Dr Kelly Thornbury1, Dr Pratik Rastogi1, Dr Robert Gates1
1Royal North Shore Hospital
Patients with severe burns are subject to significant physiological, immunological and inflammatory insults in both the acute and chronic phases of their care. Within this milieu, chronic skin changes are inevitable and debilitating. Ulcers in burns patients typically present as flat and slowly progressing wound, typically without exophytic or papillomatosis changes. Verrucous carcinoma, a form of Marjolin’s ulcer, is rarely seen in burns patients. (Chun-Yuan et al, 2010.)
We present the case of a 34 year-old male who sustained 75% TBSA burns after a house fire as a 2 year old. Over a decade, he developed a chronic ulcer over his left Achilles wound, characterized by pseudo-polypoid tissue islands and progressive fibrosis. No periods of rapid growth or significant morphological change were reported. Pre-operative field incisional biopsies revealed pseudo-epitheliomatous hyperplasia without dysplastic features. The patient underwent a wide local excision of the Achilles wound and soft tissue reconstruction with a latissimus dorsi free flap. Formal histopathology unexpectedly revealed a low-grade verrucous carcinoma. He subsequently underwent re-excision of his involved margins as a complete oncological resection.
Surgeons managing chronic burns patients must maintain a high index of suspicion in surveying patients with ulcerative skin changes. Differentiating between pseudo-epitheliomatous hyperplastic changes and verrucous carcinoma remains a diagnostic challenge.
Huang. C. Feng, C., Hsiao, Y., Chuang, S. & Yang, J., 2010, Burn scar carcinoma,
Journal of Dermatological Treatment, 21:350–356
Accredited Plastic Surgery Registrar