- Email: [email protected]
Synchronous appearance of keratoacanthomas in burn scar and skin graft donor site shortly after injury
Synchronous appearance of keratoacanthomas in burn scar and skin graft donor site shortly after injury Gabriel Tamir, MD,a Sara Morgenstern, MD,b Dan Ben-Amitay, MD,c Eli Okon, MD,b and Daniel J. Hauben, MDa Tel Aviv, Israel Skin malignancies can originate in burn scars (Marjolin’s ulcer). The most common is squamous cell carcinoma, usually appearing years after injury. Split-thickness skin graft donor sites as a source of malignant transformation are far less frequent and demonstrate a shorter interval between surgery and tumor onset. Keratoacanthomas have rarely been reported to arise in such scars. We describe the simultaneous occurrence of keratoacanthomas on a spontaneously healed second-degree burn on the flank and in the scar of a skin graft donor site on the thigh, 4 months after a 40% total body surface area burn. (J Am Acad Dermatol 1999;40:870-1.)
Keratoacanthomas can arise within various cutaneous abnormalities, including burns. 1 This reflects the tendency of thermally injured skin to undergo premalignant and malignant changes, of which squamous and basal cell carcinomas and melanomas predominate.2 Tumors appearing within the donor site of split-thickness skin grafts have been reported less often, among which keratoacanthoma has been documented only twice.3 We describe a patient in whom the simultaneous appearance of 2 keratoacanthomas was noted 4 months after thermal injury. One was located in the region of a spontaneously healed burn scar, and the other in the donor site of a split-thickness skin graft. To our knowledge, this is the first report of such a case. CASE REPORT A 54-year-old policeman, with no previous personal or family history of skin malignancies, sustained a 40% total body surface area burn from a gas explosion. Examination revealed second-degree burns on the face and neck, parts of the chest, abdomen, lower back and This supplement is made possible through an educational grant from Ortho Dermatological to the American Academy of Dermatology. From the Departments of Plastic and Reconstructive Surgery,a the Pathology Institute,b and Dermatology,c Rabin Medical Center (Beilinson Campus), Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University. Reprint requests to: G. Tamir, MD, Department of Plastic and Reconstructive Surgery, Rabin Medical Center (Beilinson Campus), Petah Tiqva 49100 Israel. E-mail: [email protected] Copyright © 1999 by the American Academy of Dermatology, Inc. 0190-9622/99/$8.00 + 0 16/4/94419
870
Fig 1. Keratoacanthoma in second-degree spontaneously healed burn on left flank region. Note nearby scar.
flanks, and third-degree burns on the arms and forearms. On the fourth day after injury, the burns from both arms were excised, and replaced by split-thickness skin grafts from the thighs. The donor site was treated locally with petrolatum, and there were no signs of infection. Four months after the accident, the patient noted the simultaneous rapid growth of 2 lesions in different sites: one on the left posterior flank, in the region that had sustained a second-degree burn, and the other on the right thigh, at the margin of the healed scar of the skin graft donor site (Figs 1 and 2). Examination revealed 2 similar raised and keratinized 3-cm tumors, which were surgically excised. Both specimens revealed an irregular, keratin-filled crater, with the epidermis extending in a liplike fashion over its sides (Fig 3). The base of the crater showed epidermal proliferation with little or no atypia and areas of marked keratinization with a glassy appearance. Individual cell keratinization and horn pearls were also
Journal of the American Academy of Dermatology Volume 40, Number 2, Part 2
Fig 2. Keratoacanthoma in rectangular split-thickness skin graft donor site on right thigh. Tumor rests within borders of harvested area. noted. A chronic inflammatory infiltrate composed of lymphocytes and scattered eosinophils was present at the base of the lesions. The superficial dermis showed fibrosis and a mild lymphocytic infiltrate around the blood vessels. A diagnosis of keratoacanthoma was made. Eighteen months after surgery, there was no sign of recurrence or new lesions. DISCUSSION
The term Marjolin’s ulcer encompasses a range of skin malignancies arising from a localized degenerative process such as a burn scar, venous stasis ulcer, osteomyelitis, sinus tract, or hidradenitis suppurativa.4 It reflects an instability in a chronically irritated site that enables the formation of a neoplasm, usually squamous cell carcinoma (SCC), although other tumors such as basal cell carcinoma, malignant melanoma, and sarcoma, have also been reported.5 The vast majority appear years after injury,2 but, rarely, the rapid appearance of tumors (within months) has been documented. One patient developed multiple keratoacanthomas 3 weeks after a burn,1 and in the other reports keratoacanthomas arose within 1 year6 and 2 weeks7 after thermal injury. All these cases were multifocal, which by itself is rare.8 Split-thickness skin graft donor sites may also be a source of neoplastic transformation.9-11 Again, the predominant lesion is SCC, although surprisingly, the interval from harvesting to tumor onset is significantly shorter (usually within weeks) than those for traditional Marjolin’s lesions. Keratoacanthoma has been reported to arise in a donor site only twice, 6 and 3 weeks after graft surgery.3,12
Tamir et al 871
Fig 3. Specimen. Crater-like architecture filled with keratin plug and surrounded by proliferating squamous epithelium. (Hematoxylin-eosin stain; original magnification, ×6.)
The tendency of keratoacanthoma to originate within areas of injury or in association with previous skin diseases has been established,13 and the rapid onset and multifocality seen in our patient support this. The synchronous occurrence of the keratoacanthomas in the 2 injured sites may be a sign of reduced immune surveillance in these locations. REFERENCES 1. Hendricks WM. Sudden appearance of multiple keratoacanthomas three weeks after thermal burn. Cutis 1991; 47:410-2. 2. Bartle EJ, Sun JH, Wang XW, Schneider BK. Cancers arising from burn scars: a literature review and report of twentyone cases. J Burn Care Rehabil 1990;11:46-9. 3. Hamilton SA, Dickson WA, O’Brien CJ. Keratoacanthoma developing in a split skin graft donor site. Br J Plast Surg 1997;50:560-1. 4. Fleming MD, Hunt JL, Purdue GF, et al. Marjolin’s ulcer: a review and reevaluation of a difficult problem. J Burn Care Rehabil 1990;11:460-9. 5. Iregbulem LM. Post-burn squamous cell cancers in Nigerians. Br J Plast Surg 1987;40:488-93. 6. Ereaux LP, Schopflocher P, Fornier CJ. Keratoacanthoma. Arch Dermatol 1955;71:73-83 . 7. Odom RB, Goette DK. Treatment of keratoacanthomas with intralesional fluorouracil. Arch Dermatol 1978;114: 1779-83 . 8. Ahmed AR. Multiple keratoacanthoma. Int J Dermatol 1980;19:496-9. 9. Neilson D, Emerson DJM, Dunn L. Squamous cell carcinoma of skin developing in a skin graft donor site. Br J Plast Surg 1988;41:417-9. 10. Hammond JS, Thomsen S, Ward G. Scar carcinoma arising in a skin graft donor site. J Trauma 1987;27:681-3. 11. Abadir R, Zurowski S. Case report: squamous cell carcinoma of the skin in both palms, axillary node, donor skin graft site and both soles—associated hyperkeratosis and porokeratosis. Br J Radiol 1994;67:507-10. 12. Soto-de-Delas J, Leache A, Vasquez-Doval J, et al. Keratoacanthoma over the donor site of a laminar skin graft. Med Cutan Iberio Latin Am 1989;17:225-8. 13. Schwartz RA. Keratoacanthoma. J Am Acad Dermatol 1994;30:1-19.
Keratoacanthomas can arise within various cutaneous abnormalities, including burns. 1 This reflects the tendency of thermally injured skin to undergo premalignant and malignant changes, of which squamous and basal cell carcinomas and melanomas predominate.2 Tumors appearing within the donor site of split-thickness skin grafts have been reported less often, among which keratoacanthoma has been documented only twice.3 We describe a patient in whom the simultaneous appearance of 2 keratoacanthomas was noted 4 months after thermal injury. One was located in the region of a spontaneously healed burn scar, and the other in the donor site of a split-thickness skin graft. To our knowledge, this is the first report of such a case. CASE REPORT A 54-year-old policeman, with no previous personal or family history of skin malignancies, sustained a 40% total body surface area burn from a gas explosion. Examination revealed second-degree burns on the face and neck, parts of the chest, abdomen, lower back and This supplement is made possible through an educational grant from Ortho Dermatological to the American Academy of Dermatology. From the Departments of Plastic and Reconstructive Surgery,a the Pathology Institute,b and Dermatology,c Rabin Medical Center (Beilinson Campus), Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University. Reprint requests to: G. Tamir, MD, Department of Plastic and Reconstructive Surgery, Rabin Medical Center (Beilinson Campus), Petah Tiqva 49100 Israel. E-mail: [email protected] Copyright © 1999 by the American Academy of Dermatology, Inc. 0190-9622/99/$8.00 + 0 16/4/94419
870
Fig 1. Keratoacanthoma in second-degree spontaneously healed burn on left flank region. Note nearby scar.
flanks, and third-degree burns on the arms and forearms. On the fourth day after injury, the burns from both arms were excised, and replaced by split-thickness skin grafts from the thighs. The donor site was treated locally with petrolatum, and there were no signs of infection. Four months after the accident, the patient noted the simultaneous rapid growth of 2 lesions in different sites: one on the left posterior flank, in the region that had sustained a second-degree burn, and the other on the right thigh, at the margin of the healed scar of the skin graft donor site (Figs 1 and 2). Examination revealed 2 similar raised and keratinized 3-cm tumors, which were surgically excised. Both specimens revealed an irregular, keratin-filled crater, with the epidermis extending in a liplike fashion over its sides (Fig 3). The base of the crater showed epidermal proliferation with little or no atypia and areas of marked keratinization with a glassy appearance. Individual cell keratinization and horn pearls were also
Journal of the American Academy of Dermatology Volume 40, Number 2, Part 2
Fig 2. Keratoacanthoma in rectangular split-thickness skin graft donor site on right thigh. Tumor rests within borders of harvested area. noted. A chronic inflammatory infiltrate composed of lymphocytes and scattered eosinophils was present at the base of the lesions. The superficial dermis showed fibrosis and a mild lymphocytic infiltrate around the blood vessels. A diagnosis of keratoacanthoma was made. Eighteen months after surgery, there was no sign of recurrence or new lesions. DISCUSSION
The term Marjolin’s ulcer encompasses a range of skin malignancies arising from a localized degenerative process such as a burn scar, venous stasis ulcer, osteomyelitis, sinus tract, or hidradenitis suppurativa.4 It reflects an instability in a chronically irritated site that enables the formation of a neoplasm, usually squamous cell carcinoma (SCC), although other tumors such as basal cell carcinoma, malignant melanoma, and sarcoma, have also been reported.5 The vast majority appear years after injury,2 but, rarely, the rapid appearance of tumors (within months) has been documented. One patient developed multiple keratoacanthomas 3 weeks after a burn,1 and in the other reports keratoacanthomas arose within 1 year6 and 2 weeks7 after thermal injury. All these cases were multifocal, which by itself is rare.8 Split-thickness skin graft donor sites may also be a source of neoplastic transformation.9-11 Again, the predominant lesion is SCC, although surprisingly, the interval from harvesting to tumor onset is significantly shorter (usually within weeks) than those for traditional Marjolin’s lesions. Keratoacanthoma has been reported to arise in a donor site only twice, 6 and 3 weeks after graft surgery.3,12
Tamir et al 871
Fig 3. Specimen. Crater-like architecture filled with keratin plug and surrounded by proliferating squamous epithelium. (Hematoxylin-eosin stain; original magnification, ×6.)
The tendency of keratoacanthoma to originate within areas of injury or in association with previous skin diseases has been established,13 and the rapid onset and multifocality seen in our patient support this. The synchronous occurrence of the keratoacanthomas in the 2 injured sites may be a sign of reduced immune surveillance in these locations. REFERENCES 1. Hendricks WM. Sudden appearance of multiple keratoacanthomas three weeks after thermal burn. Cutis 1991; 47:410-2. 2. Bartle EJ, Sun JH, Wang XW, Schneider BK. Cancers arising from burn scars: a literature review and report of twentyone cases. J Burn Care Rehabil 1990;11:46-9. 3. Hamilton SA, Dickson WA, O’Brien CJ. Keratoacanthoma developing in a split skin graft donor site. Br J Plast Surg 1997;50:560-1. 4. Fleming MD, Hunt JL, Purdue GF, et al. Marjolin’s ulcer: a review and reevaluation of a difficult problem. J Burn Care Rehabil 1990;11:460-9. 5. Iregbulem LM. Post-burn squamous cell cancers in Nigerians. Br J Plast Surg 1987;40:488-93. 6. Ereaux LP, Schopflocher P, Fornier CJ. Keratoacanthoma. Arch Dermatol 1955;71:73-83 . 7. Odom RB, Goette DK. Treatment of keratoacanthomas with intralesional fluorouracil. Arch Dermatol 1978;114: 1779-83 . 8. Ahmed AR. Multiple keratoacanthoma. Int J Dermatol 1980;19:496-9. 9. Neilson D, Emerson DJM, Dunn L. Squamous cell carcinoma of skin developing in a skin graft donor site. Br J Plast Surg 1988;41:417-9. 10. Hammond JS, Thomsen S, Ward G. Scar carcinoma arising in a skin graft donor site. J Trauma 1987;27:681-3. 11. Abadir R, Zurowski S. Case report: squamous cell carcinoma of the skin in both palms, axillary node, donor skin graft site and both soles—associated hyperkeratosis and porokeratosis. Br J Radiol 1994;67:507-10. 12. Soto-de-Delas J, Leache A, Vasquez-Doval J, et al. Keratoacanthoma over the donor site of a laminar skin graft. Med Cutan Iberio Latin Am 1989;17:225-8. 13. Schwartz RA. Keratoacanthoma. J Am Acad Dermatol 1994;30:1-19.