Zor İyileşen Yaralar: Kronik Yarada Diğer Nadir Ayırıcı Tanılar
Özet
Cilt veya yumuşak dokuların normal yapı ve fonksiyonunun harabiyete uğraması yara olarak tanımlanır ve uygun tedaviye rağmen bir ayda %50'den daha az küçülen yaralar kronik yara lehine yorumlanır. Kronik yaraların etyolojisinde diyabet, obezite ve periferik arter hastalığının yanı sıra maligniteler de yer alır; kronik bacak ülserlerinde malignite görülme oranı %10,4 olarak saptanmıştır. Malign yaralar, sağlıklı ciltte gelişen bazal hücreli karsinom (BCC) ve skuamöz hücreli karsinom (SCC) gibi primer tümörler ile yanık skarları, osteomiyelit sinüsleri veya pilonidal sinüs zemininde gelişen sekonder tümörler (Marjolin ülseri) olarak sınıflandırılır. Makroskopik olarak kronik yaralara benzediklerinden fizik muayene ile tanı zordur; ancak yara zemininde aşırı granülasyon, atipik lokalizasyon, düzensiz kenarlar, kanama, artan ağrı ve kötü koku maligniteden şüphe uyandırmalıdır. Standart tedaviyle 4 ay boyunca iyileşmeyen yaralardan, yanlış negatifliği önlemek için ülser kenar ve tabanından en az iki adet insizyonel veya punch biyopsi alınmalıdır. Tanı konulduktan sonra lenf nodu ve uzak metastazlar açısından ultrasonografi, manyetik rezonans ve bilgisayarlı tomografi ile evreleme yapılmalıdır. Tedavi esas olarak cerrahi olup, Marjolin ülserlerinde en az 1 cm güvenli cerrahi sınırla geniş eksizyon veya gerektiğinde ampütasyon uygulanır. Primer tümörler rezeksiyonla kür kabul edilirken, sekonder tümörler daha agresif seyreder ve Marjolin ülserlerinde 5 yıllık sağ kalım %30 civarındadır; bu nedenle hastalar nüks açısından ilk 2 yıl yakından takip edilmelidir.
Skin or soft tissue damage disrupting normal structure and function is defined as a wound, and wounds shrinking less than 50% in a month despite appropriate treatment are interpreted in favor of a chronic wound. Along with diabetes, obesity, and peripheral artery disease, malignancies are also involved in chronic wound etiology; the incidence of malignancy in chronic leg ulcers has been detected as 10.4%. Malignant wounds are classified as primary tumors such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) developing on healthy skin, and secondary tumors (Marjolin's ulcer) arising from sites like burn scars, osteomyelitis sinuses, or pilonidal sinuses. Diagnosis via physical examination is difficult as they macroscopically resemble chronic wounds; however, excessive granulation on the wound bed, atypical localization, irregular borders, bleeding, increasing pain, and foul odor should raise suspicion of malignancy. For wounds unhealed for 4 months with standard treatment, at least two incisional or punch biopsies must be taken from the ulcer edge and base to prevent false negatives. Following diagnosis, staging for lymph node and distant metastases must be performed using ultrasonography, magnetic resonance imaging, and computed tomography. Treatment is primarily surgical, involving wide excision with at least a 1 cm safe surgical margin in Marjolin's ulcers or amputation when necessary. While primary tumors are considered cured after complete resection, secondary tumors follow a more aggressive course, and the 5-year survival rate for Marjolin's ulcers is around 30%; therefore, patients must be closely monitored for recurrence during the first 2 years.
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