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Malignant Melanoma in a Burn Scar

Orlet, Hermann K. MD; Still, Joseph MD; Law, Edward MD; Gertler, Charles PA-C

Case Reports
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Cancers of various sorts are occasionally encountered in burn scars. These lesions are usually squamous cell carcinomas, and the burn scars are usually old. Very rarely, malignant melanoma is encountered. An 87-year-old nursing home patient who had been burned by a lightening strike at age 16 was evaluated. She had sustained a wound covering 2% or 3% of her body surface involving her neck and the upper portion of her anterior trunk that had required several grafts. A lesion was noted over the suprasternal notch approximately 3 months before admission. The biopsy was reported as malignant melanoma. She was subsequently treated by wide reexcision with an associated Z-plasty for neck release. Because of the patient’s age and the presence of four areas of regional lymph nodes nearby into which metastasis might spread, no lymph node dissections were carried out. The specimen from the reexcision was reported as squamous cell carcinoma in situ, melanoma in situ, and multinucleated giant cell reaction, acute and chronic infiltrates. The wound margins were clear.

From The Joseph M. Still Burn Center, Augusta, GA.

Received Jul 3, 2000, and

in revised form Aug 11, 2000.

Accepted for publication Aug 11, 2000.

Address correspondence and reprint requests to Dr Law, Physicians’ Multispecialty Group, PC, 1220 George C. Wilson Drive, Augusta, GA 30909.

Carcinomas are occasionally encountered in old scars, including burn scars, usually in wounds that have never healed. Most such cancers are squamous cell carcinomas and are referred to as Marjolin’s ulcer. Occasional cases of malignant melanoma in burn scars are reported. We report one such case in an 87-year-old nursing home patient.

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Patient Report

An 87-year-old female nursing home patient sustained a burn injury when she was struck by lightning at age 16. The wound had undergone grafting on several occasions at the time and had remained well healed subsequently. Roughly 3 months before admission, a dark skin lesion was noted over the suprasternal notch. The lesion was removed. It was described grossly as a raised, keratotic black lesion measuring 1 × 0.8 × 0.6 cm. The microscopic sections were reported as showing “a proliferation of atypical melanocytes individually and in nests and cords within the dermis and extending to higher levels of the epidermis. The individual melanocytes are large with prominent nucleoli and some multinucleated cells. There is variable pigmentation. A patchy chronic infiltrate is present at base of the expansile lesion formed by the melanocytes. Focally the inflammatory infiltrate is lost and large atypical melanocytes infiltrate the dermis as individual cells.” The excisional biopsy reported malignant melanoma; Clarks level IV; and Breslows depth, 1.9 mm (Fig). After this report was received, a wide excision of the area was carried out with skin grafting, and a Z-plasty designed to release a neck contracture in the area was also performed. No lymph node dissections were carried out. The final pathology report was melanoma in situ, squamous cell carcinoma in situ, multinucleated giant cell reaction, and acute and chronic infiltrates. All margins were negative for malignancy. The wound healed uneventfully.

Figure

Figure

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Discussion

In the literature, squamous cell carcinoma is the lesion encountered most commonly in old burn scars. 1–5 Many of these lesions have never healed. 1 The original injury is typically reported as taking place years before the diagnosis of cancer, with the mean time from injury to diagnosis of cancer ranging from 23 to 37 years. 1,3–5 Malignant melanoma is uncommon in burn scars but has been reported previously. 5–9 Green and colleagues 10 reported a correlation between radiation (multiple sunburns) during the patient’s lifetime and later development of malignant melanoma. After controlling for other risk factors, they felt that there was an important dose-response relationship, with the relative risk associated with exposure to two to five sunburns during the patient’s lifetime as 1.5 and an incidence of 2.4 associated with six or more episodes of severe sunburn.

Alconchel and coworkers 6 reported four cases retrieved from a review of the literature. They also add a case of malignant melanoma in a burn scar with associated squamous cell carcinoma and malignant fibrous histiocytoma. Lee and associates 8 reported a neurotrophic melanoma in a stable burn scar. Akiyana and colleagues 9 reported malignant melanoma together with squamous cell carcinoma in one tumor in a burn scar, somewhat similar to our patient. This association of lesions appears to be quite uncommon. Fleming and coworkers 5 report six cases of burn scar-related cancers: five squamous cell lesions and one melanoma. In our patient the decision to treat by wide excision was based on a biopsy diagnosis of malignant melanoma. Node dissection was considered, but because of the location of the lesion with potential for multiple sites of lymphatic drainage to both sides of the neck and both axillae, coupled with the extreme age of the patient, this option was rejected. The risk of the occasional occurrence of lesions of this type in patients with old burn scars should be recognized.

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References

1. Edwards M, Hirsch R, Broadwater J, et al. Squamous cell carcinoma arising in previously burned or irradiated skin. Arch Surg 1989; 124: 115–117
2. Barr L, Menard J. Marjolin’s ulcer. The LSU experience. Cancer 1983: 52: 173–175
3. Stromberg B, Keiter J, Wray R, et al. Scar carcinoma. Prognosis and treatment. South Med J 1977; 70: 821–822
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6. Alconchel M, Olivares C, Alvarez R. Squamous cell carcinoma, malignant melanoma, malignant fibrous histiocytoma arising in burn scars. Br J Dermatol 1997; 137: 793–798
7. Nancarrow J. Malignant melanoma arising in an unstable burn scar. Br J Plast Surg 1979; 32: 135
8. Lee J, Kapadia S, Musgrave R, et al. Neurotropic malignant melanoma occurring in a stable burn scar. J Cutan Pathol 1992; 19: 145–150
9. Akiyama M, Inamoto N, Nakamura K. Malignant melanoma and squamous cell carcinoma forming one tumor in a burn scar. Dermatology 1997; 194: 157–161
10. Green A, Iskind Z, Bain C, et al. Sunburn and malignant melanoma. Br J Cancer 1985; 51: 393–397
© 2001 Lippincott Williams & Wilkins, Inc.