When a Burn Scar Invades the Brain: A Case Report of Advanced Marjolin Ulcer of the Scalp

Marjolin ulcer is a malignancy arising in a chronic wound or scar, usually a squamous cell carcinoma.Spread from the scalp into the brain is uncommon and makes treatment difficult.We report a case of a 38-year-old female with a scalp scar from a childhood thermal burn.An ulcer appeared about 33 years after the injury and grew over two years, faster during the last three months before presentation.A persistent foul odor led her to seek care.Examination showed a large ulcerated, exophytic scalp tumor, but she was fully conscious and had no focal neurological deficit.Computed tomography showed extensive destruction of the skull and herniation of brain tissue through the bone defect.A dural biopsy showed a well-differentiated, infiltrating, keratinizing squamous cell carcinoma.Magnetic resonance imaging two weeks later confirmed invasion of the dura and the adjacent brain, with marked edema and an intraparenchymal hematoma.There were no regional or distant metastases.The tumor was judged unresectable.The multidisciplinary team proposed definitive radiotherapy to 66 Gy in 33 fractions with weekly cisplatin, but the patient declined.Immunotherapy was not available.Two months later, she developed symptoms of intracranial hypertension.She received corticosteroids and palliative radiotherapy to 30 Gy in 10 fractions.She completed all fractions and tolerated them well at first, but her symptoms did not improve.She died about one month after radiotherapy.This case shows that progressive changes in an old burn scar should be biopsied, and that extensive intracranial spread can be present before any neurological deficit appears.