Development of a Marjolin’s ulcer within a non-healing laparotomy wound

Introduction: A Marjolin’s ulcer (MU) is a rare and aggressive cutaneous malignancy arising within chronic wounds, most commonly burn scars and chronic ulcers. Development within a chronic laparotomy wound is exceptionally uncommon. Case Report: A 65-year-old man was referred for management of a chronic abdominal wall wound with recurrent enterocutaneous fistula (ECF). The wound originated following multiple laparotomies for a gunshot injury more than 30 years earlier and had remained persistently open despite conservative management. Progressive wound deterioration prompted biopsy, demonstrating moderately to poorly differentiated squamous cell carcinoma (SCC) consistent with an MU. Staging computed tomography (CT) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed extensive abdominal wall involvement without regional or distant metastases. The patient underwent radical resection of the abdominal wall tumor, with a large elliptical incision to incorporate the ECF. Approximately 25 cm of small bowel was found adherent to the tumor, which was removed en bloc. The large defect was reconstructed and reinforced with fully resorbable monofilament mesh in an in-lay fashion. Histopathology confirmed a 115 mm moderate-to-poorly differentiated squamous cell carcinoma, invading through abdominal wall and into the wall of the adjacent small bowel with macroscopically and microscopically clear resection margins. There was no perineural invasion, with equivocal lymphatic spread. His postoperative course was complicated by wound breakdown and development of a high-output enteroatmospheric fistula requiring prolonged nutritional and medical support. The patient was discussed at the cancer multidisciplinary meeting, with a consensus decision not to offer adjuvant therapies due to histopathological clear margins and the absence of metastatic disease. Despite this, local recurrence and a large hepatic metastasis developed eight months later. Immunotherapy was commenced. However, the patient deteriorated and died after one month. Conclusion: Marjolin’s ulcer arising within a chronic laparotomy wound is exceedingly rare. This case highlights the malignant potential of longstanding abdominal wounds, particularly in the setting of chronic inflammation and ECF. Early biopsy of suspicious wound changes and definitive management of chronic wounds are essential, as MU demonstrates aggressive biological behavior with high rates of recurrence and metastasis despite apparently curative resection.