BURN SCARS AND CANCER DEVELOPMENT

Kokkalis G., Trichifis E, Mixiou M.

Department of Plastic and Reconstructive Surgery, Hellenic Anticancer Institute, Saint Savas Hospital, Athens, Greece

SUMMARY. Unstable scar formations following burn or radiation injury frequently result in malignant degeneration, particularly squamous cell carcinoma and fibrosarcoma. Metastasis to regional lymph nodes is comparatively rare. The main treatment is necessarily surgical.

Chronic unstable scars after burns or radiation may give rise to cancer development. This malignant change is the ultimate expression of burn and radiation injuries.
The purpose of this paper is to describe our experience in the treatment of such malignancies developing into burn scar injuries.
Since 1980 we have treated in the Department of Plastic and Reconstructive Surgery of the Hellenic Anticancer Institute 86 patients who developed cancer in scars after burns or irradiated injuries. In most cases the cancer developed at least 5-20 years after the initial injuries.
The most common malignancy was squamous cell carcinoma; there were two cases of basal cell carcinoma and two of fibrosarcoma.
In 16 cases there was regional lymph node meta'stasis at the time of admission.
In 20 cases we observed regional lymph node metastasis 6-12 years after radical excision and repair of the wound.
The usual treatment of malignancies developing on the scars after burn or radiation injury was excision of the tumour and split-thickness skin graft coverage or skin flap and myocutaneous flap reconstruction.

Discussion
It is well documented that unstable scars after burn or radiation injuries may result in malignant degeneration (1,2).
Unstable scars after burn and radiation injury render the tissue ischaemic and susceptible to injury, with easy breakdown. The tissue progresses through the stages of atrophy, pseudoepitheliomatous hyperplasia, and finally carcinoma.
The development of avascular scar tissue around the ulcer forming after burn injury (Marjolin's ulcer) is a barrier against metastasis.
A circumferential scar prevents lymphatic growth, placing the carcinoma in an immunological privileged site.
All ulcers developing in a burn or radiation injury should be suspected of cancer and biopsied.
In such injured skin the most common malignancies are squamous cell carcinoma and fibrosarcoma.
The usual treatment is excision and split-thickness skin coverage or reconstruction with dermal and myocutaneous flaps, depending on the extent and location of the lesion; sometimes, if the surrounding tissues are destroyed, one can use advanced tube flaps or flaps with microsurgical techniques for reconstruction of the excised areas.
In conclusion, carcinomas developing on scar tissues after burn or radiation injuries are not uncommon in Cancer Institutes and are rarely metastasized to regional lymph nodes. The main treatment for the primary tumour and metastases must be surgery.

RESUME Les formations cicatricielles instables A la suite des brfflures on les 1ésions dues aux radiations provoquent fréquemment une dégénération maligne, en particulier le carcinome des cellules squarneuses et le Fibrosarcome. La m&tastase aux ganglions lymphatiques régionaux est relativement rare. Le traitemente principal doit ~tre inévitablement chirurgical.

BIBLIOGRAPHY

1. Ariyan S., Krizek T.: "Radiation effects: Biological and surgical considerations". Vol. 1, p. 831, Saunders, Philadelphia, 1990.
2. Malbec E. F. et al.: Carcinomatous complications in radiodermatitil- Plast. Rec. Surg., 32: 447, 1963.
3. Warren J.: Radiation carcinogenesis. Bull. N.Y. Acad. Med., 46: 131, 1970.