Three cases of malignant melanoma arising on burn scars

Malignant melanoma arising in a burn scar

Secondary malignancies are rare but devastating complications of longstanding burn scars. Squamous cell carcinoma is the most common, followed by basal cell carcinoma and melanomas. There are fewer than 50 total reported cases of malignant melanomas arising in burn scars. We report a case of malignant melanoma arising within a longstanding burn scar confirmed by histology, FISH, and PRAME staining to further characterize melanomas arising in burn scars and to illustrate the diagnostic challenges they present.

Current Trends in Management of Marjolin's Ulcer: A Systematic Review

Marjolin's ulcer (MU) is a rare, aggressive entity with frequent delay in diagnosis for a variety of regions. Although well described and classically taught in medical school, aspects of its treatment remain ill-defined and controversial. A systematic review was performed according to PRISMA guidelines to identify studies discussing patients who underwent surgical treatment of MU. A total of 31 papers, reporting on 1016 patients, were included. Burns were the most common etiology of malignant degeneration (68%), followed by trauma. The lower extremity was most affected (51%) and Squamous Cell Carcinoma (SCC) was found in 94% of cases, with the majority being well differentiated. Basal cell carcinoma and melenoma composed a minority of cases. Melanoma occurred more frequently in previously skin grafted wounds and had a higher rate of metastases than SCC. Most patients did not have associated regional or distant metastases present at diagnosis. Wide local excision (71%) was performed in most cases, unless amputation was indicated for severe disease or bone involvement. Lymphadenectomy and sentinel lymph node biopsy were variably reported, with conflicting evidence on the efficacy. Lymphadenectomy was most commonly indicated for known lymph node involvement. In cases of metastatic disease chemotherapy and radiation were used in conjunction with surgical treatment. Despite numerous articles on this topic, controversy remains in the management of MU. Early diagnosis of suspicious chronic wounds and prompt surgical intervention remains imperative to its treatment.

Characteristics of Marjolin's Ulcers in 21st Century: A Retrospective Study, Systematic Review, and Surgical Guideline Recommendation

Marjolin's ulcer is rare and aggressive malignancy. The objective was to conduct a review of Marjolin's ulcer cases to gain a better understanding and its management. A retrospective study of patients with Marjolin's ulcers at our hospital between 2010 and 2019 was conducted. For the systematic review, the electronic database of the National Library of Medicine was searched and articles published between 2000 and 2019 were included. A total of 14 patients were included in the retrospective study. Twelve patients were male. The mean age was 59.71 years. The latency period was 27.78 years. The most common malignancy was squamous cell carcinoma, and 71.43% had developed on the lower extremities. Well-differentiated squamous cell carcinomas occurred in 38.46% of the cases Rates of lymphovascular and perineural invasion were 30.77 and 23.08%, respectively. Results from the literature search yielded 80 case reports (91 cases) and 42 retrospective reviews (1216 cases). Most cases were male and the most common location was lower extremities. The latency period for the acute and chronic periods was 2.75 months and 20.75 years, respectively. The most common malignancy was squamous cell carcinoma (92.27% in the retrospective reviews) and 59.98% of the cases exhibited well-differentiation. Rates of regional lymph node involvement and distant metastases were 10.20 and 12.09%, respectively. Marjolin's ulcer in 21st century is not so rare. The most common is well differentiated squamous cell carcinoma. Early flap surgery or skin grafts for chronic ulcers or burn scars are recommended to reduce risk. Guideline for surgical management is established.

Analysis of Factors Affecting Chronic Ulcers of Scalp Transforming Into Marjolin's Ulcer: A Single Center Experience

The Marjolin's ulcer (MU) is a rare malignant lesion, which is characterized by primary, chronic wound initially and formation of cancer after a certain incubation period eventually. Though few reports or a small case series about MU on the scalp have been published, special risk factors are still unknown about the formation of malignancy on the scalp with chronic ulcer. The aim of the article is to explore the risk factors. Seventy-four patients with the chronic ulcer were included in the study. In between, the chronic ulcer transformed into the MU on the scalp (tumor group) in 42 cases, while the chronic ulcer did not transform into the MU on the scalp (tumor-free group) in 32 cases as controlled group. We made a comparative study between the above two groups so as to find which risk factors were critical for cancer development. In tumor group, lymph node dissection was implemented if the lymph node metastasis was found. Artificial dura was used in eight cases when the dura was removed. Seven cases died. Two patients are currently undergoing follow-up. Other cases were without tumor detection from 1 to 7 years. When the comparative study between the above two groups, there is statistical significance about the influential factor: scar adherence to the skull (F = 5.602 P = .018). Scar adherence to the skull may be the most critical risk factor for cancer development for the scalp with chronic ulcer.

Multiple melanoma in a burns scar

It is well known that up to 2% of chronic burn scar lesions can transform into malignant tumours, however, melanoma formation at these sites is extremely rare. This case report describes a burns case, which progressed to four melanomas in a 78-year-old male patient’s little finger, 40 years after the initial incident. The patient underwent 3 mm punch biopsies, then digital amputation of the finger with pathology-proven melanoma. Histopathology investigation demonstrated three melanoma in situ and one invasive melanoma with a Breslow thickness of 1 mm. These findings are rare with few reports of melanoma in burn scars in the literature. This case report highlights the vigilance required from clinicians when performing skin examinations, and the importance of biopsies to newly pigmented lesions.

Tumorigenicity Testing in Athymic Mice of Cultured Human Melanocytes for Transplantation in Engineered Skin Substitutes

Autologous engineered skin substitutes (ESS) have been shown to close excised, full-thickness burns, but are consistently hypopigmented due to depletion of human melanocytes (hM) during culture of keratinocytes. Hypothetically, addition of hM to ESS may restore uniform pigmentation, but may also promote neoplasia and tumor formation. To evaluate this risk, 16 strains of hM were isolated and propagated in selective culture medium, then injected subcutaneously into athymic mice (1 χ 107 hM/animal; n = 6/strain) and followed for 24 weeks. Human melanoma cells (SK-Mel-2, SK-Mel-5) served as positive controls. No detectable tumors formed from hM strains derived from normal skin. In contrast, SK-Mel-2 formed tumors in 50% of mice, and SK-Mel-5 formed tumors in 83% of mice. Histopathology confirmed the tumorigenic anatomy of the controls and the presence of hM that were not tumorigenic in the test groups. These results support the safety of cultured hM for transplantation to restore uniform skin pigmentation in wounds closed with ESS.

Radiation dermatitis, burns, and recall phenomena: Meaningful instances of immunocompromised district

Ionizing and ultraviolet radiations, as well as burns, can selectively damage and immunologically mark the cutaneous area they act on through direct and indirect mechanisms. After the causal event has disappeared, the affected skin district may appear clinically normal, but its immune behavior is often compromised forever. In fact, irradiated or burned skin areas undergo a destabilization of the immune control, which can lead to either a reduction of immunity (as suggested by the facilitated local occurrence of tumors and infections) or an excess of it (as suggested by the possible local onset of disorders with exaggerated immune response). In other words, these areas become typical immunocompromised districts (ICD). Also, in recall phenomena the damaged skin area usually behaves as an ICD with an exaggerated immune response toward a wide range of drugs (especially chemotherapeutic agents) that prove to be harmless on the undamaged skin surface. The occurrence of any skin disorder on an irradiated, photoexposed, or burned skin area can be defined as an isoradiotopic, isophototopic, or isocaumatopic response, respectively; however, the opposite may also occur when elsewhere generalized cutaneous diseases or eruptions selectively spare irradiated, photoexposed, or burned skin sites (isoradiotopic, isophototopic, and isocaumatopic nonresponse, respectively). The pathomechanisms involved in any secondary disorder occurring on irradiated or burned skin areas may be linked to locally decreased or altered lymph flow (with dysfunction of lymph drainage) on the one hand, and to fibrotic throttling or reduction of peptidergic nerve fibers (with dysfunction of neuroimmune signaling) on the other hand, resulting in a significant dysregulation of the local immune response. Future clinical observations and experimental investigations on radiation dermatitis, sunburns, and thermal or chemical skin injuries should shed new light on the mechanisms regulating regional resistance to infectious agents, local oncogenesis, and district propensity to dysimmune reactions.

Do inflammatory pathways drive melanomagenesis?

Inflammatory pathways serve to protect the host and promote tissue healing/repair; however, over-activation or dysregulation can be pathological with unintended consequences including malignant progression. A correlation between inflammation and cancer has been well established, and anti-inflammatory medications have been shown to be chemopreventive in certain malignancies. Data are now becoming available that outline an inflammatory pathway that may have a critical role in melanomagenesis. ATP-regulated membrane channels/receptors P2X7 and PANX1 have been directly implicated in melanoma tumor growth. Among other potential effects, opening of the P2X7/PANX1 channel results in activation of the NALP3 inflammasome, which in turn leads to caspase-1 activation and increased levels of activated IL-1β. Elevated levels of caspase-1 and IL-1β have been correlated with melanoma progression, and inhibitors of the inflammasome, caspase and IL-1β activity have all been shown to inhibit melanoma growth. Among many other potential actions, IL-1β increases cyclooxygenase-2 expression leading to local increases in inflammatory mediators such as prostaglandin E2 (PGE2). Anti-inflammatory medications targeting the end of this pathway have had positive results for certain cancers but overall remain mixed for melanoma. A better understanding of the pathways and appropriate intervention points may help direct future therapies. In this viewpoint, we will review data and attempt to model an inflammatory pathway that may be critical for melanomagenesis and propose future directions for exploration.

[Cutaneous malignancies in occupationally-induced scars]

BACKGROUND

The occurrence of neoplasms in injury scars--as consequence of occupational accidents--may lead to compensation according to the statutory accident insurance regulations. According to newer regulatory attempts in occupational dermatology, certain criteria have to be met before the diagnosis of a neoplasm induced by a scar is accepted and compensation is due.

MATERIAL AND METHODS

Based on a retrospective analysis of 217 dermatological claim files between 2007 and 2009 of the IPA (including 22 follow-ups), medical opinions on neoplasms developing in possible occupational scars were re-evaluated using criteria of the German social accident insurance and the Bamberg medical bulletin, part II (Bamberger Merkblatt, BM II) to see how well they qualified for recognition as an occupational or accident-related disorder.

RESULTS

Three cases were identified where a neoplasm was suspected of having developed in an occupationally-related scar. One of the insured events entitled for compensation. Following the guidelines of the BM II, this case was approved as an occupational disease secondary to injuries with resultant reduction in earning capacity, whereas the others did not meet the requirements.

CONCLUSIONS

Two problems in evaluating malignant tumors in occupational scars are the long latency period and the documentation of a scar. The tumor excision specimen should be histologically re-examined to document the presence of an associated scar.

The effects on human health from stratospheric ozone depletion and its interactions with climate change

Ozone depletion leads to an increase in the ultraviolet-B (UV-B) component (280-315 nm) of solar ultraviolet radiation (UVR) reaching the surface of the Earth with important consequences for human health. Solar UVR has many harmful and some beneficial effects on individuals and, in this review, information mainly published since the previous report in 2003 (F. R. de Gruijl, J. Longstreth, M. Norval, A. P. Cullen, H. Slaper, M. L. Kripke, Y. Takizawa and J. C. van der Leun, Photochem. Photobiol. Sci., 2003, 2, pp. 16-28) is discussed. The eye is exposed directly to sunlight and this can result in acute or long-term damage. Studying how UV-B interacts with the surface and internal structures of the eye has led to a further understanding of the location and pathogenesis of a number of ocular diseases, including pterygium and cataract. The skin is also exposed directly to solar UVR, and the development of skin cancer is the main adverse health outcome of excessive UVR exposure. Skin cancer is the most common form of malignancy amongst fair-skinned people, and its incidence has increased markedly in recent decades. Projections consistently indicate a further doubling in the next ten years. It is recognised that genetic factors in addition to those controlling pigment variation can modulate the response of an individual to UVR. Several of the genetic factors affecting susceptibility to the development of squamous cell carcinoma, basal cell carcinoma and melanoma have been identified. Exposure to solar UVR down-regulates immune responses, in the skin and systemically, by a combination of mechanisms including the generation of particularly potent subsets of T regulatory cells. Such immunosuppression is known to be a crucial factor in the generation of skin cancers. Apart from a detrimental effect on infections caused by some members of the herpesvirus and papillomavirus families, the impact of UV-induced immunosuppression on other microbial diseases and vaccination efficacy is not clear. One important beneficial effect of solar UV-B is its contribution to the cutaneous synthesis of vitamin D, recognised to be a crucial hormone for bone health and for other aspects of general health. There is accumulating evidence that UVR exposure, either directly or via stimulation of vitamin D production, has protective effects on the development of some autoimmune diseases, including multiple sclerosis and type 1 diabetes. Adequate vitamin D may also be protective for the development of several internal cancers and infections. Difficulties associated with balancing the positive effects of vitamin D with the negative effects of too much exposure to solar UV-B are considered. Various strategies that can be adopted by the individual to protect against excessive exposure of the eye or the skin to sunlight are suggested. Finally, possible interactions between ozone depletion and climate warming are outlined briefly, as well as how these might influence human behaviour with regard to sun exposure.

Úlcera de Marjolin: carcinoma sobre cicatriz por quemadura

The term Marjolin's ulcer means the malignant transformation of chronic ulcers, sinus tract and burn scars. The most frequently produced neoplasm is squamous cell carcinoma. The pathogeny is unknown, involving mutations in the Fas gene. Main therapeutic management are consist of prophylactic measures, avoiding repeated traumas and prolonged cure periods. We present the case of a 48-year-old male with squamous cell carcinoma on the old burn scar of legs that evolved favorably after excision.

Squamous Cell Carcinoma Developing on Burn Scar

BACKGROUND

It is estimated that 2% of burn scars undergo malignant transformation. Squamous cell carcinoma (SCC) is the most common type of cancer that develops.

MATERIALS AND METHODS

We report a retrospective study, which consists of 510 patients who have 570 cases of tumors of SCC. We examined SCCs developing on burn scars retrospectively among 570 cases, and we found that 36 cases had SCC developing on burn scars. The records of those 36 cases were analyzed in terms of age, sex, latent period between burn and carcinoma, anatomic localization of the carcinoma, and the presence of metastases. These findings were compared with the SCC group that did not have burn history.

RESULTS

The number of SCC developing on burn scars among the 570 cases was 36 (6.31%), 15 of which were women (41.66%) and 21 were men (58.33%). The average age was 46.77 years. The average latent period between burn and the development of carcinoma was found to be 32.22 years. It should be mentioned that the burn scar carcinoma group was younger. In addition, burn scar carcinoma was more likely to localize on lower extremities and metastasize (P<0.001).

CONCLUSION

Having high aggressive features, the suspicion of development of SCC in burn scar should be kept in mind, so patients with burn scar must be followed periodically.

Perivascular myoma of myopericytoma and myofibromatosis-type arising in a chronic scar

We describe a case of a cutaneous perivascular myoma with features overlapping between the myofibromatosis and the myopericytoma type. The patient is a 58-year-old woman with a painless plaque-like and multinodular lesion in the pretibial dermis and subcutaneous tissue. She had repeated trauma to this site, first in her early youth that left an area of hyperpigmentation, and then again at age 40. The biopsy showed a biphasic pattern with a myofibromatosis-type component composed of spindle cell myoid nodules and more cellular round cell areas. The myopericytoma-like areas appeared to be infiltrating along vessels. These areas contained aggregates of immature-appearing cells arranged concentrically around vascular lumina in a manner reminiscent of pericytes. Immunohistochemical stains showed focal positivity for smooth muscle actin. Immunohistochemical and ultrastructural studies have showed these pericyte-like cells to be of a myoid origin. The reason for the neoplastic proliferation of perivascular myoid cells is presently unknown. The association of trauma and neoplastic transformation of the skin is rare. We report the first case of a cutaneous perivascular myoma arising in a chronic scar.

Cutaneous melanoma arising in a burn scar: two recent cases and a review of the literature

Melanoma arising in a burn scar is extremely uncommon. We report two recent cases, including one patient in whom six distinct primary melanomas arose in the setting of an extensive truncal burn scar. Only 27 patients have been reported previously, and only three previous cases of multiple primary melanomas arising in a burn scar have been described.

Burn scar neoplasms: a literature review and statistical analysis

BACKGROUND

Although squamous cell carcinoma (SCC) is the most common burn scar neoplasm, other neoplasms have also been reported.

OBJECTIVE

To compile the burn scar neoplasm cases in the literature and to analyze their frequency and demographic characteristics.

MATERIALS AND METHODS

Cases were obtained through literature searches.

RESULTS

There were 412 cases gleaned from 146 articles between 1923 and 2004. Seventy-one percent (293) of the tumors were squamous cell carcinoma, 12% (48) were basal cell carcinoma (BCC), 6% (23) were melanoma, 5% (21) were sarcoma, 4% (16) were other neoplasms, 1% (6) were squamo-basal cell carcinoma, and 1% (5) squamous cell-melanoma. The mean age at tumor diagnosis was 50 years, the mean age at the time of burn injury was 20 years, the mean latency interval was 31 years. Only 5% of the reported cases were excised and grafted at the time of injury (p<0.001). BCC occurred at a significantly later age compared to SCC and sarcoma groups (p<0.02) and had a shorter latency period compared to SCC and sarcoma groups (p<0.004) and melanoma (p<0.008). Local recurrence was present in 16% of the cases, while regional lymph node involvement was seen in 22% of the cases and distant metastases was present in 14% of the patients. The mortality rate was 21%.

CONCLUSIONS

Although the main burn scar neoplasm was SCC, other neoplasms contributed to the morbidity and mortality of burn patients. Excision and grafting of deep burns, and close follow-up of non-healing ulcerated burn scars is essential for the prevention and early detection of burn scar neoplasms.