When the wound healing period lengthens due to the a lack of proper treatment, severe scars left behind and chronic ulcers occur due to repeated injury, particularly in the protrusion of the bone or joint. In such ulcers, repeated incomplete epithelialization attempts, called Marjolin's ulcer, cause malignant degeneration after a long period of time [6
]. Marjolin's ulcer refers to all malignant tumors that occur in chronic ulcers, scars, and inflammation areas [2
]. Jean Nicholas Marjolin first illustrated tumorous changes in chronic burn scars in 1828 [2
]. Treatment involves a wide surgical excision with a range of at least 2 cm, including thick scar tissue in the margin of the ulcer [8
]. The size of the tumor is decreased with chemotherapy before the surgery and chemotherapy is conducted after the surgical excision as a combination therapy [9
]. Although the cure rate is high after the operation, in cases in which there is no lymph node metastasis, the cancer progresses quickly and leads to death within 2 years once metastasis occurs [8
]. Regardless of active treatment, a higher proportion of recurrence and poor prognosis are exhibited for Marjolin's ulcer compared to other skin cancers [6
]. Although representative factors that have an impact on the prognosis of the patient are the histologic grade of the carcinoma before the surgery and lymph node metastasis, little is known about the signs that can quickly identify the recurrence with regard to follow-up treatment. While concentrating on the importance of the surgical resection margin, Bozkurt et al. [10
] reported that the aggressive approach is able to improve prognosis based on the fact that there was only 1 recurrence out of 16 cases with a 5 cm surgical margin. At the same time, Chalya et al. [11
] reported that early recognition, aggressive treatment, and close follow up are helpful in the improvement of the prognosis, considering the medical treatment conditions of northwestern Tanzania.
Therefore, it is important to take an aggressive approach and quickly notice the recurrence after surgery for Marjolin's ulcer to improve the prognosis of the patient. As shown in the results of this study, disturbed wound healing has a statistically significant relationship to the recurrence of carcinoma. In case a problem occurs in the wound healing process after surgery, active diagnosis and treatment may be urgently needed to improve the prognosis. With regard to the recurrence of carcinoma, Aydogdu et al. [12
] reported that, on average, 8 out of 12 patients experienced recurrence within 5.4 months (range, 3 to 10 months) after the surgery, and Onah et al. [13
] reported that there was recurrence in 11 out of 25 patients, including 5 cases of recurrence within 3 months, 2 cases of recurrence within 6 months, and 4 cases of recurrence within 1 year after the surgery. In our case, there was recurrence within 4.66±2.07 months (range, 2 to 8 months). The short period of time from the removal of carcinoma to its recurrence should be taken into consideration.
A comparison of the clinical characteristics of the patients has been conducted between the recurring group and non-recurring group. During the period under study, 13 males and 7 females were in the non-recurring group while 2 males and 4 females were in the recurring group. Burns were the most common causative lesions in the recurring group and non-recurring group. Most primary wound sites were healed by skin graft. The extremities were the most common sites of Marjolin's ulcer (6 in the upper extremities and 7 in the lower extremities in the non-recurring group; 1 in the upper extremities and 2 in the lower extremities in the recurring group). The latent period was 41±15.45 years (range, 22 to 64 years) in the non-recurring group and 37.9±13.74 years (range, 13 to 64 years) in the recurring group, but statistical analysis was not possible ().
Demographic data, causative previous lesions, previous therapy, latent period, site of lesions, and length of follow-up
Recurrence at the same site of the surgery within a short time, strictly speaking, may mean that complete resection was not performed. However, depending on the results of the frozen section biopsy, the authors determined the extent of the surgery and the resection was performed with 1 to 4 cm margins. It was also confirmed that there were no cancer cells in a permanent biopsy on the resection margin and base of the final resected main mass. The authors have no doubt that complete resection was performed clinically in all possible cases. Nevertheless, given the higher proportion of recurrence, it is assumed that our clinically complete resection may not have been adequate treatment.
The results of this study do not show delayed wound healing as a prognostic factor because this study could not exclude other factors due to the lack of a sufficient number of cases. The point of this paper is that, in cases in which a problem occurs in the wound healing process after surgery, one should keep in mind that there is a possibility of recurrence of carcinoma and active treatment is urgently needed to improve the prognosis.
As a result of conducting a retrospective study on the clinical chart of 26 Marjolin's ulcer patients treated in the plastic surgery clinic of our hospital, it was revealed that the proportion of recurrence increases when the histologic grade of carcinoma is low or lymph node metastasis is presented at diagnosis, which is consistent with the previous literature. Furthermore, it was shown that disturbed wound healing after surgery has a statistically significant relationship to the recurrence of carcinoma.
A limitation of this study is the lack of a sufficient number of cases. Nonetheless, the evidence shows that in the case a problem occurs in the wound healing process after surgery, there is a higher possibility of recurrence. To assist in the treatment of the patient, careful observation and active diagnosis should be conducted through additional examinations to obtain early diagnosis of recurrence.