Marjolin's Ulcer Presenting with In-Transit Metastases: A Case Report and Literature Review

Squamous Cell Carcinoma Arising from Chronic Osteomyelitis in the Extremities: Treatment Approach and Oncological Outcomes-A Systematic Review of the Literature

Aims

In chronic osteomyelitis-derived squamous cell carcinoma, what are the demographic and clinical variables, risk factors associated with worse outcomes, and results of treatment modalities used?

Methods

A systematic review was performed using PubMed and EMBASE. Articles were evaluated for inclusion and exclusion criteria, and for quality analysis. PRISMA guidelines were applied. Demographic and clinical data and therapeutic approaches were presented narratively and in descriptive statistics registered at PROSPERO.

Results

Most patients were male (40/49), trauma was the most common etiology (27/36), and about half of all SCC were in the tibia (25/48). Amputation was the main definitive treatment (42/47). Adjuvant treatments were not analyzed. Well-differentiated SCC accounted for 58.3% (21/36) of all tumors. Bone invasion was described in 82.8% (24/29); recurrence, in 7.7% (3/39); and metastasis, in 7.7% (3/39). Recurrence and metastasis occurred more frequently when bone invasion was present (p = 0.578 and p = 0.646, respectively). SCC with lymph node involvement showed a higher tendency to metastasize (p = 0.377). Compared with limb salvage, amputation was associated with a tendency for less recurrence (p = 0.312) and longer survival (p = 0.219).

Conclusions

COM-derived SCC mostly occurs after trauma and is usually located in the tibia. Bone invasion is common, and patients predominantly undergo amputation. This treatment is associated with a trend toward higher survival, compared to limb salvage.

Extraordinarily aggressive cutaneous sarcomatoid squamous cell carcinoma of the face: a case report

Sarcomatoid squamous cell carcinoma (SSCC), a biphasic malignant tumor consisting of atypical squamous epithelial and mesenchymal elements mixed with epithelioid and spindle cells, is a variant of squamous cell carcinoma. Cutaneous SSCC is very rare and aggressive and has a poor prognosis. Here, we report a case of cutaneous SSCC with satellites and in-transit metastases. A 79-year-old woman presented with a protruding mass on the left temporal area sized 1.2×1.0 cm. The punch biopsy report indicated keratoacanthoma or well-differentiated squamous cell carcinoma. The size of the tumor increased to 2.7×2.0 cm after 8 days. An excisional biopsy was performed with a 2 mm safety margin. The tumor was identified as SSCC with a clear resection margin. Reoperation was performed thrice with an increased safety margin of 10 mm; however, the cancer recurred along with satellites and in-transit metastases. Chemoradiotherapy was administered; however, the size of the tumor increased along with satellites and in-transit metastases. The patient expired 162 days after the initial excision. Complete excision and immediate multidisciplinary approach should be combined during the early stages due to the aggressiveness and poor prognosis of cutaneous SSCC with satellites and in-transit metastasis.

Clinical characteristics, treatment, and prognosis of squamous cell carcinoma arising from extremity chronic osteomyelitis: a synthesis analysis of one hundred and seventy six reported cases

PURPOSE

Squamous cell carcinoma (SCC) arising from extremity chronic osteomyelitis (COM) has not been well-understood due to its low prevalence. This study aimed to synthesize the cases recently published to clarify their clinical characteristics, treatment, and prognosis.

METHODS

PubMed, Embase, and Cochrane Library databases were searched for English literature reporting cases diagnosed of SCC originating from extremity COM between January 1, 1990, and September 30, 2019. The National Institutes of Health (NIH) assessment tool was used to evaluate the quality of reports included, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to summarize the quality of available evidence. The data synthesized for analysis were clinical features, treatment strategy, and incidences of local recurrence, metastasis, all-cause, and SCC-related deaths. In addition, potential factors that might have influenced treatment efficacy and prognosis of SCC were also investigated.

RESULTS

Included for this analysis were 60 studies of 176 patients (a male-to-female ratio of 6.7). COM mostly occurred following trauma (73%), the tibia was the most frequent site (61%), and a sinus tract was the most common symptom (61%). The mean duration from COM to SCC was 27 years. Positive rate of pathogen culture was 90%, with 73% being polymicrobial. Limb amputation was performed in 80.5% of the patients. Incidences of local recurrence, metastasis after treatment, all-cause, and SCC-related mortalities were 16.7%, 12%, 31.1%, and 12.6%, respectively. Patients with local lymphadenopathy at diagnosis had significantly higher risks of local recurrence (P = 0.01), SCC-related (P = 0.02), and all-cause deaths (P = 0.01) than those without. Patients with moderately-to-poorly differentiated SCC types had significantly higher risks of local recurrence (P = 0.01) and all-cause death (P = 0.02) than those with a well-differentiated type.

CONCLUSIONS

SCC arising from extremity COM favoured males and the tibia. Although limb amputation was the mainstay of treatment, the overall incidences of local recurrence, metastasis, and SCC-related death exceeded 10%. Patients with local lymphadenopathy at diagnosis of SCC and those with moderately-to-poorly differentiated SCC types should be followed up closely.

TRIAL REGISTRATION

CRD42020154221.

[Diagnostic pitfall: Early arising, multiple and recurrent Marjolin's ulcer. About 8 patients (16 tumors) and literature review]

INTRODUCTION

Marjolin's ulcer (MU) is a large entity representing skin cancers resulting from the transformation of chronic wounds of a heterogeneous nature. Burn scars are the most at risk of degeneration, in particular because there are the sites of important skin tension. Atypical forms are not uncommon. The objective of this study is to present these exceptions which are underestimated.

MATERIALS AND METHODS

All patients with UM in our centre between January 2011 and February 2019 have been included permitting to report the initial pathology, the location, the latency time, the histology and the management carried out.

RESULTS

Eight patients were treated in our center for MU, they developed 16 skin cancers. Fourteen were squamous cell carcinomas (SCC). The shortest latency period was 2 months. The youngest patient was 22 years old when she was diagnosed with MU. Three patients had at least 2 synchronous SCC. One patient had a recurrence after a split-thickness skin grafting on artificial dermis and 2 patients had second locations.

CONCLUSION

Atypic forms are not rare. MU is commonly recurrent, multiple, early arising and may appear in young people. The treatment of chronic wounds cannot be dissociated from the treatment of contractures, otherwise the wound will inevitably reappear.

A spindle cell squamous cell carcinoma on the cheek presenting with in-transit metastases and a satellite lesion

Spindle cell squamous cell carcinoma (SpSCC) is a biphasic tumor composed of squamous cell epithelial and spindle cell mesenchymal components, both of which are malignant. Cutaneous SpSCC can cause diagnostic and therapeutic difficulties because of its rarity, heterogeneity, morphological similarity to other cutaneous spindle cell neoplasms, and uncertain pathogenesis and prognosis, particularly when the squamous cell carcinoma component is minimal or missing. Intransit metastasis and satellite lesion (satellitosis) constitute a spectrum of non-nodal regional metastases. Here the author reports the first known case of cutaneous SpSCC presenting with intransit metastases and a satellite lesion, which were exceptionally aggressive. A 77-year-old female patient presented with a 3× 3× 0.5 cm mass on her right cheek. Despite wide excision and postoperative radiation, the patient resulted in local recurrence and multiple distant metastases within 3 months. If many high-risk factors-particularly satellitosis and in-transit metastases are observed in a tumor with epithelial to mesenchymal transition, then further wide excision and adjuvant chemoradiation should be considered early in the treatment process. A multidisciplinary approach could be the key to cure the most aggressive malignancies of the skin, as in other organs.

Clinical Features and Expression Patterns for Burn Patients Developed Marjolin Ulcer

Marjolin’s ulcer is a type of skin cancer that generated from chronic nonhealing trauma. For years, its pathogenesis mechanisms remain unclear. Regarding this situation, the authors retrospectively analyze the patients admitted to their department from 2005 to 2019 to present several representative cases and examine the expression patterns of survivin and its role in this process. Among these patients, the latent period ranges from 2 to 25 years, with 8.43 years in average. There is no notable relationship between the latent period and age (P = .643 > .05). Therefore, Marjolijn’s ulcer arises from extremities and joints more often compared with other parts (P < .05). The expression ratio of survivin in Marjolin’s ulcer is significantly higher than that in skin ulcer (P < 0.05). And the expression ratio of survivin in patients diagnosed with Marjolin’s ulcer is also correlated with lymphatic metastasis (P < .05). Frequent follow-ups and prompt diagnosis and management are necessary as the prognosis is poor for patients with metastasis. Survivin may be a potential target for future development of target therapy in order to maximize the efficacy and improve the quality of life for patients suffering from Marjolin’s ulcer.

Clinical features and treatment of 140 cases of Marjolin's ulcer at a major burn center in southwest China

Marjolin's ulcer is a type of malignant tumor that occurs in scar tissue. The present study aimed to summarize and analyze the aetiology, clinical characteristics, treatment methods, metastasis and prognosis of this disease. A total of 140 cases of Marjolin's ulcer encountered at the Institute of Burn Research, Southwest Hospital (Chongqing, China) between January 2013 and December 2017 were retrospectively analyzed. Demographic data, clinical characteristics, occurrence of bone invasion and lymph node metastasis, as well as treatment and prognosis were statistically analyzed. Among the 140 patients, the initial injury or primary disease occurred at 1–75 years of age, while Marjolin's ulcer occurred at 15–85 years of age (mean, 53.3±1.2 years). The mean latency period was 28.8±1.7 years. The most common initial injury of the patients was flame burns, followed by skin masses, trauma, skin ulcerations caused by repeated scratching/friction, and scalding. The age at onset of initial injury or disease in patients had a significantly negative correlation with the latency period (P<0.01). The most common lesion locations were the lower limbs (42.1%), followed by the head, face and neck (34.5%). Of the 140 patients, 46 cases (32.9%) had bone invasion, 33 cases (23.6%) had lymph node enlargement and only 5 cases (3.6%) had lymph node metastasis. The skull was the bone that was most susceptible to Marjolin's ulcer invasion. The prevalence of bone invasion in patients with head, face and neck lesions was significantly higher than that in patients with lesions in other locations (P<0.01). The surgical methods applied were skin grafting, local flap repair, amputation and island flap repair. In the 65 cases who underwent follow-up, recurrence mainly occurred within 1 year after surgery. In conclusion, Marjolin's ulcer mainly occurred in males and was a scar carcinoma after a flame burn in most cases. Autologous skin grafting and local skin flap repair were the major repair methods. The peak period of recurrence was within one year after surgery and patients should receive regular follow-ups.

In-Transit Metastasis From Squamous Cell Carcinoma

BACKGROUND

In-transit metastasis from cutaneous squamous cell carcinoma (SCC) is an uncommon form of metastasis through lymphatics and occurs more commonly in immunosuppressed patients.

OBJECTIVE

To identify cases of in-transit SCC and determine patient characteristics, tumor features, management, and prognosis.

METHODS AND MATERIALS

A multicenter case series treated by Australian and New Zealand clinicians.

RESULTS

In 31 patients, median age was 72 years (range 52-99) and 68% were immunocompetent. Tumors occurred on the head and neck in 94% of cases, with 71% of all tumors occurring on the scalp, forehead, or temple. The median time to presentation with in-transit SCC from treatment of the initial tumor was 5 months. Management included surgery (94%), radiotherapy (77%), chemotherapy (10%), and reduction of immunosuppression (3%). Median follow-up was 12 months. Overall survival at 3 and 5 years were 27% and 13%, respectively.

CONCLUSION

In-transit metastases are described in 31 patients, of whom the majority was immunocompetent. The scalp, forehead, and temple were the most common sites. New clinical and histological diagnostic criteria are proposed. Prognosis was poor with 5-year survival of 13%. Recommended management is a combination of surgery and adjuvant radiotherapy. Reduction of any iatrogenic immunosuppression should be considered.