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LETTER TO THE EDITOR
Year : 2019  |  Volume : 27  |  Issue : 2  |  Page : 91-92

Sinuses: Another diagnostic marker of malignant transforming pressure ulcer


Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Web Publication27-Mar-2019

Correspondence Address:
Dr. B A Ramesh
Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education and Research, No. 1, Ramachandra Nagar, Porur, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_69_18

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How to cite this article:
Ramesh B A, Jayaraman SK, Mohan J. Sinuses: Another diagnostic marker of malignant transforming pressure ulcer. Turk J Plast Surg 2019;27:91-2

How to cite this URL:
Ramesh B A, Jayaraman SK, Mohan J. Sinuses: Another diagnostic marker of malignant transforming pressure ulcer. Turk J Plast Surg [serial online] 2019 [cited 2019 Apr 20];27:91-2. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/2/91/255012



Dear Editor,

The Marjolin's ulcer can develop from a chronic sinus. However, the formation of sinuses near longstanding pressure ulcer may indicate its malignant transformation. A 32-year-old female presented with the left ischial pressure ulcer which is present for the past 5 years. Before the current ulcer, she had recurrent ulceration on the same site with none lasting more than 1 year. She was operated for lumbar meningomyelocele at 3 years of age resulting in decreased sensation on both buttocks. She was ambulant with good control over her bladder and bowel. She was operated 20 years back for the left ischial ulcer, and a Hamstring V-Y advancement flap was done. She noticed the sudden formation of sinuses on the lateral side of her left upper thigh, for the past 4 weeks. She also had increasing pain and changing odor of discharge with the development of sinus. Physical examination revealed left ischial ulcer measuring 10 cm by 15 cm and deep to the bone. There were three skin sinuses on the left trochanteric region communicating with an ulcer. Sinuses were indurated and produced a foul-smelling discharge. The margin of the ulcer was not elevated [Figure 1]. The wound bed was covered with velvety granulation tissue, which is prone to bleeding. The culture of sinus discharge grew Gram-negative organisms. Clinically, ipsilateral inguinal nodes were palpable and firm in consistency. The magnetic resonance imaging showed ulcer extension to the ischial bone [Figure 2]. Excision of sinuses with surrounding indurated tissue and pseudotumor excision was done [Figure 3]. She was planned for delayed wound closure. The histological examination revealed moderately differentiated squamous cell carcinoma. The left inguinal node fine needle aspiration showed malignant cell deposits. Ablative surgeries such as hemipelvectomy or hemicorporectomy were recommended, but the patient refused any radical procedure. Wide local excision with two cm margin on the residual malignant ulcer and ipsilateral ilioinguinal lymph node dissection was done. The medial extent of the ulcer was up to vulval margin. The anal sphincter and rectal muscle were unaffected. The defect was closed with tensor fascia lata flap, and donor site primarily closed [Figure 4]. The final pathology report was moderately differentiated squamous cell carcinoma with deep margin (from the sacrum, ischiorectal fossa, and ischial bone) positive for tumor cells. The pathological finding of node was moderately differentiated squamous cell carcinoma deposits. The patient was subjected to postoperative adjuvant radiotherapy. The survival of the patient was only 4 months.
Figure 1: Malignant pressure sore with V-Y advancement scar

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Figure 2: Magnetic resonance imaging showing depth of ulcer

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Figure 3: Lateral view showing excision of sinuses

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Figure 4: Tensor fascia lata flap cover

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Marjolin's ulcer is commonly present on chronic wounds including postburn scar, venous ulcers, osteomyelitis ulcer, sinuses, and nonhealing pressure ulcer. The term was named by, Jean-Nicolas Marjolin, in 1828 for an ulcerating lesion within scar tissue. Pressure sore carcinoma is rare. In a retrospective analysis of 83 Marjolin's ulcer by Sadegh Fazeli et al. only one was due to a pressure ulcer.[1] The latent period of carcinomas arising from pressure sores is approximately 20 years, but for carcinoma for burns or stasis ulcer is 30 years.[2] Four clinical signs proposed as distinctive for malignant degeneration of pressure ulcer: The appearance of a mass, recent onset of pain, a change in volume and odor of drainage, and difference in the character of drainage.[2] The indurated sinuses communicating with ulcer was described as another sign of malignant degeneration by Nthumba.[3] We would like to reaffirm the same in our article. The possible explanation for the formation of the sinus is by tumor-infiltrating beyond the fibrotic margin into subcutaneous tissue. The subcutaneous tissue then becomes infected and opens onto the skin as sinuses communicating with the ulcer. Hence, the formation of sinus on the skin might be a telltale sign of advanced Marjolin's ulcer. Marjolin's ulcer due to pressure ulcer have dismal prognosis when compared with other causes.[2] Mustoe et al. presented that three of their four pressure sore carcinoma patients developed metastases. The metastasis rate was 38% in 104 cases with burn scar carcinoma and 14% in 112 cases with carcinomas in osteomyelitis. The Marjolin's on pressure sore is characterized by a short latency period and a perilous clinical course with the high metastatic rate.[4] The Marjolin's ulcer does not usually produce lymph node involvement because of fibrosis of surrounding lymphatics. The node becomes positive if a tumor or surgery breach the fibrotic plane. The presence of regional lymph node metastasis is considered the most important prognostic factor.[5] The other poor prognostic factors in a Marjolin's ulcer are an infiltrative type and tumor size of more than 2 cm.[3] Radiotherapy used as palliation in inoperable primary or recurrent tumors. The relative poor vascularity of these cancers may also explain their poor response to systemic chemotherapy. The prevention of Marjolin's pressure ulcer is by avoiding pressure using airbed, preventing ulcer by strict protective lifestyle and when ulcer develops early biopsy. This patient is presented to recognize sinuses as another diagnostic sign of malignancy (Marjolin's) developing in long-standing pressure ulcer.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sadegh Fazeli M, Lebaschi AH, Hajirostam M, Keramati MR. Marjolin's ulcer: Clinical and pathologic features of 83 cases and review of literature. Med J Islam Repub Iran 2013;27:215-24.  Back to cited text no. 1
    
2.
Robert K, Janis JE. Pressure sore. In: Neligan PC, editor. Lower Extremity, Trunk and Burns. 3rd ed., Vol. 4. New York: Elsevier; 2013. p. 379-80.  Back to cited text no. 2
    
3.
Nthumba PM. Marjolin's ulcers: Theories, prognostic factors and their peculiarities in spina bifida patients. World J Surg Oncol 2010;8:108.  Back to cited text no. 3
    
4.
Mustoe T, Upton J, Marcellino V, Tun CJ, Rossier AB, Hachend HJ. Carcinoma in chronic pressure sores: A fulminant disease process. Plast Reconstr Surg 1986;77:116-21.  Back to cited text no. 4
    
5.
Novick M, Gard DA, Hardy SB, Spira M. Burn scar carcinoma: A review and analysis of 46 cases. J Trauma 1977;17:809-17.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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