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Squamous-cell carcinoma and cutaneous horn in a burn scar
SQUAMOUS-CELL CARCINOMA A N D CUTANEOUS HORN IN A BURN SCAR Case Report
By BENJAMIN C. COHNEY, F.R.C.S. Department of Plastic Surgery, The Churchill Hospital, Oxford IT is well known that squamous-cell carcinoma may arise in an old burn scar, especially when the scar is unstable or the seat o f chronic ulceration. Cutaneous horns also occur in various skin conditions but have not previously been seen in b u r n scars. T h e occurrence of both squamous-cell carcinoma and cutaneous horn in the same burn scar in a patient aged 26 years must be very rare. Case Report.--Miss Ann K., aged 26 years, sustained severe burns of the right leg when she was 3 years old. The burns were treated by dressings, were not grafted, and took several months to heal. The leg had remained healed until eight months before she was first seen on i3th November I959. Examination Findings.--The right thigh and leg were extensively scarred and contracture in the popliteal fossa had produced 20 degrees of fixed flexion at the knee joint. There was an oval-shaped infected ulcer in the popliteal fossa with hard and raised edges. There was a cutaneous horn growing from the scar tissue on the lower part of the thigh (Figs. I and 2). The right inguinal lymph nodes were enlarged, tender, and discrete. It was thought possible at this examination that the ulcer might be the seat of carcinomatous change. Therefore, it was considered that the enlargement of the inguinal lymph nodes might be due to metastatic deposits; alternatively their enlargement might be due to inflammatory changes. Operative Treatment.--The ulcer was excised together with a 2 in. margin of scar tissue. The cutaneous horn was similarly excised with a margin of surrounding scar. Scar tissue was divided gradually until full extension of the knee joint was possible. The large defects were covered by split-skin grafts and the leg immobilised with the knee in extension. Histological Examination.--The ulcer proved to be a squamous-cell carcinoma (Broders' Grade II) and had been completely excised in all dimensions. Subsequent Progress.--The inguinal lymph nodes decreased in size but remained enlarged. A block dissection was therefore performed. Histological examination showed that one in ten of the nodes was invaded by squamous-celled carcinoma. There has been no recurrence up to date. The right leg has remained healed with full function. DISCUSSION Carcinoma occurring in an old burn scar is usually referred to as a Marjolin ulcer, although Sevitt (I957) gives priority to Hawkins, an English surgeon, who described two cases three years prior to Marjolin. It is said to be a relatively benign lesion. T h e carcinoma is usually a squamous-cell carcinoma, although some basal-cell carcinomas have been reported, and the relative proportion o f each has varied with each writer. It is also impossible to determine the exact 216
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C A R C I N O M A AND C U T A N E O U S H O R N
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A BURN SCAR
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frequency of carcinoma following burns, but Sevitt (1957) states that it cannot be high, and quotes Levi (1956) as giving its incidence as 1.3 per cent. of 699 epitheliomas and o'7 per cent. of 1,794 rodent ulcers examined by him. Treves and Pack (193o) give figures of 2 per cent. of I,O9I epitheliomas and o'5 per cent. of 1,374 basal-cell tumours seen by them. Other writers vary in their estimates
FIG. I FIG. 2 Pre-operative views showing the ulcer and cutaneous horn.
of the incidence of carcinoma ; Mason (1929) gave an incidence of 19"4 per cent., whilst Taylor et al. (1941) gave an incidence of 5"4 per cent. of their series. In the squamous-cell type spread is usually a late feature, presumably because of the relative avascularity of the surrounding scar tissue ; when it does occur, it is to the regional lymph nodes. Hmmatogenous dissemination is rare, as is also visceral metastasis. The usual duration of the scar prior to neoplastic change is greater than ten years ; the majority of reported cases are over the age of 4 ° years. According to Treves and Pack (I93O), despite its relatively benign nature the prognosis of the Marjolin ulcer is bad, and eight out of their twenty-two patients were dead at the time of their report. In view of this known tendency of burn scars which ulcerate to develop malignant change, it is well worth bearing in mind the necessity for excision and
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grafting at an early stage o f any unstable areas which are liable to trauma, and thus prevent the early changes which proceed to malignant degeneration. According to Conway (I956) cutaneous horns may occur anywhere i n the body but are not commonly seen in persons under the age of 4 ° years. T h e y are relatively rare, as indicated by the fact that there were only nine out o f 22,654 t u m o u r specimens examined in the Surgical Pathological Department in the N e w York Hospital in a six-year period. T h e y are to be looked upon as pre-malignant lesions, and Conway quotes that roughly 20 per cent. undergo malignant degeneration (squamous-cell carcinoma) at their base. T r e a t m e n t is therefore surgical excision with an adequate margin.
I wish to thank Mr Eric Peet, Director of the Department of Plastic Surgery, Churchill Hospital, Oxford, for permission to use the records of his patient, and to publish this case report. REFERENCES CONWAY,H. (I956). " Tumours of the Skin." Springfield, Ill. : Charles C. Thomas. LEVI, J. M. (I956). Quoted by S. Sevitt (I957). MASON,M. L. (r929). Quoted by S. Sevitt (I957). SEVITT, S. (x957). " Burns : Pathology and Therapeutic Applications." London : Butterworth. TAYLOR, G. W., NATHANSON,I. T., and SHAW,D. T. (194I). Ann. Surg., Ix3, 268. TRnVES,N., and PACK,G. T. (r93o). Surg. Gynec. Obstet., 5x, 749.
By BENJAMIN C. COHNEY, F.R.C.S. Department of Plastic Surgery, The Churchill Hospital, Oxford IT is well known that squamous-cell carcinoma may arise in an old burn scar, especially when the scar is unstable or the seat o f chronic ulceration. Cutaneous horns also occur in various skin conditions but have not previously been seen in b u r n scars. T h e occurrence of both squamous-cell carcinoma and cutaneous horn in the same burn scar in a patient aged 26 years must be very rare. Case Report.--Miss Ann K., aged 26 years, sustained severe burns of the right leg when she was 3 years old. The burns were treated by dressings, were not grafted, and took several months to heal. The leg had remained healed until eight months before she was first seen on i3th November I959. Examination Findings.--The right thigh and leg were extensively scarred and contracture in the popliteal fossa had produced 20 degrees of fixed flexion at the knee joint. There was an oval-shaped infected ulcer in the popliteal fossa with hard and raised edges. There was a cutaneous horn growing from the scar tissue on the lower part of the thigh (Figs. I and 2). The right inguinal lymph nodes were enlarged, tender, and discrete. It was thought possible at this examination that the ulcer might be the seat of carcinomatous change. Therefore, it was considered that the enlargement of the inguinal lymph nodes might be due to metastatic deposits; alternatively their enlargement might be due to inflammatory changes. Operative Treatment.--The ulcer was excised together with a 2 in. margin of scar tissue. The cutaneous horn was similarly excised with a margin of surrounding scar. Scar tissue was divided gradually until full extension of the knee joint was possible. The large defects were covered by split-skin grafts and the leg immobilised with the knee in extension. Histological Examination.--The ulcer proved to be a squamous-cell carcinoma (Broders' Grade II) and had been completely excised in all dimensions. Subsequent Progress.--The inguinal lymph nodes decreased in size but remained enlarged. A block dissection was therefore performed. Histological examination showed that one in ten of the nodes was invaded by squamous-celled carcinoma. There has been no recurrence up to date. The right leg has remained healed with full function. DISCUSSION Carcinoma occurring in an old burn scar is usually referred to as a Marjolin ulcer, although Sevitt (I957) gives priority to Hawkins, an English surgeon, who described two cases three years prior to Marjolin. It is said to be a relatively benign lesion. T h e carcinoma is usually a squamous-cell carcinoma, although some basal-cell carcinomas have been reported, and the relative proportion o f each has varied with each writer. It is also impossible to determine the exact 216
SQUAMOUS-CELL
C A R C I N O M A AND C U T A N E O U S H O R N
IN
A BURN SCAR
217
frequency of carcinoma following burns, but Sevitt (1957) states that it cannot be high, and quotes Levi (1956) as giving its incidence as 1.3 per cent. of 699 epitheliomas and o'7 per cent. of 1,794 rodent ulcers examined by him. Treves and Pack (193o) give figures of 2 per cent. of I,O9I epitheliomas and o'5 per cent. of 1,374 basal-cell tumours seen by them. Other writers vary in their estimates
FIG. I FIG. 2 Pre-operative views showing the ulcer and cutaneous horn.
of the incidence of carcinoma ; Mason (1929) gave an incidence of 19"4 per cent., whilst Taylor et al. (1941) gave an incidence of 5"4 per cent. of their series. In the squamous-cell type spread is usually a late feature, presumably because of the relative avascularity of the surrounding scar tissue ; when it does occur, it is to the regional lymph nodes. Hmmatogenous dissemination is rare, as is also visceral metastasis. The usual duration of the scar prior to neoplastic change is greater than ten years ; the majority of reported cases are over the age of 4 ° years. According to Treves and Pack (I93O), despite its relatively benign nature the prognosis of the Marjolin ulcer is bad, and eight out of their twenty-two patients were dead at the time of their report. In view of this known tendency of burn scars which ulcerate to develop malignant change, it is well worth bearing in mind the necessity for excision and
218
BRITISH JOURNAL OF PLASTIC SURGERY
grafting at an early stage o f any unstable areas which are liable to trauma, and thus prevent the early changes which proceed to malignant degeneration. According to Conway (I956) cutaneous horns may occur anywhere i n the body but are not commonly seen in persons under the age of 4 ° years. T h e y are relatively rare, as indicated by the fact that there were only nine out o f 22,654 t u m o u r specimens examined in the Surgical Pathological Department in the N e w York Hospital in a six-year period. T h e y are to be looked upon as pre-malignant lesions, and Conway quotes that roughly 20 per cent. undergo malignant degeneration (squamous-cell carcinoma) at their base. T r e a t m e n t is therefore surgical excision with an adequate margin.
I wish to thank Mr Eric Peet, Director of the Department of Plastic Surgery, Churchill Hospital, Oxford, for permission to use the records of his patient, and to publish this case report. REFERENCES CONWAY,H. (I956). " Tumours of the Skin." Springfield, Ill. : Charles C. Thomas. LEVI, J. M. (I956). Quoted by S. Sevitt (I957). MASON,M. L. (r929). Quoted by S. Sevitt (I957). SEVITT, S. (x957). " Burns : Pathology and Therapeutic Applications." London : Butterworth. TAYLOR, G. W., NATHANSON,I. T., and SHAW,D. T. (194I). Ann. Surg., Ix3, 268. TRnVES,N., and PACK,G. T. (r93o). Surg. Gynec. Obstet., 5x, 749.