Skin SCC following mustard gas testing in a British Army recruit

Abstract

An 84-year-old army veteran presented with a 1.5×1-cm keratotic lesion on the dorsum of his right hand. The lesion had developed at the site of previous mustard gas testing, which he had been subjected to as a soldier in the British army in 1944. He reported that the site had been painful, erythaematous and ulcerated for a number of years following the mustard gas tests. This had eventually settled, leaving a flat, erythaematous but generally asymptomatic lesion described as a ‘burn’ that the patient had ignored. Over the past 10 years, however, the lesion had become raised and increasingly symptomatic, with itching and occasional bleeding. It was treated by dermatologists with topical 5-flurouracil and serial curettage for 8 years but had persistently recurred. Serial biopsies had shown chronic, severely inflamed skin with evidence of Bowen’s disease. The patient was referred to our plastic surgery oncology clinic (Fig. 1). A detailed history was taken, which revealed the mustard gas tests. He had no past history or family history of skin malignancies. Examination showed an irregularly shaped pigmented lesion measuring 15 mm in diameter × 3 mm in height. Systemic examination demonstrated no palpable peripheral lymphadenopathy and no other skin malignancies. He underwent excision of the lesion under local anaesthesia with a 10-mm clearance margin. The defect required a full-thickness skin graft. Histological assessment of the lesion demonstrated a welldifferentiated, squamous cell carcinoma, measuring 3.5 mm in width × 2.2 mm in depth. The overlying epidermis was hyperplastic, with a hyperkeratotic surface, but demonstrated no evidence of dysplasia in the epidermal keratinocytes, a possible result of previous topical treatments. Vascular invasion was not identified and excision margins were clear (Fig. 2). The patient recalled that the process of mustard gas testing involved the application of a spoonful of mustard gas paste onto the back of the hand, followed by a 30-min period of observation, after which the soldiers were permitted to wash their hands. This test was conducted on 30 soldiers from his regiment. He and the rest of the subjects, at the time, were not aware of the reasons for the test.