Yonago Acta medica 2011;54:33–36

Squamous Cell Carcinoma Derived from a Skin Flap Usedfor Reconstruction of the Hypopharynx
Aigo Yamasaki, Nobuya Monden, Teruaki Takishita, Yasuhiko Yamashita, TohruIshikawa, Norihiro Teramoto* and Hiroya Kitano†
Department of Head and Neck Surgery and *Department of Pathology, Shikoku Cancer Center,Matsuyama 791-0280 and †Division of Otolaryngology, Head and Neck Surgery, Department ofMedicine of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine,
Yonago 683-8504, JapanDevelopment of a secondary primary cancer in a skin flap is a rare complication. A70-year-old man underwent partial laryngopharyngectomy, right neck dissection and reconstruction with a radial forearm free flap in 2004. Five years later, an exophytic tumor
was found on the hypopharynx reconstructed with the radial forearm free flap. He underwent total laryngopharyngectomy, left neck dissection and reconstruction with a jejunal
free flap in June 2009. Pathological findings suggested this was a primary cancer rather
than a metastasis. Localization to the epidermis and dermis indicate that the tumor wasderived from the surface of the skin flap.
Key words: flap; hypopharynx; secondary primary cancer; squamous cell carcinoma

Various flaps are used to reconstruct the defect after resection of head and neck cancer, and these areassociated with complications such as ischemia ofa free flap, infection, fistula and stenosis. However,the development of a secondary primary cancer
in a flap is rare (Genden et al., 2004). Recurrenceof the original primary tumor usually occurs inresidual mucosa of the pharynx or oral cavity. In
the present report, we described a case of a malepatient with a secondary primary squamous cell
carcinoma which arose in a skin flap 5 years after
the initial treatment of hypopharyngeal cancer.
Pathological features and therapeutical proceduresof the squamous cell carcinoma were minutely presented.

cell carcinoma of the right pyriform sinus of the
hypopharynx (T2N0M0). He underwent partial
laryngopharyngectomy, right neck dissection andreconstruction with a radial forearm free flap. We
confirmed complete resection of the tumor by pathological examination. The patient was discharged
without postoperative radiation therapy and had
regular follow-up thereafter. The patient stopped
smoking and drinking after the 1st surgery in 2004.
Five years later, in April 2009, he noticed a massin the anterior neck and visited our hospital inMay. Ultrasonography showed that this tumor waslocated anterior to the thyroid cartilage and was 4
cm in diameter. Cytologic examination of a fineneedle aspiration specimen revealed squamous cell
carcinoma. Flexible fiberoptic laryngoscopy revealed no tumor in the pharynx or larynx. Gastrointestinal endoscopy detected an exophytic tumor
in the hypopharynx. This tumor was located atPatient ReportA 70-year-old man was admitted to Shikoku Cancer Center in 2004 for treatment of squamous

Abbreviations: MRI, magnetic resonance imaging; PET/CT,
positron emission tomography with computed tomography

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the apex of the right pyriform sinus reconstructedwith the radial forearm free flap (Fig. 1). No othertumor was present in the pharyngeal or esophageal
mucosa. Endoscopic biopsy of the hypopharyngeal tumor was performed, leading to a diagnosisof squamous cell carcinoma. Magnetic resonanceimaging (MRI) demonstrated only the anteriorcervical cancer, and this was located outside thethyroid cartilage, away from the hypopharynx (Fig.
2). Positron emission tomography with computed
tomography (PET/CT) detected both the hypopharyngeal and anterior cervical tumors (Fig. 3)
but showed no distant metastasis. The patient wasdiagnosed with a secondary primary cancer on theskin flap and cervical recurrence of hypopharyngeal cancer.
MRI and PET/CT suggested the anterior cervical cancer was adherent to the thyroid cartilage, sowe decided that the larynx could not be preserved.
We therefore performed total laryngopharyngectomy, left neck dissection and reconstruction with ajejunal free flap in June 2009. Postoperation radiotherapy was performed with a total dose of 60 Gy.

Fig. 1. Gastrointestinal endoscopy detected an exophytic
tumor in the hypopharynx. This tumor was located at theapex of the right pyriform sinus that had been reconstructed with a radial forearm free flap (arrow).

Pathological findings
The hypopharyngeal cancer was separate from theanterior cervical cancer and was localized to theright pyriform sinus reconstructed with the 1.0-cm
diameter skin flap (Fig. 4). It showed exophytic

Fig. 2. MRI demonstrated only the anterior cervicalcancer, which was external to the thyroid cartilage, awayfrom the hypopharynx (arrow). MRI, magnetic resonanceimaging.

Fig. 3. PET/CT detected both hypopharyngeal cancer
and anterior cervical cancer (arrows). PET/CT, positronemission tomography with computed tomography.

Fig. 4. Hypopharyngeal cancer localized to the right pyriform sinus reconstructed with the 1.0-cm diameter skinflap (arrow).

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Secondary primary cancer in a skin flap

Fig. 5. The hypopharyngeal cancer showsexophytic growth from the skin flap (hematoxylin and eosin). Bar = 3 mm.

growth from the skin flap (Fig. 5). Most of thetumor was contained within the epidermis and dermis of the skin flap, with little in the subcutaneous
tissue. No tumor was present in the pharynx, larynx or cervical esophageal mucosa of the resected
specimen. This tumor was diagnosed as welldifferentiated squamous cell carcinoma (Fig. 6).

The anterior cervical cancer was located anterior to the thyroid cartilage with little invasion,and measured 5.2 × 3.0 × 2.4 cm. It extended to thepre-epiglottic space and reached the first tracheal
cartilage without invasion of the thyroid gland.
Pathological diagnosis was poorly differentiatedsquamous cell carcinoma. No metastatic lymph
nodes were found.

Fig. 6. Most of the cancer was localized to the epidermis and dermis of the skin flap, with little in the subcutaneous tissue. It was diagnosed as well-differentiated squamous cell carcinoma (hematoxylin and eosin). Bar = 340 μm.

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cinogenesis. Careful and long-term observation ofpatients contributes to improving prognosis of thedisease.

Discussion
Pathological findings suggested that the skin flap
tumor was a primary cancer rather than a metastasis. Localization to the epidermis and dermis
showed that this cancer was derived from the surface of the skin flap. In contrast, metastatic skincancer usually occurs in subcutaneous tissue, andleaves the epidermis intact (Reingold, 1966). The
development of a secondary primary cancer in aflap is rare. Several factors were reported to cause
this complication, including chronic irritation thatthe skin does not suffer at its normal site, for example, from smoking, drinking and food (Monnieret al., 2008; Woolgar and Triantafyllou, 2009).
The present patient stopped smoking anddrinking after the 1st surgery in 2004, and cancerof the skin flap was detected 5 years later. Hence,physical or chemical stimulation from food, saliva
or stomach acid might have been involved in carcinogenesis. In an autopsy case of squamous cell
carcinoma derived from a reconstructed esophagus,
papillomatous cancer developed in the epitheliumof the skin tube, which demonstrated hyperkeratosis, papillomatous proliferation and severe anaplasia (Kanisawa et al., 1959). The authors consideredthat carcinogenesis had resulted from stimulation
by food and drink.
In the present patient, the cancer developed
5 years after the 1st surgery, which seems to be a
relatively short period. The latency of 6 to 40 years
was reported between reconstructive surgery anddevelopment of cancer in the skin flap (Johnson etal., 1983; Deans et al., 1990; Scott and Klaassen,
1992; Sa’do et al., 1994; Iseli et al., 2002). But theperiod of carcinogenesis is unknown. In treatinghim, we performed total laryngopharyngectomy
and reconstruction with a jejunal free flap because
the anterior cervical cancer was adherent to thethyroid cartilage. Cancer of the skin flap tends tobe localized to the surface of the flap, and could
often be removed by partial resection of the flap
(Yoshino et al., 1989). Skin flap-derived cancer is arare complication with an unknown period of car-References
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Received December 13, 2010; accepted January 4, 2011
Corresponding author: Hiroya Kitano, MD

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