Marjolin’s ulcer on a burn graft site after 86 years

Sir, Marjolin's ulcer has generally been accepted to refer to as a long-term malignant complication of the scars resulting from burns [1]. It has been estimated that about 2 % of the burn scar undergo malignant transformation, with an overrepresentation in males [1]. The precise pathogenesis of burn scar carcinomas is not known; however, it is clearly distinct from that of more usual skin cancers. A 90-year-old man, with past medical history of prostate hyperplasia and high blood pressure presented to plastic surgery practice for an easily bleeding chronic ulceration between the skin graft and local flap involving the right flank, since autumn 2008. He originally suffered from a full thickness flame burns, % total body surface area (TBSA) 10 %, at the age of 4 and was treated operatively. The ulceration was managed conservatively by general practitioners with dressings and topical antibacterial and anti-fungoidal treatments. After unsuccessful conservative treatment, he was referred to plastic surgical consultation for further management. A tumour with fungating appearance with ulceration covering the whole tumour surface in between the skin graft and intact skin fold was noted (Fig. 1). At this time, no histology was evaluated. The tumour's appearance and history was unmistakable malignant and operative treatment was planned. The right axilla was preoperatively scanned with ultrasound and revealed no enlarged masses. Sentinel node biopsy was omitted. Wide excision at the level of fascia was carried out with 5cm margins. The specimen measured 12×8×2.5 cm. There was a fold of loose, intact skin that could be released and used as a local random pattern flap to cover the defect. In the first postoperative day, the distal part of the flap was bluish and venous congestion was suspected. Soon the purple colour disappeared and flap vascularity was excellent. The wound was found completely healed when the patient came to outpatient clinic visit on day 21 (Fig. 2) Histological description of the specimen was welldifferentiated squamous cell carcinoma (SCC). The diameter was histologically 35 mm and depth of invasion 10 mm, no perivascular or perineural invasion was detected. The malignant transformation of burn scars is a long-term complication of burns. Kowal-Vern and Criswell summarized 146 articles on burn scar cancer between 1923 and 2004 indicating a mean scar age of 31 years [1]. We were interested in the long latency period after and sought to find articles with latency>50 years, Table 1 [2–8]. Thus, to best of our knowledge, our case represents the longest latency between the initial thermal injury and malignant transformation in burn scar. Two population-based cohort studies from Scandinavia determined skin cancer in people with scarring as a result of burn injuries [9, 10]. There were no differences in the rates of skin cancer (in general, on any site) compared with the general population. The Danish study provided Standardized incidence ratios for SCC 0.9 (95 % confidence interval (CI)00.6–1.5), for basal cell carcinoma (BCC) 0.7 (95 % CI00.6–0.9) and for malignant melanoma (MM) 0.7 (95 % CI00.4–1.1) [9]. The respective figures for the Swedish study were 0.88 (95 % CI0 0.70–1.09) for SCC and 0.88 (95 % CI00.68–1.12) for MM [10]. The Danish group analysed further skin cancers restricted to the anatomic site of the burn injury, the standardized incidence ratio (SIR) for SCC increased to 1.2 (95 % CI00.4–2.7) [9]. Marjolin's ulcers usually occur in old burn site that was not grafted and left to heal secondarily. Only 5 % of the T. A. Partanen (*) Department of Surgery, South Karelia Central Hospital, Valto Kakelan katu 1, 53100 Lappeenranta, Finland e-mail: partanenta@gmail.com