Marjolin ulcer in pressure injury scar: a case report Case Report

Marjolin ulcer (epidermoid carcinoma) is a rare condition that arises from a chronic skin lesion. We present a patient who developed an epidermoid carcinoma in the scar tissue of a pressure ulcer. After eleven years of surgery to correct a pressure ulcer in the right gluteus, the patient developed an epidermoid carcinoma in a pressure ulcer in the left gluteus and neglected the condition. Wide resection of the lesion was performed with free margins in the final histopathological result. Marjolin ulcer is an expression that commonly refers to the malignant degeneration of chronic wounds that have not healed or healed by secondary intention. It is often described as various types of lesions, including the scars of pressure ulcers. The pathogenic mechanisms behind the malignant transformation of these lesions have not yet been completely elucidated. The diagnosis is initially made by clinical examination due to the lesion aspect and is confirmed by biopsy. Surgery is the choice treatment closing the defect with flaps or grafts, depending on each case. ABSTRACT

Marjolin ulcer (epidermoid carcinoma) is a rare condition that arises from a chronic skin lesion. We present a patient who developed an epidermoid carcinoma in the scar tissue of a pressure ulcer. After eleven years of surgery to correct a pressure ulcer in the right gluteus, the patient developed an epidermoid carcinoma in a pressure ulcer in the left gluteus and neglected the condition. Wide resection of the lesion was performed with free margins in the final histopathological result. Marjolin ulcer is an expression that commonly refers to the malignant degeneration of chronic wounds that have not healed or healed by secondary intention. It is often described as various types of lesions, including the scars of pressure ulcers. The pathogenic mechanisms behind the malignant transformation of these lesions have not yet been completely elucidated. The diagnosis is initially made by clinical examination due to the lesion aspect and is confirmed by biopsy. Surgery is the choice treatment closing the defect with flaps or grafts, depending on each case. appearance of a pressure ulcer in the right gluteal region 11 years ago, an operative debridement was performed with a subsequent skin graft to correct the defect. It measured around 10cm in its largest diameter. Nine years and six months later, an ulcerated lesion emerged in his left gluteal region, showing rapid and progressive growth. However, the patient did not seek medical attention.
On physical examination, the patient presented an extensive ulcer (30x30cm²) in the left gluteus and the right hip in the posterior region that extended to the perianal zone. The ulcer had a foul odor, purulent secretion, necrotic base and raised edges. The patient had anemia, poor general health status, and received two units of red blood cell concentrate and cefepime. No suspected lymph nodes were found in the inguinal region, and chest X-ray was normal. Biopsy of the lesion confirmed a moderately differentiated epidermoid carcinoma. After handling the infection and anemia, the patient underwent an enlarged resection of the lesion. Final histopathological analysis confirmed a G2 epidermoid carcinoma with free lateral and deep margins. Postoperatively, the patient acquired an E. coli infection sensitive to cefepime. After granulation of the surgical wound and infection control, a total skin graft was discharged from the hospital.
Two months after surgical treatment, the patient underwent a free skin graft on the left gluteus with complete graft integration. Two months after treatment, the patient achieved a good recovery and showed no

INTRODUCTION
Marjolin ulcer (epidermoid carcinoma) is a rare and well-described complication of a precursor chronic skin lesion. Usually occurs in burn scars, ulcers due to venous insufficiency, chronic fistulas in osteomyelitis and less often in scars of pressure ulcers 1 .
Pressure ulcer is a common problem that affects the older people and with physical disabilities. Continuous pressure, shear, or light friction may cause microvascular occlusion, ischemia, and necrosis 2 . Epidermoid carcinoma is diagnosed by biopsy of the lesion. The clinical course is usually fast, and the mortality rate is high 3 .
Surgery is the treatment of choice. Radiotherapy has been used as a palliative treatment 4 . We present a case of epidermoid carcinoma after ten years of graft surgery by pressure ulcers in the gluteus and the appearance of a new ulcer neglected by the patient, which led to extensive epidermoid carcinoma development. Besides, we discuss the aspects that led to the suspicion of this condition and the therapeutic options.

DISCUSSION
Marjolin's ulcer is the eponym of malignant degeneration of chronic wounds that did not proceed with the normal healing process or healing by secondary intention. Marjolin ulcers have been commonly described in various types of lesions such as pressure ulcers, venous insufficiency ulcers, irradiated tissues, diabetic ulcers, osteomyelitis, and other less common lesions such as hidradenitis, pilonidal cysts, urination fistulas, vaccination scars, herpes zoster scars, and even graft scars. However, it is described more frequently as a malignant transformation of burn scars 5 . This study is a rare report of Majorlin's ulcer that arises in scars of pressure ulcers.
The pathogenic mechanisms behind the development of malignant transformation in burn scars or wounds exposed to repetitive trauma, significantly those that heal by second intention, have not yet been fully clarified. However, some authors have suggested that these lesions' immunological environment is unfavorable for immunosuppression due to the low vascularization of scar tissue 6 . It has been suggested that the elevated expression of proto-oncogenes is a mechanism of malignant degeneration 7 . Other researchers have suggested that avascular scar tissue in chronic wounds may interfere with the motility of lymphocytes 8 .
Marjolin's ulcer is commonly confused with infected ulceration that is produced in scar tissue. Changes such as the appearance of non-healing ulcers and increased bone circumference with raised edges, foul odor, pain, and blood drainage indicate a malignant transformation. At more advanced stages, invasion and underlying bone destruction may occur. A surgical biopsy performed in multiple locations is recommended to confirm the diagnosis 9 .
In this report, the patient developed a malignant neoplasm after the appearance of a new pressure ulcer that grew rapidly nine years and six months after the treatment of a previous pressure ulcer in the ipsilateral gluteus, showing the aggressive nature of the tumor. Biopsy of rapidly increasing pressure ulcers that suggest a malignant transformation is essential to improve the prognosis of the patient 3 . In the literature, we found seven published cases of epidermoid carcinoma that occur in pressure ulcers. The patients' age ranged from 30 to 85 years, and the disease's progression was 14 years on average (Table 1).
According to Pekarek et al., in 2011 10 , welldifferentiated lesions are less aggressive; therefore, patients with these lesions have a better prognosis. The overall 3-year survival rate is 65% to 75%, while the 10year survival rate is 34%. However, metastases in the inguinal lymph nodes result in a three-year survival rate of 35% to 50%. In the present case, inguinal lymph nodes were normal in clinical and sonographic examinations. On patient follow-up, attention should be focused on examining inguinal lymph nodes, as ganglion metastases may occur after treating the primary lesion. There should be rapid identification of ganglion metastases and the institution of surgical treatment with inguinal lymphadenectomy.