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Squamous cell carcinoma developing in the scar of Fournier's gangrene – Case report
© Chintamani et al; licensee BioMed Central Ltd. 2004
Received: 15 December 2003
Accepted: 27 April 2004
Published: 27 April 2004
Squamous cell carcinoma of the scrotum is rare and its development in the scar of Fournier's gangrene is still rarer.
A 65-year-old gentleman presented with a small non-healing ulcer developing on right hemi-scrotum two years after the treatment for Fournier's gangrene. On histological examination it was found to be squamous cell carcinoma. He was successfully managed by surgery in the form of wide local excision and ilio-inguinal lymph node dissection followed by adjuvant radiotherapy and chemotherapy.
Squamous cell carcinoma can develop in the scar of Fournier's gangrene after a long delay, which differentiates it from other scar carcinomas or Marjolin's ulcer.
Squamous cell carcinoma (SCC) developing in the scar of Fournier's gangrene is rare and has only been described once by Schneider et al . Various other cancers however have been found to be associated with the Fournier's gangrene like colonic cancer, lymphoma, multiple myeloma etc [2, 3]. Fournier's gangrene is necrotizing fascitis involving the perineum with occasional extension up the abdominal wall. The usual organism is an anaerobic streptococcus synergistic with some second organism. Early therapy in the form of debridement of dead tissue, intravenous broad-spectrum antibiotics are recommended. The skin cover is obtained either by primary closure of the wound or skin grafting [1–3].
Scar carcinoma developing in a chronic scar following burns has been described in the literature as Marjolin's ulcer, however the time lapse before the development of this carcinoma in a chronic scar is considerably longer and sometimes may be up to 50 years [4, 5]. Squamous cell carcinoma is a neoplasm of the keratinising cells that show malignant characteristics including anaplasia, rapid growth, local invasion and metastatic potential. The treatment recommended for SCC is surgery in the form of wide local excision and block dissection of the draining lymph nodes [6–9].
A 65-year-old non diabetic and otherwise healthy retired bank clerk was treated at our tertiary centre 24 months previously for Fournier's gangrene involving the right scrotum with necrotizing fascitis extending on to the right lower anterior abdominal wall. He was managed by debridement, split thickness skin grafting of the scrotum and primary closure of skin on the lower abdominal wall. The wound healed satisfactorily after three months of treatment and the follow up was satisfactory.
Two years following his discharge from the hospital the patient was referred to our tertiary centre for a small non-healing ulcer developing on the right hemiscrotum. The ulcer was increasing in size rapidly and bleeding on touch with a foul smelling discharge. Examination revealed a healthy, well-nourished patient with vitals within normal limits (Pulse: 80/mt, BP: 130/78 mm). He had no bowel or bladder complaints.
The patient made an uneventful recovery and was discharged on the tenth postoperative day. He subsequently received adjuvant radiotherapy (dosage: 60 Gy in fractionated doses) and four courses of combination chemotherapy (Methotrexate, Bleomycin and Cisplatinum in standard doses). He was on a regular follow up and made satisfactory progress. Two years after his surgery the patient had an attack of inferior wall myocardial infarction (MI) involving three vessels for which he was managed by the interventional cardiologist but succumbed to a subsequent attack of MI within two months.
Since the description of squamous cell carcinoma in chimney sweeps by Percival Pott in the year 1775 [5, 6], soot-related cancer of the scrotum and penis has become anecdotal. This was amongst the first described environmental causes of cancer. Scrotal carcinomas may also occur as a result of non-specific factors such as poor hygiene and chronic irritation, rather than industrial exposure alone [6–8]. This may be partially explained by the similarity in the mechanism of formation of scars by fibrosis and tumorogenesis [7, 8]. Scar carcinomas like Marjolin's ulcer and the carcinoma developing in the scar of Fournier's gangrene may also be explained by this similarity in the mechanism.
The prognosis of scrotal carcinomas depends upon the stage and the grade at presentation therefore the significance of early diagnosis for prolonging the survival in a patient of squamous cell carcinoma cannot be over-emphasized. High-grade tumours usually have positive lymph node metastases, which carry a grave prognosis [7–12]. Marjolin's ulcer, a scar carcinoma commonly observed in chronic burn scars is usually slow growing but may also behave aggressively in the form of local recurrence, along with lymph node metastases if the normal tissue is infiltrated. Classically the latency in some cases may extend up to 50 years [4, 5].
The most significant predictor of survival in patients with squamous cell carcinoma of the scrotum is age, stage and histological grade at the time of initial diagnosis therefore a high index of suspicion to make an early diagnosis is mandatory in order to improve survival. Diagnosis is established by biopsy and the primary modality of therapy is surgery in the form of wide local excision with a safe margin of 3–5 cm in order to achieve R0 resection (microscopically free margin) along with ilio-inguinal block dissection on the affected side [7, 8]. The wide local excision in some patients may leave large defects amounting to hemiscrotectomy and the testes on the affected side may either have to be sacrificed for non availability of accommodation or translocated to the contra lateral hemiscrotum facilitating closure of the surgical wound and preservation of testes, as was done in the reported case .
The neo-adjuvant therapy (both chemo- and radiotherapy) has also been recommended to downstage (reduction in the tumour size and lymph node status thus improving the stage of the disease) a very large lesion in order to achieve R0 resection [10, 11]. Adjuvant radiotherapy and combination chemotherapy in the form of four courses of (Methotrexate, Bleomycin and Cisplatinum) is also recommended to achieve a better disease free survival . The prognosis in squamous cell carcinomas depends on various factors like age of the patient, size, grade and stage of the tumour and the adequacy of surgery [7, 8].
Written consent for publication of the case was obtained from a relative of the patient.
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