An 86-Year-Old Man With Bilateral Chronic Wounds of the Legs: Figure 1.

Diagnosis: Bilateral invasive squamous cell carcinomas (Marjolin ulcers). This patient presented with chronic bilateral lower extremity ulcers, thought to be due to chronic venous insufficiency. The wounds failed to heal despite several attempts at debridement, grafting, and vein stripping procedures. Skin biopsies and wound cultures were performed to assess for other potential primary dermatologic conditions, such as pyoderma gangrenosum, malignancy, and chronic wound infections. Skin biopsy revealed bilateral invasive squamous cell carcinomas (Figure 1). Marjolin ulcers, first described in 1928 by French surgeon Jean Nicholas Marjolin, are the result of malignant degeneration of chronic wounds or scars [1]. The mean time period between development of a wound to malignancy is 30–35 years [2, 3]. The most commonmalignancies seen inMarjolin ulcers are squamous cell carcinomas, but basal cell carcinomas and melanomas have been reported [3]. Classically, Marjolin ulcers are a complication of burn scars, and an estimated 2% of burn scars undergo malignant transformation [1, 4]. They can also occur in any chronic wound including osteomyelitic fistulae (approximately 0.2%– 1.7% undergo malignant transformation) and venous stasis ulcers [3, 4]. These lesions can be difficult to distinguish from infection clinically, and definitive diagnosis is achieved with skin biopsy [3]. Biopsies should be taken from the most indurated or nodular area of the lesion. It is also helpful to obtain a sample that includes the edge of the ulcer and part of the ulceration to increase the diagnostic yield of the biopsy. Finally, in the case of a large lesion that is suspicious for malignancy, several biopsies from different areas of the ulcer may be obtained to ensure that an accurate representation of the entire lesion is reviewed by the pathologist. The treatment of Marjolin ulcers usually involves surgical intervention [1, 5, 6]. This may include Mohs surgery, wide local excision with skin grafting, or, in some situations, limb amputation [3]. Choice of therapy depends on the location of the lesion and the extent of involvement, but no definitive treatment protocol exists [3]. Radiation and chemotherapy have been attempted, but the evidence to support their efficacy in Marjolin ulcers is controversial and inconsistent [3]. The 5-year survival rate in Marjolin ulcers has been reported to be between 40% and 69%, and almost all lesions recur within 3 years [7, 8]. Following amputation for extensive tumor involvement, metastasis has been documented in 20%–35% of individuals [2]. Disease that is metastatic to lymph nodes has a worse prognosis than local disease, with a 3-year survival rate of 35%–50% [4]. Figure 1. A, Left leg ulcer (hematoxylin and eosin [H&E] stain, magnification ×20) with invasive keratinizing squamous cell carcinoma, moderately differentiated, arising in a chronic ulcer. The invasive carcinoma displays a nested architecture and keratin pearls. B, Right leg ulcer (H&E stain, magnification ×10) with invasive keratinizing squamous cell carcinoma, moderately differentiated, with overlying skin surface ulceration. The tumor appears as invasive nests of cells with intervening dermal stromal inflammation.