Giant squamous cell carcinomas of the shoulder
Mounir Yahyaoui1,&, Najib Abbassi1, Abdelhafid Derfoufi1, Abdelkarim Daoudi1, Omar Agoumi1, Hicham Yacoubi1, Abdeljaouad Najib1, Badr Serji2, Tijjani Elharroudi2, Nabil Mouzouri3, Siham Dikhaye3, Nada Zizi3, Hanane Hadjkacem4
1Trauma-orthopedics Service, University Hospital Mohammed VI-Oujda, Morocco, 2Oncology Surgery Service, University Hospital, Mohammed VI-Oujda, Morocco, 3Dermatology Service, University hospital Mohammed VI-Oujda, 4Radiology Service, University Hospital Mohammed VI-Oujda, Morocco
Mounir Yahyaoui, Trauma-orthopedics Service, University Hospital Mohammed VI-Oujda, Morocco
Giant squamous cell carcinomas (SCC) larger than 5 cm in diameter are uncommon; there is no guideline on the size of an SCC that is considered giant. Treatment
may be difficult with the need for large tissue resections and complex surgical reconstruction. We report a rare case of giant squamous cell carcinoma
shoulder attached to deep anatomic planes. The entire mass was removed, resulting in a large defect that was repaired with myocutaneous flap rotation
of the latissimus dorsi. Three courses of radiotherapy were performed after surgery.
Fifteen months after the operation, the patient is well and working without
any local recurrence and metastasis.
Squamous cell carcinoma (SCC)is the second most common skin malignancy . It is prevalent in men and increases with age. The prevalence and incidence of SCC is increasing because of longevity and increased UV exposure associated with changes of lifestyle . The larger and the deeper it grows, SCC is more likely to become metastatic .
Cutaneous SCC is an invasive and destructive tumor who is associated with a higher risk of disfigurement, local recurrence, and metastasis. We report the case of a patient with a giant SCC of the shoulder followed for 24 months post treatement without signs of local recurrence and/or metastasis.
Patient and observation
A 50-year-old woman presented with a mass on her shoulder that had
been increasing in size over the last 20 years. Physical examination revealed
a 12x8cm extensive tumor of infiltrated and exophytic appearance (Figure
by necrotic material that was attached to deep anatomic planes (Figure
Staging showed no lymph node involvement or metastasis. The specimensrevealed
a diagnosis of well differentiated squamous cell carcinoma.The
lesion was surgically removed with lateral margins of 2.5 cm. On excision, infiltration
of the local muscles (pectoralis major, pectoralis minor and trapezius) was observed.
All compromised structures were removed. The entire mass was removed, resulting
in a large defect that was repaired with myocutaneous flap rotation of the latissimus
dorsi (Figure 3). Histopathology
showed findings that were consistent with well-differentiated SCC without perineural
invasion and with clear surgical margins. Three courses of radiotherapy were
performed after surgery. Fifteen months after the operation, the patient is well
and working without any local recurrence and metastasis.
SCC accounts for approximately 20% of cutaneous malignancies 
and occurs predominantly in elderly fair-skinned men. It has been
shown to develop more frequently in chronically precursor lesions, including
ulcers, sinus tracts, burns or osteomyelitis .
The incidence of SCC has increased considerably over the past 20 years, because
of the growing life expectancy, and increased sun exposure .
A history of exposure to sunlight during childhood may be the greater risk
factor because of the harmful effects of ultraviolet exposure .
SCC can show de novo onset or more often mark the progression of several
precursor lesions: actinic keratosis and Bowen disease .
Among patients with invasive SCC, multivariable analysis showed a significantly
higher likelihood of large size for SCC arising on chronic lesions and treatment
delay longer than 1 year, and for SCC on not easily visible sites, it has
reported a lower likelihood of significant association between larger lesions
and anatomic site .
Giant SCC larger than 5 cm in diameter are uncommon; there is no guideline on
the size of an SCC thatis considered giant . To our
knowledge, there was no report of SCC case in this location treated by such
a very extensive resection. Unexpectedly, no metastasis and local recurrence
have been observed for long. It may suggest that radiation therapy and extensive
operation we performed was effective treatment for such a huge SCC In the
majority of cases. Large SCC is associated with a higher risk of disfigurement
significant tissue destruction, requiring major plastic surgery with a potentially
positive impact on morbidity, mortality, and costs.
Tumor diameter is a major prognosis criterion. Lesion size ≥ 4 cm and histologic
evidence of perineural and deep invasion into the deeper tissues were the clinical-pathologic
factors associated with higher rates of local recurrence and regional metastasis
and lower rates of survival , they carry twice the risk
for recurrence and 3 times the risk for metastasis .
Early studies have shown that whilst both tumour diameter and tumour thickness
are independent risk factors for metastatic only the latter is an independent
risk factor for local tumour recurrence , actually risk
factors associated with metastasis include also histologic grade,location, recurrence,
and immunosuppressed state .
Histological-poor prognostic signs include a desmoplastic growth type, tumor
thickness of 3.5 mm, only with invasion depths of Clark level IV or more did
recurrence take place and metastatic spreading only occurred from Clark level
V , the other factors were ulceration, poor differentiation,
and over ten mitoses/3 HPF 400 on the tumor growth front .
Biopsy is done to confirm preoperative diagnosis before extensive surgery and
if the clinical diagnosis is uncertain ; surgical excision
remains the gold standard with oncological complete excision and histologically
tumor free margins . SCC should be appropriately excised
with surgical margins of 4 to 10 mm, depending on the size of the tumor .
Surgical margins of at least 6 mm are needed to achieve healthy margins in tumors
with a diameter greaterthan 2 cm. The judgement of where a tumor ends and when
a deep plane is clean can be complicated by local anatomy, however Tumor thickness
and depth of invasion are important prognostic factors in SCC ,
a better deep clearance may be achieved by excising an extra deep fascial plane
respecting fascia, periosteum, and perichondrium because these structures are
not in direct contact with or invaded by the tumor .
Nevertheless, Mohs micrographic surgery remains an interesting treatment for
these larger tumors and high-risk SCC . Conventional
surgery has a higher cure rate than Mohs surgery overall, but it is less successful
with tumors that poorly differentiated, or recurrent .
Appropriate reconstruction methods should be based on the location and size of
the defect created after tumor excision,in our patient flap rotation of the latissimus
dorsi were satisfactory options for reconstruction.
Radiotherapy may be considered for cases in which tumor cells are close to surgical
margins or in which negative margin control is not possible .
One study of 167 patients with SCC and perineural invasion revealed a local recurrence
rate of 43% with surgical excision alone compared with 20% with excision and
adjunctive radiation. Likewise, disease-free survival increased from 53% to 73%
in the 2 groups, respectively , they conclude that a
more conservative surgical approach followed by adjuvant radiotherapy may be
a reasonable way.
Squamous cell carcinomas that reach large dimensions are accompanied by the risk of disfigurement, local recurrence, and metastasis. Aggressive treatment is the best way to reduce the morbidity and mortality associated with this disease.
The authors declare no competing interests.
All authors contributed to the conduct of this research and read and approved the final version of the manuscript.
Figure 1: a 12x8-cm solid nodular mass on the left shoulder with infiltrated and exophytic appearance
Figure 2: the mass invaded into deep anatomic planes
Figure 3: six months after excision of the tumoral lesion and coverage with myocutaneous flap rotation of the latissimus dorsi
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