Immune system alterations may also play an important role in the pathogenesis of these malignancies. Castillo and Goldsmith25 and others1,26 have suggested that obliterated lymphatics and a poor blood supply compromise the normal antitumor antibody response early in the growth of a malignancy, allowing the tumor to reach a critical size before initiation of an antibody response. Dellon et al27 noted that two patients with Marjolin's ulcer had decreased T-cell counts and suggested that depressed cellular immunity may be a contributing factor. A negative punch biopsy must be interpreted with caution because sampling error can occur. Although some aspects of the treatment of Marjolin's ulcer remain controversial, most authors agree on several basic principles.
Preventive care is of greatest importance.
In general, recurring ulcers should be excised even if they are not malignant, and skin grafts or flaps should be used for coverage to facilitate complete healing as quickly as possible.1,18 Wide local excision with a margin of at least 1 cm of healthy tissue should be done in cases of Marjolin's ulcer. Amputation is indicated when wide local excision is prevented by deep invasion, bone or joint space involvement, infection, or hemorrhage, or when excision would impair function and encumber the patient.3 From an oncologic standpoint, amputation is probably not superior to wide local excision.28 Regional lymph node dissection is indicated whenever nodes are palpable.1,18,28,29 Lymph node dissection in the absence of palpable nodes, however, is controversial. Lifeso and Bull30 showed that histologic grading can be helpful in deciding which patients will benefit from nodal dissection. This rate was more than twice the metastatic rate from any other primary site. Whereas Marjolin's ulcers typically arise in old burn scars, they can originate from any long-standing scar or region of chronic inflammation, such as the nonhealing foot wound described in this report.