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

Carcinoma Arising in Burn Scar

DEBA P. SARMA, MD, ANDTHOMAS 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 relation- ship of the burn scar and chronic irritation by the artificial leg to the can- cer 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, 19651. Whereas leg amputation followed by use of artificial leg is quite common, occurrence of can- cer 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 dyna- mite 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 6 x 6 cm fungating mass (Fig. 1) arising within an old scar on the postero- medial 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

tests were normal. A biopsy of the leg lesion revealed a below-knee amputation stump. Tumor is in the area of burn scar and not on the line of skin closure. squamous cell carcinoma (Fig. 2).

roentgenogram and routine and Fig. 1 . Fungating tumor on the posteromedial aspect of the left

The patient underwent a left above-knee amputation Accepted for publication May 30, 1984. with uneventful postoperative course- pathologic exami- nation showed the carcinoma invading the scar tissue and

Address reprint requests to: D. &ma, MD, V.A. Medical center, 1601 Perdido Street, New Orleans, LA 70146.

0 1985 Alan R. Liss, Inc.

90 Sarma and Weilbaecher

Fig. 2. Microscopically, the tumor is a squamous cell carcinoma (H&E, X 100).

subcutaneous adipose tissue. The surgical margin of am- putation 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 squarnous cell carcinoma developed in

an area of burn scar rather than in the scar of the ampu- tation stump closure. There is about a 2% incidence of occurrence of squamous cell carcinoma in previously burned skin [Treves and Pack, 19301, and the lag period from the time of the burn to the development of carci- noma is about 30 or more years [Giblin et al, 19651. Our patient appeared to have developed a rather typical malig- nant degeneration of burn scar except for the clinical appearance of a fungating raised tumor mass at presen- tation 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 artifi- cial leg played any role either as an initiating or a poten- tiating 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 IArons et al, 1965; Bondi, 19601. 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, 19651. Incidence of metastases from burn scar carcinomas vary from negligible [Bowers and Young, 19601 to as high as 36% [Arons et al, 19651. Poor prognosis and high rate of metastases in these cancers appear to be due to advanced stage reached before ther- apy rather than the aggressive nature of the cancer itself [Giblin et al, 19651.

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 carci- noma. 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, 1 W .

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.