Squamous cancer on hand stump

Clinical History

Male patient, 69 years old, with a rapidly growing and ulcerating mass on a scar of one hand stump.

Imaging Findings

The patient came to our department for a rapidly growing mass on the amputation stump of his left hand. The amputation was due to an injury that had occurred about 30 years before, where the phalanges of the third, fourth and fifth finger and the fifth metacarpus were removed. A biopsy was performed and the histological assessment showed a well-differentiated squamous carcinoma. MR (Fig. 1-2) was performed to evaluate cancer extension; the surgeon wanted to determine the infiltration of the first two fingers. The tumour was located near the 5th, 4th and 3td metacarpal bones; therefore the resection did not include the thumbs and the forefingers with a scop of better functional performance of the hand. CT (Fig. 4) and US (Fig. 3) study were performed to evaluate lymph nodes and metastasis. Pathologic lymph nodes were found in left arm pit.
MR was performed on dedicated 0.3 T scanner.

Discussion

Malignancies that arise in chronic venous ulcers, chronic injuries, scars, burns, chronic osteomyelitis or sinuses are referred to as Marjolin’s ulcers. Patients have an average age of about 50 years at the time of diagnosis and there seems to be a male to female preponderance of 2:1; the latency period is reported to be about 31 years. The reported types of neoplasm are squamous cell carcinoma (71%), basal cell carcinoma (12%), melanoma (6%), and a remaining 11% of other neoplasm. These malignacies are often localised at the lower extremity (33%), but also upper extremity (19%) and head or face (30%) are involved. The pathogenesis of these lesions remains unclear. Key factors in the development seem to be a slow healing process and chronic instability of scar tissue. There also might be a role for hereditary abnormalities of the P53 gene and somatic mutation in FAS gene. The onset and/or intensification of pain, fetid suppuration of abnormal volume, exophytic and friable areas, an increase in the size of the lesion, hardening and a tendency to haemorrhage are signs that are strongly indicative of malignant transformation [1, 2].
The diagnosis is based on the evidence of lesion and patient history; the clinical suspicion must be histological confirmed. Various biopsies should be made to reduce the probability of false-negative results [2].
Radiography provides information about periosteal reaction; bone destruction is the most important radiological finding for the surgeon.
The MRI scan had the advantage of demonstrating excellent soft tissue detail, the extent of the ulcer, its margins, the extension of tumour into cortex and bone marrow, the periosteal reaction and the involvement of surrounding structures. MRI scanning is superior to CT as it demonstrates the extent of medullary bone, soft tissue and neuro-vascular involvement. T2 weighted images are best suited for soft tissue characterisation and T1 weighted images for distinction between marrow and tumour. STIR sequences are useful for detection of subtle marrow or soft tissue lesions [3].
CT and US examination are useful to evaluate the lymph node status and metastasis [3, 4].
Marjolin’s ulcer tends to be more aggressive than other types of skin cancer and has a higher regional metastasis and fatality rate. The 5-year survival rate is only about 40–60%. The presence of distant metastases is obviously indicative of poorer prognosis [5].
Treatment of marjolin’s ulcer consists of surgery, radiotherapy, chemotherapy, lymph node dissection, and most often a combination of these procedures.

Differential Diagnosis List

Final Diagnosis

Squamous skin cancer

URL:	https://www.eurorad.org/case/9748
DOI:	10.1594/EURORAD/CASE.9748
ISSN:	1563-4086