British Journal of Plastic Surgery (1982) 35, 474477 0 1982 The Trustees of British Association of Plastic Surgeons

0007-1226/82/0369-0474 $02.00

Malignant melanoma and squamous cell carcinoma in a burn scar

M. F. MUHLEMANN, R. W. GRIFFITHS and J. C. BRIGGS

Department of Medicine, Southmead Hospital, Bristol and the Plastic Surgery Unit, Frenchay Hospital, Bristol

Summary-The rare combination of contiguous squamous cell carcinoma and malignant melanoma arising synchronously in a burn scar is described.

Squamous cell carcinoma may arise in the scars following a single injury to the skin (Stilwell and which follow thermal injury (Hawkins, 1833; Sclare, 1980) and in post-burn scars (Giblin et al., Treves and Pack, 1930 and Arons et al., 1965). 1965; Gellin and Epstein, 1975; McGovern, 1976; Malignant melanomata have been described Novick et al., 1977 and Nancarrow, 1979). We

A

Fig. 1 A. The scarred region over the back of the shoulder show pigmentation at the upper pole.

with a central area of tumour. B. Close-up view of the tumour to

474

MALIGNANT MELANOMA AND SQUAMOUS CELL CARCINOMA IN A BURN SCAR 475

wish to record the simultaneous development of both a squamous cell carcinoma and a malignant melanoma in a long-standing burn scar.

Case report

A Caucasian male sustained a burn to the skin over the right axilla and scapula during the second World War. The axillary region was subsequently grafted but the area over the scapula had been left to heal spontaneously. At the age of 59 he presented with a three months history of a painless swelling arising in the healed partially depigmented burn scar overlying the right scapula. Examination showed a patchily pigmented warty lesion 18mm in diameter within the confines of the burn scar (Figs. 1 A and B). The axillary and cervical lymph nodes were not clinically palpable.

Biopsy strongly suggested the co-existence of squamous cell carcinoma and malignant melanoma.

Three weeks later the lesion and the surrounding scar were excised and the underlying muscle bed covered with split-skin 24 hours later. The post-operative course was uneventful.

Histological examination of the specimen showed it to contain a well differentiated squamous cell carcinoma (Fig. 2), with a malignant melanoma arising in the immediately adjacent epithelium (Fig. 3). The latter lesion did not penetrate beyond the basement membrane and was regarded as a malignant melanoma in situ still in the radial growth phase (a superficial spreading type of melanoma).

Discussion

The occurrence of both malignant melanoma and squamous cell carcinoma in a burn scar is a rare event and we can find only one other recorded case (Novick et al., 1977). Malignant melanoma in a chronic burn scar is uncommon (Giblin et

Fig. 2 Photomicrograph of the squamous cell carcinoma (H.&E. x 85). Note well-differentiated nests of keratin pearls and a dense associated inflammatory intiitrate.

476 BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 3 Section of melanoma area (H.&E. x 85). Note complete filling of the epidermal basement membrane with atypical melanocytes, some single but many in clusters. These cells are migrating into the overlying epidermis and pigment can be seen shed on the surface. Some pigmentary incontinence is also present in the papillary dermis together with scattered inllammatory exudate. No invasion by the melanocytes has taken place into the underlying dermis.

al., 1965; Gellin and Epstein, 1975; McGovern, 1976 and Nancarrow, 1979) although trauma as a possible cause of malignant melanoma has been described (Stilwell and Sclare, 1980). It is well known that chronic burn scars can undergo malignant change (Marjolin, 1828; Treves and Pack, 1930 and Hawkins, 1833). There is a possible incidence of malignant change in 2% of the cases (Treves and Pack, 1930) and the same authors suggest a role for trauma and the relative avascularity of the scar in the aetiology of this malignant change. Bostwick et al. (1976) have also proposed that conditions exist within the scar to allow neoplastic cells to proliferate unchecked, due to the absence of normal immunosurveillance mechanisms. If this is so, the development of the two neoplasms within a single scar lends support to this hypothesis. The fact that this double tumour is rare may well be due to the paucity of melanocytes in the depigmented scar tissue.

Acknowledgements

We are grateful to Dr Cameron Kennedy and Mr R. W. Pigott for allowing us to report the details of this patient and to Mr Roger Cook, FIMLS, for help with the photomicrographs.

References

Arom, M. S., Lynch, J. B, Lewis, S. R. and Blocker, T. G. (1965). Scar tissue carcinoma. Part 1. A clinical study with special reference to bum scar carcinoma. Annals of Surgery, 161, 170.

Bostwick, J., Peodergrast, W. J. and Vaseones, L. 0. (1976). Marjolin’s ulcer: an immunologicaiiy privileged tumour? Plastic and Reconstructive Surgery, 57, 66.

Cellin, G. A. and Epstein, W. L. (1975). Malignant melanoma from thermal burn scar. Arches of Dermatology, 111, 1214.

Giblin. T, PIckreII. K., PItta W. and Armstroae. D. (1965). Malignant degeneration in burn scars: Marj;dlin’s ‘ulcer. Annals of Surgery, 162, 291.

Hawk@ C. (1833). On warty tumours in cicatrices. London Medical Gazette, 13, 481.

MALIGNANT MELANOMA AND SQUAMOUS CELL CARCINOMA IN A BURN SCAR 477

Marjolin, J. N. (1828). Dictionnnire de MPdecine. Vol. 21, Paris.

McGovern, V. J. (1976). Malignant melanoma: clinical and histological diagnosis. New York: John Wiley.

Nancarrow, J. D. (1979). Malignant melanoma arising in an unstable burn scar. British Journal of Plastic Surgery, 32, 135.

Novick, M., Card, D. A., Hardy, S. B. and Spira, M. (1977). Burn scar carcinoma: a review and anlysis of 46 cases. Journal of Trauma, 17, 809.

Stilwell, J. H. and Sclare, G. (1980). Malignancy following a single injury to the skin. British Journal of Plastic Surgery. 33, 74.

Treves, N. and Pack, G. T. (1930). The development of cancer in burn scars. An analysis and report of 34 cases. Surgery, Gynecology and Obstetrics, 51, 749.

The Authors M. F. Mutdemmn, BSc, MRCP, (UK), Medical Registrar,

Southmead Hospital, Bristol. R. W. GriffitJm FRCS. Senior Reaistrar in Plastic Sureerv.

Frenchay Hospital, Bristol. - _ <,

J. C. Briggs, FRCPatk, Consultant Histopathologist, Frenchay Hospital, Bristol.

Requests for reprints to: M. F. Muhlemann, BSc, MRCP (UK), Department of Dermatology, New Addenbrooke’s Hospital, Cambridge.