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Fırat Tıp Dergisi | |||||||||||||
2012, Cilt 17, Sayı 4, Sayfa(lar) 252-254 | |||||||||||||
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Squamous Cell Carcinoma Development Secondary to Chronic Osteomyelitis: A Case Report | |||||||||||||
Naci EZIRMIK1, Kadri YILDIZ2 | |||||||||||||
1Ataturk University, Faculty of Medicine, Departments of Orthopedics & Traumatology, Erzurum, Turkey 2Erzurum Training and Research Hospital, Orthopedics & Traumatology Clinic, Erzurum, Turkey |
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Keywords: Squamous cell carcinoma, Chronic osteomyelit, İlizarow, Rotational falp, Skuamöz hücreli karsinom, Kronik osteomyelit, İlizarow, Rotational flap | |||||||||||||
Summary | |||||||||||||
Squmaous cell carcinoma is a very rare clinical condition encountered as a complication of chronic osteomyelitis. Chronic osteomyelitis is a serious
complication of fractures or crush injuries that has to be treated appropriately. Similarly, squamous cell carcinoma is considered as the last complication
that has been considered by most of the orthopaedists. In this case report, it was aimed to highlight the importance of correct diagnosis and treatment
of both chronic osteomyelitis an done of its complication squamous cell carcinoma. |
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Introduction | |||||||||||||
Squamous cell carcinoma (SCC) is a rare but welldocumented
complication of chronic osteomyelitis1.
Squamous cell carcinoma is reported in chronic
osteomyelitis of sinus cases2. A case that had
penetrating injuries of the extremities in Vietnam had
been presented. The patient had frequent complication
of chronic osteomyelitis and eventually developed the
rare complication, squamous cell carcinoma3.
Squamous cell carcinoma is a complication of chronic
tibial osteomyelitis which can be treated with limbpreserving
surgery or amputation4. This case report presents a patient with refracture due to trauma while he was playing football. During evaluation squamous cell carcinoma was diagnosed as an outcome of previously untreated chronic osteomyelitis. |
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Case Presentation | |||||||||||||
A 43 years-old male with chronic osteomyelitis who
had fractured his right tibia at age of 14 was admitted.
The patient had been diagnosed as chronic
osteomyelitis after three years. His had right tibial fracture at 40 years-old again while playing football.
He was diagnosed to have squamous cell carcinoma at
age 43. On admission of the patient, a very thick right
tibia and tibial refracture were found (Figure 1a-1b).
There were no other injuries nor any gross pathology
on inspection. He had normal general medical
condition. A detailed physical examination revealed a
107x52 mm mass lesion on anterior part of the leg
(Figure 2-3). Initially, a wide debridement and external
fixator were performed (Figure 3). Patient was treated
by surgical Ilizarow wire technique and rotational fullthickness
flap (Figure 4-5-6). There was no problem
with flap at the second year follow up. Tibial union
was three-cortical; but was not sufficient. At third year
follow-up, the patient admitted with recurrence of the
squamous cell carcinoma in an aggressive manner on
anterior part of the leg despite receiving oncological
treatment. Disarticulation was performed to right
extremity below knee after extensive discussion of
multidisciplines.
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Discussion | |||||||||||||
The formation of epidermoid carcinoma on fistula of
osteomyelitis has been known since the 19th century.
The frequency of this late complication cannot be
determined precisely, but it has been estimated about
0.5/100 of fistulous osteomyelitis. Signs are often not
specific and that causes delayed diagnosis. Signs are
unusual pain, ulceration, granulation and discharge.
The diagnosis depends on histology and requires a
deep and wide surgical biopsy involving the entire
sinus tract, but uncertainties sometimes persist
concerning atypical pseudoepitheliomatous
hyperplasia. The best treatment is amputation with
removal and biopsy of regional lymph nodes when
present, but it does not always prevent the formation of
metastases which are seen in 20 out of 100 cases,
usually during the first three years following the
diagnosis5-6. Thus, several authors emphasized the
importance of these cases and suggest squamous cell
carcinoma risk as an unusual complication that should
be considered in all patients showing atypical changes
in an old fistulous osteomyelitis5-6. Malignant changes following chronic osteomyelitis with draining sinuses are rare (0.38- 2.7%). The duration from onset of osteomyelitis to the development of malignant varies, however, it requires an average time of approximately 30 years. Most patients are males between 50 and 60 years of age. If there is any doubt about malignancy (bleeding, tumor growth) biopsy should be performed and repeated if histological findings reveal uncertain results. Metastases should be excluded by x-ray of the chest, scintigraphy and computerized tomography of the regional lymph nodes. Appropriate surgical treatment can only be done by amputation or disarticulation of the extremity. Patients who were operated because of squamous cell carcinoma of chronic osteomyelitis sinus ought to be controlled in a regular follow-up including blood tests (tumor markers)7. These tumors are usually managed by amputation alone. Some authors believe that in patients with histologically undifferentiated and invasive tumors, aggressive treatment should be carried out by way of amputation, excision of regional lymph nodes and a short course of chemotherapy/radiotherapy2. Limb-sparing surgery is another treatment option for this disease8. Some authors believe that local wide excision and staged microvascular reconstruction is an excellent alternative treatment for malignancy4, whereas some believe that excision and application of ilizarov with bone graft is another4,8. Chronic osteomyelitis after fractures are difficult to treat. They often require both medical and surgical treatment. In some of these cases, chronic sinuses form which possesses a high risk of having epidermoid carcinoma due to chronic irritation. Chronic osteomyelitis is a medical condition which must be followed up carefully because of high risk of malignancy. All fistulae should especially be treated medically and surgically and they also must be followed up in routine clinical examinations. This case report was presented since it's a rare case and highlights the importance of development of squamous cell carcinoma after chronic osteomyelitis. |
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References | |||||||||||||
1) Saglik Y, Arikan M, Altay M et al. Squamous cell carcinoma
arising in chronic osteomyelitis. Int Orthop 2001; 25: 389-91.
2) Sadat-Ali M, Geeranavar SS. Malignancy in chronic
osteomyelitis sinus. Report of three cases. Indian J Cancer
1996; 33: 139-44.
3) Coy J. Combat injury with chronic osteomyelitis complicated
by squamous cell carcinoma. Mil Med 1994; 159: 665-7.
4) Ueng WN, Wei FC, Hsueh S et al. Squamous cell carcinoma
complicating tibial osteomyelitis treated with local wide
excision and staged microvascular reconstruction. Clin Orthop
Relat Res 1993; 293: 274-9.
5) Dereure O, Guillot B, Bonnel F et all. Carcinomatous
degeneration of chronic osteomyelitic fistulae. 4 cases. Ann
Dermatol Venereol 1993; 120: 675-8.
6) Singh DR, Gaur SC, Singh RB et all. Epidermoid carcinoma
and pathological racturedeveloping in a case of chronic
osteomyelitis. Indian Med Assoc 1984; 82: 449-50.
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