
Insights from Magnetic Resonance Imaging in Diagnosis of Marjolins Ulcer
Correspondence Address :
Dr. Saraswathula Bharadwaj,
Room T5, Ragobaji PG Hostel, Jawaharlal Nehru Medical College, Wardha-442001, Maharashtra, India.
E-mail: slgvrbharadwaj@gmail.com
A 62-year-old female presented to the Surgery Outpatient Department with a four-month history of a wound on the lateral aspect of her right thigh, with an underlying history of trauma a few days prior. She had suffered a flame burn injury 50 years ago. There was a progressive increase in the size of the wound over the past four months, with an associated pricking type of pain. The patient denied other symptoms such as fever or discharge. Local examination revealed a 14×12 cm solitary ulcer on the posterolateral aspect of the right thigh with irregular margins and rolled-out edges (Table/Fig 1). The base was formed by muscle induration, associated with slough and an absence of any discharge or bleeding. Multiple wedge biopsies from the wound margins and base were performed, revealing moderately differentiated Squamous Cell Carcinoma (SCC).
The patient was advised to undergo an Magnetic Resonance Imaging (MRI) of the thigh for further management planning. The MRI revealed heterogeneously enhancing soft-tissue thickening at the ulcer margins, approximately 13.3×4.1×1.5 cm in size, involving the skin and subcutaneous tissue in the posterolateral aspect of the thigh (Table/Fig 2).
The lesion appeared heterogeneously hyperintense (Table/Fig 3), showing diffusion restriction and no blooming on Susceptibility Weighted Imaging (SWI). Hyperintensity was seen deep in the lesion in the subcutaneous plane and showed mild postcontrast enhancement (Table/Fig 4). The underlying bones and muscles appeared normal. Mild inguinal lymph nodes on the right-side appeared rounded and showed postcontrast enhancement.
The differentials that were considered for this case were actinic keratosis, allergic contact dermatitis, atopic dermatitis, atypical fibroxanthoma, limbal dermoid, osteomyelitis, ulcer osteoma, and basal cell carcinoma. The MRI findings, along with histopathological examination, confirmed the diagnosis.
The patient was initially treated with vinegar dressing, followed by wide local excision of the Marjolin ulcer (Table/Fig 5) and Vacuum- Assisted Closure (VAC). After two weeks, the VAC dressing was removed, and the patient was managed with a sterile dressing with gentamicin for a few weeks. The patient was referred to a plastic surgeon, and a thick skin graft was placed over the excised ulcer (Table/Fig 6). A frozen section was sent when the ulcer was excised, which suggested no infiltration of malignant cells, and Histopathological Examination (HPE) revealed SCC (PT3Mx) (Stage IB).
A Marjolin ulcer is the unusual occurrence of cutaneous SCC in the presence of a scar or ulcer. It typically arises at an old thermal burn scar (1). Marjolin ulcers generally appear 30 years after a skin injury. They can afflict persons of all ages, with males diagnosed 2-3 times more frequently than women (2). They can affect the legs, feet, head, and neck, lasting from six weeks to a year after the incident. Marjolin ulcers are most commonly found on the legs and feet but can also develop on the head and neck. The incidence is around 1-2% of all burn scars (3),(4).
Radiologically, MRI is vital for the assessment of the involvement of underlying soft tissue structures and bony involvement. Marjolin ulcer presents as a soft tissue mass in MRI. On contrast enhancement, the ulcer shows avid enhancement due to increased vascularity. As the ulcer progresses, MRI helps determine the extent of invasion of the ulcer and underlying structures such as muscle, bone, and deeper layers. In chronic cases, regional lymphadenopathy suggests the possibility of metastasis (5). Due to the destructive and progressive nature of the ulcer, MRI is essential in identifying bony destruction, marrow involvement, and periosteal reaction.
Marjolin ulcer is a rare malignant tumour that requires prompt discovery, proper diagnosis, and treatment. Histopathology supports the diagnosis, and MRI is essential for determining the size and extension of the lesion, underlying muscle and bone involvement, and metastasis.
Avid enhancement, Squamous cell carcinoma, Thermal burn
DOI: 10.7860/JCDR/2024/72686.19717
Date of Submission: May 07, 2024
Date of Peer Review: May 21, 2024
Date of Acceptance: Jun 06, 2024
Date of Publishing: Aug 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 08, 2024
• Manual Googling: May 24, 2024
• iThenticate Software: Jun 04, 2024 (6%)
ETYMOLOGY: Author Origin
EMENDATIONS: 5
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Embase
- EBSCOhost
- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com