Age / Sex : 76 / F

Past medical history : 

Right tibia operation, due to osteomyelitis

Right tibia OP site dressing, due to
pus discharge since 7~8 years ago

Marjolin’s ulcer (Ulcerating squamous cell carcinoma)

Discussion

Findings:

Radiograph images
show a mass like opacity with periosteal reaction and cortical
disruption in peritibial area of mid portion of right lower leg

MR images
show
heterogeneous hyperintense ulcerative protruding mass on T2WI and  hypointense on T1WI in pretibial area of mid
portion of right lower leg.

Gd enhanced
T1WI shows an infiltrative mass that extends from surface to bone marrow of mid
shaft of tibia. Tumor shows heterogeneous good enhancement

Diagnosis: Marjolin’s ulcer (Ulcerating squamous cell
carcinoma)

Differential Diagnosis: Osteomyelitis with abscess and skin ulcer

Discussion:

Term “marjolin ulcer” refers to carcinomas arising from
chronically inflamed, or scarred skin.

The
incidence of marjolin ulcer is 1.2 to 2 % of skin cancers. The average age at diagnosis
is in the fifth decade of life with a range of 18–84 years, and men are three
times more frequently affected than women. The majority
of reported cases are squamous cell carcinoma, but other types of malignancies
such as basal cell carcinoma, malignant melanoma, liposarcoma, osteosarcoma,
adenocarcinoma, and fibrosarcoma can also be seen, although they are rare. Most
lesions of Marjolin’s ulcer occur on the extremities (60%), with ulcers on the
head and face occurring less frequently (30%) and those on the trunk the least
frequent at 10%.

A multidisciplinary approach
is necessary in these patients when considering further workup for metastatic
disease, including MRI and CT to evaluate soft tissue and bone, along with
appropriate lymph node surveillance and dissection when necessary. Radiography
provides information about periosteal reaction. The most valuable study in
these patients is MRI because it shows the margins and extent of destruction
well. Wide excision (surgical margin of at least 2 cm) together with skin
grafting is usually considered appropriate in the treatment of Marjolin’s ulcer

References:

1.     Kuo-Hsien Chiang¹, Andy Shau-Bin
Chou¹, Yung-Hsiang Hsu¹, Sea-Kiat Lee¹, Chau-Chin Lee¹, Pao-Sheng Yen¹, Chang-Ming
Ling¹, Wei-Hsing Lee¹, Chao-Chun Lin¹ and Pau-Yang
Chang¹, Marjolin's Ulcer: MR
Appearance, AJR 2006;186: 819-820

2.    
Smith J¹, Mello LF, Nogueira Neto NC, Meohas W, Pinto LW, Campos VA, Barcellos MG, Fiod NJ,Rezende JF, Cabral CE. Malignancy in chronic ulcers and scars of the leg
(Marjolin's ulcer): a study of 21 patients. Skeletal Radiol. 2001 Jun;30(6):331-7.