A Case of Marjolin’s Carcinoma Cured with Hekla Lava

by

 Dr. Rajneesh Kumar Sharma

Background

Marjolin’s Ulcer :

Synonyms and related keywords: decubitus ulcer, bed sore, pressure sore, nonhealing wound, non-healing wound, wound healing complication, wound-healing complication, pressure ischemia, paraplegia, quadriplegia, spina bifida, immobilization, multiple sclerosis, MS, Marjolin ulcers, pressure sore reconstruction, flap procedures, chronic wound, pressure sore carcinoma.

Definition

Marjolin initially described malignant transformation of a chronic scar from a burn wound. But presently, the term Marjolin ulcer has been used interchangeably for malignant transformation of any chronic wound, including pressure sores, osteomyelitis, venous stasis ulcers, urethral fistulas, anal fistulas, and other traumatic wounds. This malignant transformation is, histologically, a well-differentiated squamous cell carcinoma.

Squamous cell carcinoma (SCC)

This is a malignant tumour of the epidermis or its appendages.

Incidence

Less common than basal cell carcinoma.

Age

Usually in later life with increasing incidence after 60.

Sex

7 Male : 3 Female

Pathophysiology

It can occur anywhere but more usually occurs in a pre-existing skin lesion, or as a result of previous irradiation. It is also common in those with scleroderma pigmentosum when lesions appear in early adulthood.

Predisposing factors:

• Sunlight exposure
• long-standing chronic granulomas e.g. syphilis, lupus vulgaris, leprosy
• Chronic ulcers
• Osteomyelitis
• Hydradenitis suppuritiva
• Long-standing venous ulcers
• Old burn scars

A SCC developing in a chronic ulcer is called a Marjolin's ulcer.    

MACROSCOPIC

Nodule or ulcer. The latter has an everted edge.

MICROSCOPIC

Tumours of epidermal keratinocytes characterised by invasive nests of cells with variable central keratinisation and horn cell formation. These 'onion-like' clusters of cells are often called 'epithelial pearls'.
There is no peripheral palisading as seen in Basal Cell Carcinoma (BCC).
Cells are pleomorphic, varying from well-differentiated with vesicular nuclei and prominent nucleoli to anaplastic. Most tumours invade as adherent strands and metastases usually have the same pattern.

CLINICAL FEATURES

History
A lesion in a region commonly exposed to the sun e.g. backs of hands and forearms, face ( in males especially the lips and pinna).
Lump or bleeding ulcer
Increasing size, usually present for few months
May be painful (if deeper structures are involved)
May be several lesions

Examination
Position- Anywhere, usually exposed skin or skin exposed to chemicals or irritation

Colour-   Everted edge usually a dark red-brown colour due to its vascularity
Temperature- Normal
Tenderness- Usually non-tender
Shape- Begin as small nodules, the center of which becomes necrotic as size increases, progressing to a circular ulcer
Edge- Everted edges (as it grows over normal skin)
Relations to surrounding structures- depends on extent of malignant infiltration
Regional lymph nodes- often enlarged but not always due to metastases. About 1/3 due to infection.
State of local tissues- may be oedematous. Subcutaneous spread may be along nerves causing neuritis. Involvement of blood vessels- may cause thrombosis.

There are often multiple types of skin lesions in the same patient e.g. BCC, SCC and melanomas
There are often signs of sunlight damage in the adjacent skin:

 

Signs of sunlight damage-

• Elastotic degeneration of the dermis
• Keratosis
• Irregular pigmentation
• Telangiectasia
• Leucoplakia
• Fissuring of the lips

 

Induration is the first sign of malignancy.
Regional lymphadenopathy occurs because of infection or from metastases.

DIAGNOSIS

Clinically and by biopsy.

 

DIFFERENTIAL DIAGNOSIS

Basal cell carcinoma
Keratoacanthoma
Melanoma
Solar keratosis
Pyogenic granuloma
Infected seborrhoeic wart

Case History

Patient’s name- Lakhvinder Singh,

Male- 45 years

Occupation- Farming.

Chief complaints-

• Weakness and weariness.
• No hope of recovery.
• H/O burn at right upper arm.
• Chronic ulcer at the site of burning.
• Burning pains at the site, worse with pressure.
• Always sleepy. Yawning, even during sleep.
• Can not rest because it aggravates the pain.
• H/O injury to the burnt area, which caused abrasion that, turned into ulceration.
• H/O gum abscess.
• H/O nasal polyp.

Biopsy-

Sufdarjang Hospital New Delhi, vide pathology no. 10763/ 16- 12- 2003/ well differentiated squamous cell carcinoma, Marjolin’s Ulcer.

Rubrics-

1.        SLEEP - SLEEPINESS - evening

2.        GENERALS - CANCEROUS affections - sarcoma

3.        GENERALS - WEARINESS

4.        GENERALS - PRESSURE - agg.

5.        GENERALS - INJURIES (including blows, bruises, falls) - bones; fractures of

6.        SLEEP - YAWNING

7.        NOSE - POLYPUS

8.        GENERALS - REST - agg.

9.        MOUTH - ABSCESS of Gums

10.      NOSE - EPISTAXIS

Repertorization-

      hecla hep.  phos. sil. merc. alum. am-c. calc. lach. lyc. nit-ac. petr.

       873  793   793  793   714   634   634   634   634  634    634    634 

-------------------------------------------------------------------------------

  1:   1    2     2    2     1     2     1     3     2    1      1      2  

  2:   1    -     -    -     -     -     -     -     -    -      -      -  

  3:   1    2     3    3     3     3     2     2     3    3      1      2  

  4:   1    3     1    3     2     1     1     1     3    3      2      -  

  5:   1    1     1    2     -     -     -     1     -    1      1      2  

  6:   1    1     2    2     1     1     2     2     1    2      1      1  

  7:   1    1     2    2     1     -     -     3     -    1      1      -  

  8:   1    1     1    1     2     1     1     1     2    3      1      1  

  9:   2    2     1    2     1     1     1     -     1    -      -      1  

 10:   2    2     3    2     3     1     3     3     3    2      3      2

Further quarries-

Thirst for small quantities of water.

Dryness of mouth.

Restlessness.

Disgust for medicine.

 

18-12-2003

Hekla lava 200 one dose stat

SL x 7 days.

 

27-12-2003

Burning pain markedly diminished.

No thirst.

Hekla lava 200 one dose stat

SL x 7 days.

 

07-01-2004

Much better in all respects.

SL x 25 days.

 

12-02-2004

Much better in all respects.

Biopsy- Safdarjang Hospital, New Delhi, vide path. No. 797 \ 28.01.04- Histopathological picture reveals squamous cell reaching just up to the deeper resected margin. Lateral resected margins are free of tumour.

Sac lac x 40 days.

 

30-04-2003

Much better.

Same treatment continued…..

(All the investigation reports in attached Power Point Presentation)

Author:

© Dr. Rajneesh Kumar Sharma

Homoeo Cure & Research Centre P. Ltd.

N.H. 74, Moradabad Road, Kashipur— 244713, Uttaranchal, INDIA

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