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Spindle Cell Melanoma Arising from Decades-Old Burn Scar

Sheff, Jordan S. D.P.M.; Pane, Thomas A. M.D.

Plastic and Reconstructive Surgery: November 2009 - Volume 124 - Issue 5 - p 274e-275e
doi: 10.1097/PRS.0b013e3181b98e1a
Viewpoints

Newport Family Foot Care; Newport, R.I. (Sheff)

Private practice; Jupiter, Fla. (Pane)

Correspondence to Dr. Pane; 641 University Boulevard, Suite 103; Jupiter, Fla. 33458; tapane@yahoo.com

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Sir:

A 55-year-old man presented for evaluation of a painless mass of his left lateral heel. He related a history of spilling scalding grease on this site nearly 30 years previously. After the site had healed, he had been left with a small pink lesion, which had recently grown after having been stable for 30 years.

Physical examination included an intact neurovascular examination. At the lateral aspect of his left heel, a 4 × 4-cm, round, raised, wide-based, smooth lesion was noted (Fig. 1). It was reddish blue, with thinned skin. It was nontender and soft, yet not particularly mobile. Nonpulsatile waveforms on Doppler examination were suggestive for a vascular malformation. Radiographs of the foot were unremarkable and a superficial vascular malformation was reported on magnetic resonance angiography (Fig. 2).

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

The mass was excised. The lesion appeared well encapsulated and was removed en toto. The skin overlying the lesion appeared to be normal.

Histologic examination revealed a spindle cell melanoma. Because the overlying skin was spared during excision, the lesion could not be staged, although the mass had a thickness of over 1 cm.

The patient was referred to a surgical oncologist and underwent wide local excision along with sentinel node biopsy. The wound was covered with a split-thickness skin graft. The margins were clear in the second procedure, as were his sentinel node biopsy specimens. Results of a metastatic workup including computed tomography and magnetic resonance imaging were negative. He has regular oncology follow-up and remains free of disease, with no limitations in his activities.

Nearly 2 percent of chronic burn scars can transform into malignant lesions years after the burn, most commonly squamous cell and basal cell carcinomas and rarely malignant melanoma.1–3 Carcinomas arising in burns are rare and are also known as Marjolin ulcers,3 in reference to the Parisian surgeon Jean-Nicolas Marjolin who, in 1828, described trauma- and burn-induced skin lesions. Interestingly enough, Marjolin himself had never correlated the progression of a burn ulcer to carcinoma.

The cause of carcinomas arising from burn scars is unknown; however, thermal injury is thought to be the primary cause.4 Others have theorized that the local environment at the periphery of the burn scar is not accessible to the body's natural immunosurveillance.5 Supporters of this theory cite that the dense fibrous tissue in addition to the altered lymphatics at the burn site do not allow the tumor's antigens to reach the regional lymph nodes and thus the body's immunologic system does not recognize the carcinoma, allowing it to grow.

Early intervention in burns can assist in preventing burn scar carcinoma. A combination of wound débridement and coverage with biomaterial and antimicrobials when needed can prevent malignant transformation of the wound. Treatment of carcinomas arising within a burn scar consists of wide local excision with graft coverage along with node dissection.

Jordan S. Sheff, D.P.M.

Newport Family Foot Care

Newport, R.I.

Thomas A. Pane, M.D.

Private practice

Jupiter, Fla.

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REFERENCES

1.Akiyama M, Inamoto N, Nakamura K. Malignant melanoma and squamous cell carcinoma forming one tumor on a burn scar. Dermatology 1997;194:157–161.
2.Kikuchia H, Nishida T, Kurokawa M, Setoyama M, Kisanuki A. Three cases of malignant melanoma arising on burn scars. J Dermatol. 2003;30:617–624.
3.Steffen C. The man behind the eponym: Jean-Nicholas Marjolin. Am J Dermatopathol. 1984;6:163–165.
4.Treves N, Pack GT. The development of cancer in burn scars: An analysis and report of thirty four cases. Surg Gynecol Obstet. 1930;51:749–782.
5.Futrell JW, Myers GH Jr. The burn scar as an immunologically deprived site. Surg Forum 1972;23:129–131.
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