Squamous cell carcinoma developed in a chronic radiation-induced chest wall ulcer that is difficult to undergo thorough preoperative histological examination

INTRODUCTION: We report a case in which squamous cell carcinoma (SCC) developed in a large chronic radiation-induced thoracic ulcer after flap surgery in areas where preoperative histological examinations are difficult. PRESENTATION OF CASE: The patient was a 75-year-old female. She had undergone resection and radiotherapy for left breast cancer 15 years earlier. Six years ago, the ulcer expanded from the subclavian to xiphoid levels, exposing the lung and pericardium. A histopathological examination, which avoided the lung and pericardium, was performed. Inflammation was diagnosed. We reconstructed the chest wall with a pedicled rectus abdominis flap. Eighteen months later, three verrucous tissue-lined fistulas formed. A histological examination revealed well-differentiated SCC. Six months later, the patient died of massive bleeding from a fistula. DISCUSSION: It is unclear exactly when the SCC occurred. As three fistulas formed at the margins of the flap around the pericardium, we suspect that the cancer developed within or near the pericardial region. We need to reflect on the lack of a thorough biopsy. As no pericardial biopsy was performed, we should have asked a thoracic/cardiac surgeon to conduct a biopsy during the debridement operation. If the tumor had been localized to the pericardium, it could have been removed. CONCLUSION: It is necessary to consider the best method for performing the most thorough histological examination possible, even in areas where histological examinations are difficult, as all ulcers can contain tumors.