Squamous Cell Carcinoma in the Setting of Hidradenitis Suppurativa

Dr. Austin Dixon and Dr. Thea Price share key background and details from their literature review, “Squamous Cell Carcinoma in the Setting of Hidradenitis Suppurativa: A Retrospective Review of the Literature.” Read the full paper here.

Transcript

Austin Dixon, DO:

Hello, my name is Austin Dixon. I am a DO and I'm a first-year surgical resident at Sinai Hospital in Baltimore, Maryland.

Thea Price, MD:

And I'm Dr. Thea Price. I'm an acute care surgeon, trauma surgeon, burn surgeon, and wound care surgeon extraordinaire at Rush University Medical Center in Chicago.

Dixon:

Basically, what we were studying is we were interested in squamous cell carcinoma development in the setting of, really, chronic wounds in general, but we decided to focus on in the setting of hidradenitis suppurativa. This is also typically referred to as a Marjolin ulcer. And the big motivation in us attempting this paper was really, we had 2 main patients, but really 1 specific patient that was very well known to Dr. Price's practice. She was a patient with chronic HS who was seen quite regularly, and she unfortunately succumbed to squamous cell carcinoma that ended up being discovered by biopsy in her setting of chronic HS. And after it was diagnosed, she passed away within a year. So that kind of rapid progression from seeing this patient quite often to then passing away was quite shocking and we thought, why don't we look into this and why is this happening?

I guess the only other thing I'd add is once we started really getting into the weeds here and doing the literature review was one of those situations where I kind of felt we were going down the rabbit hole in a good way. Basically, there was 1 other previous paper by the author’s last name is Pena, written in 2015, and they had basically compiled together all of the instances of squamous cell carcinoma in the setting of HS that had been written or published in the literature up until that time is only about 80 cases, more or less. And so, using that as a springboard, I wanted to one look at all those papers myself and then kind of further build out into a robust table more about what these patients, different demographic factors regarding their cancer development as well as their history of HS. And that kind of came and founded the basis of our paper.

Price:

Yeah. Another thing that we really were interested in was that in this patient specifically and in both of our patients with chronic wounds, neither of them had been operated on before. And we thought that was really interesting because in general in medical education, you're taught that Marjolin ulcers or squamous cell carcinoma happens in wounds that have been operated on, right? So the classic teaching is that it happens in a scar after you've operated on a wound. We thought this was fascinating because this mutation happened without surgical debridement. So we really wanted to bring to the greater medical awareness that just because you have an area that hasn't been operated on does not mean that it is not at risk for developing squamous cell carcinoma. And it's very rapidly progressive and fatal when it's found because it tends to grow inside before it starts fungating outside. And so a lot of times by the time you actually see a skin level lesion, it's already unresectable. And so that's why we really wanted to try to bring to the larger medical community and especially wound care physicians' attention that these chronic wounds are at risk regardless of whether they've been operated on or skin grafted or not.

Dixon:

Basically, the biggest way that we narrowed down is we were looking for a squamous cell carcinoma in the setting of prior hidradenitis suppurativa, or HS as we typically refer to it. And so once we started with the large MedHub review, we ultimately narrowed it down to, I think it was 124 total patients, including our own patient, which we included in the literature review. And this was more or less, I can't remember the exact number off the top of my head, but it was more or less 60 or so papers. Some of the papers noted like multiple patients that they spoke upon that they had seen in their own practice. And from there, this was papers I think that ranged back to the 30s all the way up until November of 2021. And so, from there, we basically built out this large extensive table that looked at stuff that had been measured up until that point, or in previous papers, such as time of squamous cell carcinoma development, how long they had had HS or been living with HS, their gender location, et cetera, et cetera.

Some standard demographic breakdowns that were quite common. But then we also were looking at to build off what Dr. Price said, had they had prior surgery in the area where the HS ultimately developed, and if so, when from that did it develop? Additionally, we were curious about outcome following the diagnosis of squamous cell carcinoma and how long had elapsed until they either passed away or were they still alive, et cetera, et cetera. I'm just going to read off of some notes I have in front of me just because I don't remember all these stats, but there were quite a pretty interesting ones. So 1 note of the total patients that we included in this literature review, which again was around 124 that had ever been covered in the literature up until this point, 102 patients, outcome included details upon their life and or death, and 57 were noted to have died.

And of that 57%, 59%, or excuse me, of that 57 patients, 59%, had died within the first year of diagnosis. So that's really shocking. That's very close to 60% of patients who we know have passed away died within the first year of diagnosis. So that's obviously saying to us that by the time we are discovering it, it's either A. too late or B. it's just so rapidly progressed that it ultimately takes the patient's life. So that was quite shocking. Another point that I just want to highlight regarding the prior surgical treatment, so of the 124 patients included in our review, only 49 of the 124 had descriptions of prior surgical treatment for their HS described. And of that 49 patients whose surgical management was described, 67% had prior surgical intervention in the region where the squamous cell carcinoma ultimately developed. So again, going back to DR price's point, that means 33% the minority, and so our 2 patients that we knew about that we dealt with specifically were a minority, which further emphasized the importance of why we chose to pursue this endeavor.

Price:

Our recommendation after this is that we believe that wound doctors and really any physicians, dermatologists, anyone who takes care of hidradenitis suppurativa patients or really patients with chronic wounds in general, should probably be receiving regular biopsies of their wounds. We do have literature that shows from the dermatology world that doing punch biopsies of areas that are at risk for squamous cell carcinoma does not increase the risk of developing squamous cell carcinoma. And so in light of that, we feel as though really our message to the greater medical community would be that we need to be biopsying these things regularly. We need to have a very high index of suspicion, and we may even need to consider, depending on where the location of the wound is that we're concerned about, if it's perianal, if it is otherwise on the trunk or abdomen. I think we need to be considering early imaging in these patients as well, because as we pointed out, it often will grow internally before you see the external component.

As far as more research into this area, I think we're really just finding that hidradenitis suppurativa has been a very largely ignored disease for a very long time. If you look at it, the treatment, the research, and the surgical techniques have not been updated in a good 50 or 60 years. So our research consortium, as I like to call us, we really have focused on and our planning multiple publications for the advancement of diagnosis care and treatment of hidradenitis suppurativa in the future, and that's where we're headed. So, we have identified a few innovative surgical techniques that we are exploring and doing outcomes analysis on now, and those will hopefully lead to further publications.

Dixon:

I do want to echo one point that Dr. Price made about the importance of biopsying with a high index of suspicion for our patients that have chronic HS. We highlighted a patient that we highlighted paper from way back in 2020, and this individual had hidradenitis suppurativa for over 20 years. They started developing some suspicious lesions, and over the course of multiple different clinic visits, they were biopsied 5 different times over the course of the 3 years. And it wasn't until that last biopsy actually came back positive for cells that were concerning for squamous cell carcinoma, but it was this persistence that ultimately led to a positive outcome for the patient and that we're able to catch it early enough so that this patient is still alive today. So I think that's a perfect example that goes on to highlight how important this close clinical follow-up repeat biopsies are needed for this population.