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Journal of Surgical Oncology 29:89-90 (1985)

Carcinoma Arising in Burn Scar


DEBA P. SARMA, MD, AND THOMAS G. WEILBAECHER, MD

From the Department of Pathology, Veterans Administration Medical Center, and Louisiana State University Medical Center, New Orleans

A 60-year-old man had undergone a left below-knee amputation 30 years ago owing to trauma and burn suffered in a dynamite explosion. He has been wearing an artificial leg since then. He developed a squamous cell carcinoma on the amputation stump 30 years later. The possible relationship of the burn scar and chronic irritation by the artificial leg to the cancer is discussed.
KEY WORDS:

burn scar carcinoma, Marjolin's ulcer, cancer on amputation stump, squamous cell carcinoma in amputation stump, epidermoid carcinoma in burn scar

INTRODUCTION Malignant neoplasm is known to arise in burn scars, chronic ulcers, wounds, and sinuses or fistulous tracts [Arons et al, 1965]. Whereas leg amputation followed by use of artificial leg is quite common, occurrence of cancer in amputation stump is extremely rare. We report a case of squamous cell carcinoma arising in a burn scar in an amputation stump. The leg was amputated after being traumatized and burned in a dynamite explosion about 30 years previously. The patient has been using an artificial leg since then. CASE REPORT A 60-year-old black man was injured in a dynamite explosion 30 years ago. The traumatized and burned left leg was amputated below the knee and the patient was fitted with an artificial leg. Several months before he presented to the hospital the patient noted a gradually increasing "lump" on his amputation stump giving rise to discomfort and pain while using the artificial leg. He had stopped using the leg prosthesis for several weeks. Physical examination revealed a 6x6 cm fungating mass (Fig. 1) arising within an old scar on the posteromedial aspect of the left below-knee amputation stump. The inguinal lymph nodes were not enlarged. There was no evidence of any metastatic tumor. The results of chest roentgenogram and routine hematologic and chemical tests were normal. A biopsy of the leg lesion revealed a squamous cell carcinoma (Fig. 2). The patient underwent a left above-knee amputation with uneventful postoperative course. Pathologic examination showed the carcinoma invading the scar tissue and

Fig. 1. Fungating tumor on the posteromedial aspect of the left below-knee amputation stump. Tumor is in the area of burn scar and not on the line of skin closure. Accepted for publication May 30, 1984. Address reprint requests to: D. Sarma, MD, V.A. Medical Center, 1601 Perdido Street, New Orleans, LA 70146.

1985 Alan R. Liss, Inc.

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Sarma and Weilbaecher

Fig. 2.

Microscopically, the tumor is a squamous cell carcinoma (H&E, X 100).

subcutaneous adipose tissue. The surgical margin of amputation was free of tumor. The patient remains free of recurrent tumor or any evidence of metastasis 16 months after surgery. DISCUSSION In our patient a squamous cell carcinoma developed in an area of burn scar rather than in the scar of the amputation stump closure. There is about a 2% incidence of occurrence of squamous cell carcinoma in previously burned skin [Treves and Pack, 1930], and the lag period from the time of the burn to the development of carcinoma is about 30 or more years [Giblin et al, 1965]. Our patient appeared to have developed a rather typical malignant degeneration of burn scar except for the clinical appearance of a fungating raised tumor mass at presentation compared to the more typical indolent ulcerative type of lesion (Marjolin's ulcer) seen in the burn scars. We do not have any evidence to suspect that the chronic rubbing and irritation at the burn scar area by the artificial leg played any role either as an initiating or a potentiating factor in the development of cancer. Malignant degeneration of scar of amputation stump is extremely rare; only a few cases have been reported in the literature [Arons et al, 1965; Bondi, I960]. Our patient reported to

the physician rather early because of the discomfort that he was experiencing in use of the artificial leg. His lesion was a low-grade squamous cell carcinoma similar to those described in the burn scar carcinomas [Arons et al, 1965; Giblin et al, 1965]. Incidence of metastases from burn scar carcinomas vary from negligible [Bowers and Young, 1960] to as high as 36% [Arons et al, 1965]. Poor prognosis and high rate of metastases in these cancers appear to be due to advanced stage reached before therapy rather than the aggressive nature of the cancer itself [Giblin et al, 1965]. ACKNOWLEDGMENTS We thank Mr. Robert Maeder for excellent secretarial assistance. REFERENCES
Arons MS, Lynch JB, Lewis SR, Blocker TG: Scar tissue carcinoma. Part 1. A clinical study with special reference to burn scar carcinoma. Ann Surg 161:170-188, 1965. Bondi R: Carcinoma spino-cellulare su cicatrice da amputazione irri-tata per 40 anni. Arch Vecchi Anat Pat 34:255-279, 1960. Bowers RF, Young JM: Carcinoma arising in scars, osteomyelitis, and fistulae. AMA Arch Surg 80:564-570, 1960. Giblin T, Pickrell K, Pitts W, Armstrong D: Malignant degeneration in burn scars: Marjolin's ulcer. Ann Surg 162:291-297, 1965. Treves N, Pack G: The development of cancer in burn scars. Surg Gynecol Obstet 51:749-782, 1930.

Sarma DP, Weilbaecher TG(1985): Carcinoma arising in burn scar. J Surg Oncol 29:89-90. PMID: 4079391 [PubMed - indexed for MEDLINE]