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Periocular basal cell carcinoma arising in a site of previous trauma
CASE REPORTS
Periocular basal cell carcinoma arising in a site of previous trauma Kayvan Keyhani,*‡ MD, MPH; Michael Ashenhurst,* MD, FRCSC; Allan Oryschak,† MD, FRCPC ABSTRACT • RÉSUMÉ
Case report: We report an incidence of basal cell carcinoma of the lower lid arising in an area of trauma 68 years after the initial injury. Comments: Because patients may disregard the appearance of a wound in the setting of former trauma, medical practitioners need increased suspicion and surveillance of chronic nonhealing wounds. Observation : Nous faisons état d’un carcinome basocellulaire de la paupière inférieure qui s’est formé dans un secteur traumatisé, 68 ans après la blessure initiale. Commentaires : Comme le patient peut ne pas s’occuper de l’apparence d’une blessure dans le site d’un ancien traumatisme, les médecins doivent davantage faire attention aux blessures chroniques qui ne guérissent pas et les surveiller.
A
lthough cutaneous malignancies arising from sites of trauma, scars, or chronic ulcers are an unusual phenomenon, wounds secondary to burns, trauma, and radiotherapy are at risk for malignant degeneration. A malignancy can be difficult to distinguish from a chronic wound or scar and thus may be overlooked. Basal cell carcinoma, squamous cell carcinoma, and cutaneous meningioma have all been reported to occur at the site of cutaneous wounds secondary to trauma, surgery, or other types of cutaneous therapy.1–12 We report an incidence of basal cell carcinoma arising in an area of trauma 68 years after the initial injury. Moreover, because of the history of trauma at the site of the cancer, the patient delayed seeking medical attention for several years.
she had noticed increasing amounts of purulent discharge from the area around the retained foreign body. The patient was convinced that the lesion was a retained piece of glass because the lesion had been there since the accident more than 68 years ago. On examination, a nodular lesion was noted on the left lower lid that was clinically suspicious for basal cell carcinoma. Surgical excision of the lesion revealed multiple retained glass shards. The specimen was sent for histopathologic analysis and was revealed to be an infiltrating basal cell carcinoma, morphea type, with margins clear of malignancy (Fig. 2). She has had no evidence of recurrence or metastasis in 20 months of follow-up. COMMENTS
CASE
REPORT
An 86-year-old woman presented to our office desiring removal of a retained foreign body in her left lower lid (Fig. 1). The patient had sustained an injury as a teenager in her high school chemistry class that involved exploding glass and had resulted in glass foreign bodies retained in her left lower lid. Over the past several years,
Malignant degeneration of a wound or scar has been observed and described by various authors. In 1828, Jean-Nicholas Marjolin provided a classic description of the phenomenon, which was termed a “Marjolin’s ulcer.”1 Large retrospective reviews have shown that the
From *the Department of Surgery (Ophthalmology), Calgary General Hospital, University of Calgary, Calgary, Alta., and †the Department of Pathology and Lab Medicine, Rockyview Hospital, Calgary, Alta. ‡Dr.
Keyhani is currently with the New York Eye and Ear Infirmary.
Originally received May 26, 2006 Accepted for publication Nov. 17, 2006 Correspondence to: Michael Ashenhurst, MD, 933 17th Ave. SW, Ste. 344, Calgary AB T2T 5R6; [email protected] This article has been peer-reviewed. Cet article a été évalué par les pairs. Can J Ophthalmol 2007;42:467–8 doi: 10.3129/can.j.ophthalmol.i07-058
Carcinoma at site of previous trauma—Keyhani et al
Fig. 1—Appearance at presentation. Indurated erythematous area over left lower lid and lateral canthal area corresponding to patient’s report of old trauma.
467
Carcinoma at site of previous trauma—Keyhani et al
malignant degeneration of wounds or scars, while unusual, is not rare. Squamous cell carcinoma is the most common tumour, and it may occur up to 20–40 years after the initial injury.2 Some neoplasms are termed “acute wound cancers” because they arise within 3 to 12 months.3 One study found that 21 (1.92%) of 1091 squamous cell carcinomas and 7 (0.51%) of 1374 basal cell carcinomas originated in old scars.4 Basal cell carcinomas have been reported to arise from various sites of wounds and trauma, including chronic stasis ulcer, varicella scar, tattoos, dog bite, hair transplantation site, vaccination sites, colostomy sites, and electrical burns.1,5 Morphea-like basal cell carcinomas are the most common type of basal cell carcinoma arising from trauma.7 The mechanism of this malignant degeneration is unclear, but several theories have been put forth. One author has postulated that atrophy and decreased vascularity in scar tissue adnexa and surrounding epidermis may make the tissue more sensitive to the effects of sunlight.8 Scars caused by healing of damaged tissue are poorly nourished and may not be able to tolerate repeated mutagenic damage, such as that caused by overexposure to sunlight. Others have suggested that chronic irritation of the damaged cutaneous tissue, with attempted repair
Fig. 2—Photomicrograph. A: Section of skin from the eyelid showing neoplastic basaloid cells invading the dermis from the basal zone of the epidermis (hematoxylin–eosin; original magnification ×100). B: Cords and strands of neoplastic basaloid cells invading a markedly desmoplastic stroma and producing the morphea-like appearance (HE; original magnification ×200).
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CAN J OPHTHALMOL—VOL. 42, NO. 3, 2007
and repeated damage, may be a mechanism for malignant degeneration.9 In addition, damaged tissues release toxins that can lead to the mutation of cells. A chronic nonhealing wound exposed to these toxins for an extended time could be more susceptible to malignant degeneration.10 Finally, the implantation of epidermal cells into the dermis after trauma may cause a foreign body reaction within the dermis that alters the normal function of the tissue, including normal reparative processes, and increases susceptibility to future damage.9–11 In this patient, it is possible that the chronic irritation in the dermis secondary to the retained glass shards resulted in the malignant degeneration of the wound. The patient delayed seeking medical attention for years because she related the appearance of the wound to the original trauma. This delay may have contributed to the large size of the basal cell carcinoma of her lid and the resulting morbidity after reconstructive surgery. Patients may often disregard the appearance of a chronic wound in the setting of trauma, and this case reflects the need for increased suspicion and surveillance of chronic nonhealing wounds by the medical practitioner. REFERENCES 1. Lambert WC, Kasznica J, Chung HR, Moore D. Metastasizing basal cell carcinoma developing in a gunshot wound in a black man. J Surg Oncol 1984;27:97–105. 2. Novick M, Gard DA, Hardy SB, Spira M. Burn scar carcinoma: a review and analysis of 46 cases. J Trauma 1977;17:809–17. 3. Stilwell JH, Sclare G. Malignancy following a single injury to the skin. Br J Plastic Surg 1980;33:74–6. 4. Treves N, Pack GT. The development of cancer in burn scars: an analysis and report of thirty-four cases. Surg Gynecol Obstet 1930;51:749–82. 5. Camacho FM, Mazuecos J, Rodriguez-Adrados F. Basal cell carcinoma arising in an electrical burn scar secondary to transthoracic cardioversion. Dermatol Surg 1999;25:151. 6. Trent JT, Kirsner RS. Wounds and malignancy. Adv Skin Wound Care 2003;16:31–4. 7. Ozyazgan I, Kontas O. Previous injuries or scars as risk factors for the development of basal cell carcinoma. Scand J Plast Reconstr Surg Hand Surg 2004;38:11–5. 8. Connolly JG. Basal cell carcinoma occurring in burn scars. Can Med Assoc J 1960;83:1433–4. 9. Hill BB, Sloan DA, Lee EY. Marjolin’s ulcer of the foot caused by nonburn trauma. South Med J 1996;89:707–10. 10. Fleming MD, Hunt JL, Purdue GF, Sandstad J. Marjolin’s ulcer: a review and reevaluation of a difficult problem. J Burn Care Rehabil 1990;11:460–9. 11. Arons MS, Rodin AE, Lynch JB, Lewis SR, Blocker TG Jr. Scar tissue carcinoma. Part II. An experimental study with special reference to burn scar carcinoma. Ann Surg 1966;163:445–60. 12. Borggreven PA, de Graaf FH, van der Valk P, Leemans CR. Post-traumatic cutaneous meningioma. J Laryngol Otol 2004;118:228–30. Key words: cutaneous malignancy, scar, chronic
Periocular basal cell carcinoma arising in a site of previous trauma Kayvan Keyhani,*‡ MD, MPH; Michael Ashenhurst,* MD, FRCSC; Allan Oryschak,† MD, FRCPC ABSTRACT • RÉSUMÉ
Case report: We report an incidence of basal cell carcinoma of the lower lid arising in an area of trauma 68 years after the initial injury. Comments: Because patients may disregard the appearance of a wound in the setting of former trauma, medical practitioners need increased suspicion and surveillance of chronic nonhealing wounds. Observation : Nous faisons état d’un carcinome basocellulaire de la paupière inférieure qui s’est formé dans un secteur traumatisé, 68 ans après la blessure initiale. Commentaires : Comme le patient peut ne pas s’occuper de l’apparence d’une blessure dans le site d’un ancien traumatisme, les médecins doivent davantage faire attention aux blessures chroniques qui ne guérissent pas et les surveiller.
A
lthough cutaneous malignancies arising from sites of trauma, scars, or chronic ulcers are an unusual phenomenon, wounds secondary to burns, trauma, and radiotherapy are at risk for malignant degeneration. A malignancy can be difficult to distinguish from a chronic wound or scar and thus may be overlooked. Basal cell carcinoma, squamous cell carcinoma, and cutaneous meningioma have all been reported to occur at the site of cutaneous wounds secondary to trauma, surgery, or other types of cutaneous therapy.1–12 We report an incidence of basal cell carcinoma arising in an area of trauma 68 years after the initial injury. Moreover, because of the history of trauma at the site of the cancer, the patient delayed seeking medical attention for several years.
she had noticed increasing amounts of purulent discharge from the area around the retained foreign body. The patient was convinced that the lesion was a retained piece of glass because the lesion had been there since the accident more than 68 years ago. On examination, a nodular lesion was noted on the left lower lid that was clinically suspicious for basal cell carcinoma. Surgical excision of the lesion revealed multiple retained glass shards. The specimen was sent for histopathologic analysis and was revealed to be an infiltrating basal cell carcinoma, morphea type, with margins clear of malignancy (Fig. 2). She has had no evidence of recurrence or metastasis in 20 months of follow-up. COMMENTS
CASE
REPORT
An 86-year-old woman presented to our office desiring removal of a retained foreign body in her left lower lid (Fig. 1). The patient had sustained an injury as a teenager in her high school chemistry class that involved exploding glass and had resulted in glass foreign bodies retained in her left lower lid. Over the past several years,
Malignant degeneration of a wound or scar has been observed and described by various authors. In 1828, Jean-Nicholas Marjolin provided a classic description of the phenomenon, which was termed a “Marjolin’s ulcer.”1 Large retrospective reviews have shown that the
From *the Department of Surgery (Ophthalmology), Calgary General Hospital, University of Calgary, Calgary, Alta., and †the Department of Pathology and Lab Medicine, Rockyview Hospital, Calgary, Alta. ‡Dr.
Keyhani is currently with the New York Eye and Ear Infirmary.
Originally received May 26, 2006 Accepted for publication Nov. 17, 2006 Correspondence to: Michael Ashenhurst, MD, 933 17th Ave. SW, Ste. 344, Calgary AB T2T 5R6; [email protected] This article has been peer-reviewed. Cet article a été évalué par les pairs. Can J Ophthalmol 2007;42:467–8 doi: 10.3129/can.j.ophthalmol.i07-058
Carcinoma at site of previous trauma—Keyhani et al
Fig. 1—Appearance at presentation. Indurated erythematous area over left lower lid and lateral canthal area corresponding to patient’s report of old trauma.
467
Carcinoma at site of previous trauma—Keyhani et al
malignant degeneration of wounds or scars, while unusual, is not rare. Squamous cell carcinoma is the most common tumour, and it may occur up to 20–40 years after the initial injury.2 Some neoplasms are termed “acute wound cancers” because they arise within 3 to 12 months.3 One study found that 21 (1.92%) of 1091 squamous cell carcinomas and 7 (0.51%) of 1374 basal cell carcinomas originated in old scars.4 Basal cell carcinomas have been reported to arise from various sites of wounds and trauma, including chronic stasis ulcer, varicella scar, tattoos, dog bite, hair transplantation site, vaccination sites, colostomy sites, and electrical burns.1,5 Morphea-like basal cell carcinomas are the most common type of basal cell carcinoma arising from trauma.7 The mechanism of this malignant degeneration is unclear, but several theories have been put forth. One author has postulated that atrophy and decreased vascularity in scar tissue adnexa and surrounding epidermis may make the tissue more sensitive to the effects of sunlight.8 Scars caused by healing of damaged tissue are poorly nourished and may not be able to tolerate repeated mutagenic damage, such as that caused by overexposure to sunlight. Others have suggested that chronic irritation of the damaged cutaneous tissue, with attempted repair
Fig. 2—Photomicrograph. A: Section of skin from the eyelid showing neoplastic basaloid cells invading the dermis from the basal zone of the epidermis (hematoxylin–eosin; original magnification ×100). B: Cords and strands of neoplastic basaloid cells invading a markedly desmoplastic stroma and producing the morphea-like appearance (HE; original magnification ×200).
468
CAN J OPHTHALMOL—VOL. 42, NO. 3, 2007
and repeated damage, may be a mechanism for malignant degeneration.9 In addition, damaged tissues release toxins that can lead to the mutation of cells. A chronic nonhealing wound exposed to these toxins for an extended time could be more susceptible to malignant degeneration.10 Finally, the implantation of epidermal cells into the dermis after trauma may cause a foreign body reaction within the dermis that alters the normal function of the tissue, including normal reparative processes, and increases susceptibility to future damage.9–11 In this patient, it is possible that the chronic irritation in the dermis secondary to the retained glass shards resulted in the malignant degeneration of the wound. The patient delayed seeking medical attention for years because she related the appearance of the wound to the original trauma. This delay may have contributed to the large size of the basal cell carcinoma of her lid and the resulting morbidity after reconstructive surgery. Patients may often disregard the appearance of a chronic wound in the setting of trauma, and this case reflects the need for increased suspicion and surveillance of chronic nonhealing wounds by the medical practitioner. REFERENCES 1. Lambert WC, Kasznica J, Chung HR, Moore D. Metastasizing basal cell carcinoma developing in a gunshot wound in a black man. J Surg Oncol 1984;27:97–105. 2. Novick M, Gard DA, Hardy SB, Spira M. Burn scar carcinoma: a review and analysis of 46 cases. J Trauma 1977;17:809–17. 3. Stilwell JH, Sclare G. Malignancy following a single injury to the skin. Br J Plastic Surg 1980;33:74–6. 4. Treves N, Pack GT. The development of cancer in burn scars: an analysis and report of thirty-four cases. Surg Gynecol Obstet 1930;51:749–82. 5. Camacho FM, Mazuecos J, Rodriguez-Adrados F. Basal cell carcinoma arising in an electrical burn scar secondary to transthoracic cardioversion. Dermatol Surg 1999;25:151. 6. Trent JT, Kirsner RS. Wounds and malignancy. Adv Skin Wound Care 2003;16:31–4. 7. Ozyazgan I, Kontas O. Previous injuries or scars as risk factors for the development of basal cell carcinoma. Scand J Plast Reconstr Surg Hand Surg 2004;38:11–5. 8. Connolly JG. Basal cell carcinoma occurring in burn scars. Can Med Assoc J 1960;83:1433–4. 9. Hill BB, Sloan DA, Lee EY. Marjolin’s ulcer of the foot caused by nonburn trauma. South Med J 1996;89:707–10. 10. Fleming MD, Hunt JL, Purdue GF, Sandstad J. Marjolin’s ulcer: a review and reevaluation of a difficult problem. J Burn Care Rehabil 1990;11:460–9. 11. Arons MS, Rodin AE, Lynch JB, Lewis SR, Blocker TG Jr. Scar tissue carcinoma. Part II. An experimental study with special reference to burn scar carcinoma. Ann Surg 1966;163:445–60. 12. Borggreven PA, de Graaf FH, van der Valk P, Leemans CR. Post-traumatic cutaneous meningioma. J Laryngol Otol 2004;118:228–30. Key words: cutaneous malignancy, scar, chronic