Extensive Squamous Cell Carcinoma Originating from a Burn Scar: Marjolin's Ulcer with an Unusual Presentation.

Abstract

Dear Editor: Cutaneous squamous cell carcinoma (SCC) is a malignant tumor, originating from epidermal keratinocytes, which has an invasive nature and the potential to metastasize1. Although SCCs can arise in normal skin, they often develop from precancerous lesions (e.g., actinic keratoses and Bowen's disease) and have also been found to occur in burn scars1. Marjolin's ulcer is a rare and frequently aggressive cutaneous malignancy that arises from chronic ulcers, burns, and chronic inflammatory processes2. We report on a case with an extensive SCC originating from a preexisting burn scar. A 49-year-old man presented with a recent change in his long-standing burn scar. The patient had experienced a severe burn to his scalp at a very young age. There had been an open wound in this region for at least 48-years. The patient complained of a recent increase in discharge, bleeding, and a foul smell for two months. A physical examination revealed an extensive, exophytic, red-gray, ulcerating tumor on the scalp with a scalp bone that was partially absent (Fig. 1A). The neurological examination was unremarkable. A punch biopsy was performed and histopathological findings demonstrated a well-differentiated SCC with irregular nests of epidermal cells, dermal invasion, and keratin production (Fig. 1B). From these clinical and histopathological findings, a diagnosis of SCC was confirmed. The patient was transferred to the department of neurosurgery for further evaluation and management. Brain computed tomography (CT) and angio-CT imaging revealed a large inflammatory mass with osteolysis. The lesion exhibited heterogeneous enhancement with parietal parenchymal involvement (Fig. 1C, D). Positron emission tomography-CT imaging failed to show systemic metastasis. One month after the initial diagnosis, the patient began developing gait disturbances and experienced occasional loss of consciousness. Surgery was not a treatment option in our case. Palliative radiotherapy was performed to relieve symptoms, but this proved ineffective. Fig. 1 (A) Extensive squamous cell carcinoma (SCC) of the scalp with giant reddish plaques and yellowish discharge. The scalp bone was partially absent. (B) Histopathological evaluation reveals a well-differentiated SCC with irregular nests of epidermal cells, ... Neoplastic changes in chronically ulcerative wounds are a well-known process3. Marjolin's ulcer is a term which is used to describe the formation of a carcinoma in a non-healing scar2. The majority of burn scar carcinomas are reported to be SCCs2. SCCs arising from burn scars typically manifest between 20 and 40 years after the original burn2. As such, Marjolin's ulcers have a much greater tendency to metastasize than typical SCCs and are also associated with a significantly poorer prognosis3. One study analyzing extensive SCC cases reported most tumors as being localized to the scalp, with a single patient exhibiting cranial infiltration4. An SCC which is located in extracranial regions and demonstrates intracranial extensions has rarely been reported. Organ transplant recipients with alopecia, human immunodeficiency virus-infected patients, and patients with burn scars of the scalp are among those most at risk5. Mohs surgery and its various modifications represent the gold standard of treatment, but that bears a major risk of brain edema, which is associated with a high mortality rate5. In our case, the intracranial spread and difficulty in treatment emphasizes that SCCs arising from long-standing burn scars are too aggressive and extensive that they cannot be treated easily; therefore, early diagnosis is needed.