A 90 y.o. is sent in from the veterans home with altered mental status. He is unable to give a history but you notice a wound on his head.

What is wrong?

Our patient developed a squamous cell carcinoma in a scar from a previous craniotomy.  When he presented there was an orange sized lesion on the top of his head.  He was deemed too old to have resection with a flap covering the defect and instead had radiation.  The radiation decreased the size of the tumor but left bone exposed and residual tumor which eroded into the cranium causing a subdural empyema. 

you notice a defect in the skull

and a subdural empyema

The most common types of skin cancers are basal cell ca which constitute 70%, and cutaneous  melanomas which constitute 10%.  Of malignancies arising in scars, squamous cell carcinomas are the most common and often found in burn scars.

The  etiology of cancers in scars is not fully understood but proliferation due to chronic inflammation and poor vascularization of the scar tissue resulting in impaired immunological defense are thought to be factors. . Genetic factors may also play a role with mutations in p53 and FAS genes being associated with cancer.  These cancers also arise in scars in the lung. The presence of type III collagen and extracellular matrix suggest an ongoing fibrosing process secondary to host response to neoplasm.  The high concentration oftype III collagen in scar carcinoma indicates that the fibrous tissue isin an active immature state compared with normal collagen which contains type I and type V collagen.

Our patient had been told he was not a candidate for surgery several months PTA , was treated for a UTI and sent back to the Veteran’s home on hospice.

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