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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
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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  • Summary
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • 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.

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • 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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    Figure 1: Preoperative tibia lateral radiography (thickened bone due to osteomyelitis) (a), Preoperative tibia anteroposterior radiography (b).


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    Figure 2: Clinical appearing of squamous cell ca after chronic osteomyelitis


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    Figure 3: External fixator (acute treatment with debridement and fixing)


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    Figure 4: Excised part of tibia (histopathological examination revealed invasive squamous cell carcinoma)


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    Figure 5: Ilizarov technique for tibial fracture treatment


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    Figure 6: Ilizarov method with rotational full-thickness flap

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Disscussion
  • References
  • 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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  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • 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.

    7) Wening JV, Stein M, Langendorff U et all. Chronic osteomyelitis and cancer of the fistula. Langenbecks Arch Chir 1989; 374: 55-9.

    8) Iacobellis C, Olmeda A. The Ilizarov method in the treatment of malignant neoplasms of the tibia. Chir Organi Mov 2004; 89: 245-50.

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  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
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