Shehab Afzal M, Beg Moiz Sadiq.
Maltreated or neglected Squamous Cell Carcinoma.
J Pak Assoc Derma Nov ;10(3):44-6.

Squamous cell carcinoma (SCC) is a common skin cancer and if not treated adequately can be associated with significant morbidity and high mortality. We present one case with extensive SCC of the scalp requiring palliative surgery.

CASE REPORT: A 60 year old female presented to the Plastic Surgery Department Liaquat National Hospital, Karachi, with a large, foul smelling, fungating lesion involving almost the whole scalp. History revealed that the lesion had started as a pustule three years ago, initial treatment by GP was topical antibacterial ointment, then as the pustule got bigger it was surgically excised by a local surgeon and the wound was primarily sutured, biopsy was not done at that stage. The wound later broke down and got infested with maggots. At that stage she was admitted to a local hospital and once the local infection was controlled biopsy was carried out which showed Squamous cell carcinoma. She was then referred to a Plastic surgeon who excised the lesion and put skin graft over the defect, graft apparently failed followed by local recurrence, this prowas repeated on four occasions, but the lesion got bigger and bigger. Family was advised to take the patient to a different Plastic Surgeon for a second opinion. After thorough history and examination patient was admitted at LNH, repeat biopsy of the lesion confirmed squamous cell carcinoma, base line investigations were done including abdominal scan, chest x-ray and CT scan of the head. No evidence of metastasis was found either clinically or by other investigations. CT revealed complete erosion of the skull bones to a almost non existent state and local spread of the tumour down to the dura was noted. Neurosurgical opinion was then taken and a combined approach was planned for excision of the tumour by Neurosurgical team and reconstruction by the Plastic Surgeons. Family was counseled and potential risks were identified and discussed in detail. The tumour was excised,in certain areas outer layer of the dura was also excised which was involved with the tumour. This presented a defect involving the head from 3cms above the ear on one side to the same distance on the other side and front to backwards from 5 cms above the eyebrow to the superior nuchal line. Reconstructive options were limited to free microvascular transfer of a large muscle for which the obvious choice was latissimus dorsi muscle. Latissimus dorsi was harvested from the right side with maximum length of the pedicle (thoracodorsal vessels). The muscle was transferred to the defect on the scalp and inset, thoracodorsal artery with its vein was anastomosed to the superficial temporal vessels using microvascular techniques. This provided good coverage to the areas where the inner dura was exposed but even with the large size of the latissimus dorsi the whole defect could not be covered, the remaining areas were considered more stable and covered with split thickness skin grafts. This procedure was not the first case of its kind in literature but to our knowledge has not been reported by any unit in Paki stan. Local flaps in this case were not an option and simple skin grafts would not have provided stable coverage for the whole scalp. Other free flaps including free omentum, tesor fascia lata or rectus abdominous have been described but were not considered suitable in this case.

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