Malignant degeneration of scars in elderly people (Marjolin's ulcers)

Dear Editors, A 66-year-old woman, living in the rural area, was admitted to the hospital for multiple ulcerations of different sizes on a large previous scar. The ulcers were surrounded by inflammatory rims, covered by crusts and malodorous necrosis and distributed on both the posterior aspects of her legs. Thirty-four years earlier, she had been hospitalised, for several months, because of a fire accident. Her present medical history was uneventful, and her general condition was good at the time of admission in the hospital. Blood analyses were within the normal range. Skin biopsy was performed from different tumoural lesions and histological examination confirmed poorly differentiated squamous cell carcinoma. Tumour cells are pleomorphic/atypical, but still resemble the normal keratinocytes (large, polygonal, with abundant eosinophils and pink cytoplasm and central nucleus). Their disposal tends to be similar to that of normal epidermis: immature/basal cells at the periphery, becoming more mature at the centre of the tumour masses. Tumour cells transform into keratinised squames and form round nodules with concentric, laminated layers, the so-called cell nests or epithelial/keratinous pearls. The surrounding stroma is reduced and contains inflammatory infiltrate (lymphocytes). Tumour cells in the form of sheets or compact masses invade and destroy the subjacent connective tissue (dermis). All the tumours were excised; no lymph node involvement was proved. The patient was sent to the Oncology Unit for further and detailed examination. However, 1 year later, she died of pulmonary metastasis. A 68-year-old woman, retired person, presented with inflammatory changes in an old scar, on the inner part of her left arm, observed few months prior to the actual consultation (Figure 1). Atrophic skin was surrounded by an inflammatory rim, hard in consistency, with fibrotic changes and no excoriations. The scar was the consequence of a burn induced by hot water during her childhood. Edge biopsy was performed and histopathological examination showed basal cell carcinoma (Figure 2). A wide local excision with a tumour-free margin of 1 cm was undertaken under local anaesthesia. She was followed up regularly at 3 and 6 months and afterwards annually. There was no local recurrence of the ulcer and no metastasis. Degeneration of scars is well known from ancient times; in the first century AD, Aurelius Cornelius Celsus described cancer in chronic ulcers for the first time (1). Many centuries after Celsus, in 1828, Jean-Nicolas Marjolin from Paris University, published a half-page article in Figure 1 Large atrophic scar (10× 12 cm) and the inflammatory borderline.