clin . 1968;18:140-142 Sisrat MV, Shrikhande SS. Histochemical studies on squamous cell carcinomas of the skin arising in burn scars with special reference to histogenesis . Indian J. Cancer. 1967;3:157-169 Novick M, Gard DA, Hardy SB, Spira M. Burn scar carcinoma: A review and analysis of 46 cases. The Journal of Trauma. 1977;10:809-817. Engler HS: Cancer arising in scars of old burns. J Med Assoc Ga 1968; 57:145 11. Nthumba PM. Marjolin's ulcers in sub Saharan Africa. World J Surg. 2010;34: Asuquo ME Ikpeme IA, Bassey EE, Ebughe G. Squamous Cell Carcinoma in South-Eastern Equatorial Rain Forest in Calabar , Nigeria. Stauffer H: Zeistschr Krebsforsch . 1929;28:418 Eplasty . 2009; 9: e53