DEFINITION AND PATHOGENESIS
- Marjolin ulcer is a carcinoma arising in post-traumatic scars
- "Post-traumatic squamous cell carcinoma" a generic term for tumors arising from scars and sinuses
- A keratinocyte carcinoma
- 2nd most common skin cancer
- Population-based case-fatality rate of ~0.7%
- Early dx can only be made by a high index of suspicion which leads to bx; early bx and tx may improve outcome
- Incidence varies
- Overall incidence 250X in renal transplant pts
- Susceptiblity may be higher in Japan, N India, and China due to cultural practices
- ↑ ESR (average 33mm/hr)
- Time from initial injury to tx avarages 17.8 yrs
- Non-healing ulcer after bx of a "benign lesion"
- Can arise from chronic granulomas, leukoplakia, actinic keratosis, cutaneous horns, keratotic lesions (plantar feet)
- Risk factors
- Solar radiation
- Ionizing radiation
- Phototherapy with psoralens
- Prior SCC
- Chronic inflammation or infection
- Squamous carcinoma of the nail bed has been associated with a subungual lipoma and secondary chronic infection
- Chemical exposure
- Polycyclic/polyaromatic hydrocarbons)
- Disease states (eg, xeroderma pigmentosa, Bowen's disease, leukoplakia, epidermis dysplasia verruciformis, epidermolyis bullosa dystrophica)
- Xeroderma pigmentosa: (AD) defective DNA repair after UV radiation
- Epidermis dysplasia verruciformis: defect in cell-mediated immunity, susceptibility to human papilloma virus
- Human papiloma virus
- Actinic keratosis
- 1% progress to SCC
- 60% of SCC arise in an actinic keratosis
- Organ transplant patients
- 65X ↑ risk due to immunosupression
- T Primary tumor
- TX Primary tumor cannot be assessed
- T0 No evidence of primary tumor
- Tis Carcinoma in situ
- T1 Tumor ≤2 cm in greatest dimension with less than two high-risk features
- T2 Tumor ≥2 cm in greatest dimension or a tumor of any size with two or more high-risk features
- T3 Tumor with invasion of maxilla, mandible, orbit, or temporal bone
- T4 Tumor with invasion of skeleton (axial or appendicular) or perineural invasion of skull base
- (High-risk features: perineural invasion; location of ear, nonglabrous lip; depth ≥ 2 mm, Clark levle IV; poor- or un- differentiation
- Preop CT of lungs and liver
- MRI may be more useful than CT for regional LN metastases
- Varying sizes of sinus tracts and chronic ulcers, which may be infected
- Keratinocytes, polygonal cells with abundant cytoplasm
- Keratin pearls
- Invasion of the dermis through the basement membrane
- Grading according to the WHO criteria
- Grade I: well differentiated
- Grade II: moderately well differentiated
- Grade III: poorly differentiated
DIFFERENTIAL CLINICOPATHOLOGIC DIAGNOSIS
- Atypical verruca
- Plantar keratosis
DISEASE COURSE AND TREATMENT
- Shave or punch bx
- Bx the border between normal skin and tumor to avoid sampling only necrotic tissue
- Excision biopsy in small lesions when tension-free closure possible
- 0.0028-5.9% metastasis in primary lesions (usually only in advanced, deeply invasive lesions)
- 50% over-all metastatic rate in post-traumatic lesions (possibly ? incidence with prophylactic XRT to regional LNs for those lesions at higher risk for metastasis)
- 10% for grade I
- 59% for grade II
- 86% for grade III
- Wide local excision, attempt to get 4-6mm margin and one clear tissue (fascia preferably) plane deep to the tumor
- Chemotx for high grade lesions
- Cryotherapy for superficial, well-differentiated, and well-defined lesions of < 1 cm
- Electrodessication and curettage for superficial, well-differentiated, and well-defined lesions
- 100% of pts who develop metastases will develop regional LN metastases
- 5-yr survival with metastatic disease 27-39%
- Regional LN dissection of no benefit in improving survival
- Sentinel node bx has been reported
- Metastases in up to 11.2-16.9% with tumor size > 2 cm the independent risk factor
- Metastatic lesions in <2% of cases due to chronic sun exposure
- XRT for patients who are poor surgical candidates
- CARCINOMA (EPITHELIOMA) CUNICULATUM
- Well-differentiated, bulbous mass with multiple sinuses usually on plantar surface with foul-smelling expelled material
- Also has been reported in locations other than the foot
- "Burrowing" invasion of the dermis
- BOWEN'S DISEASE
- Carcinoma in situ, where the basement membrane remains intact
Albert MR, Ostheimer KG: The evolution of current medical and popular attitudes toward ultraviolet light exposure: Part I. J Am Acad Dermatol 47:930-7,2002.
Belinkie SA, Swartz WM, Zitell JA: Invasive squamous cell carcinoma of the carpus: malignant transformation of epidermis dysplasia verruciformis. J Hand Surg 11A:273-5,1986.
Carroll RE: Squamous cell carcinoma of the nail bed. J Hand Surg 1:92-7,1976.
Dass A, Peh WCG, Shek TWH, Chien EP: A 28-year old man with a growth at the dorsum of the left foot. Am J Orthop 33:96-9,2004.
Defiebre BK: Bowen's disease of the nail bed: a case presentation and review of the literature. J Hand Surg 3:184-6,1978.
de Gruijl FR, Sterenborg HJ, Forbes PD, : Wavelength dependence of skin cancer induction by ultraviolet irradiation of albino mice. Cancer Res 53:53-60,1993.
De Hertog SAE, Wensveen CAH, Bastiaens MT, : Relation between smoking and skin cancer. J Clin Oncol 19:231-8,2001.
Diffey BL: When should sunscreen be reapplied? J Am Acad Dermatol 45:882-5,2001.
Faille JM: Subungual lipoma, squamous carcinoma of the nail bed, and secondary chronic infection. J Hand Surg 21A:512-4,1996.
Fleming ID, Amonette R, Monaghan T, Fleming MD: Principles of management of basal and squamous cell carcinoma of the skin. Cancer 75:699-704,1995.
Glass AG, Hoover RN: The emerging epidemic of melanoma and squamous cell skin cancer. JAMA 262:2097-2100,1989.
Green A, Williams G, Nesle R, : Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: A randomized controlled trial. Lancet 354:723-9,1999.
Grodstein F, Speizer FE, Hunter DJ: A prospective study of incident squamous cell carcinoma of the skin in the Nurses' Health Study. J Natl Cancer Inst 87:1061-6,1995.
Harris RB, Griffith K, Moon TE: Trends in the incidence of nonmelanoma skin cancers in southeastern Arizona, 1985-1996. J Am Acad Dermatol 45:528-36,2001.
Hartevelt MM, Bavinck JNB, Koote AM, : Incidence of skin cancer after renal transplantation in the Netherlands. Transplantation 49:506-9,1990.
Kakar S, Endress R. Skin cancer of the hand: current concepts. J Am Acad Orthop Surg 2015;23:307-316.
Karagas MR, Greenberg ER, Spencer SK, : for the New Hampshire Skin Cancer Study Group. Increase in incidence rates of basal cell and squamous cell skin cancer in New Hampshire, USA. Int J Cancer 81:555-9,1999.
Karagas MR, Stukel TA, Greenberg R, : Risk of subsequent basal cell carcinoma and squamous cell carcinoma of the skin among patients with prior skin cancer. JAMA 267:3305-10,1992.
Koh HK, Geller AC, Miller DR, : Prevention and early detection strategies for melanoma and skin skin cancer. Arch Dermatol 132:436-43,1996.
Kraemer KH, Lee MM, Andrews AD, Lambert C: The role of sunlight and DNA repair in melanoma and nonmelanoma skin cancer. The Xeroderma pigmentosum paradigm. Arch Dermato.l 130:1018-21,1994.
Kwa RE, Campana K, Moy RL: Biology of cutaneous squamous cell carcinoma. J Am Acad Dermatol 26:1-26,1992.
Lentz SR, Raish RJ, Orlowski EP, Marion JM: Squamous cell carcinoma in epidermolysis bullowsa: treatment with systemic chemotherapy. Cancer 66:1276-8,1990.
Lifeso RM, Roney RJ, El-Shaker M: Post-traumatic squamous cell carcinoma. J Bone Joint Surg 72A:12-18,1990.
Majewski S, Jablonska S: Epidermodysplasia veruciformis as a model of human papillomavirus-induced genetic cancer of the skin. Arch Dermatol 131:1312-8,1995.
Marghoob AA, Slade J, Salopek TG, : Basal cell and squamous cell carcinomas are important risk factors for cutaneous malignant melanoma. Cancer 75:707-14,1995.
Marks R: An overview of skin cancers: Incidence and causation. Cancer 75(Suppl):607-12,1995.
Marks R: Squamous cell carcinoma. Lancet 347:735-8,1996.
Marks R, Rennie G, Selwood TS: Malignant transformation of solar keratoses to squamous cell carcinoma. Lancet 1:795-7,1988.
Miller DL, Weinstock MA: Nonmelanoma skin cancer in the United States: Incidence. J Am Acad Dematol 30:774-8,1994.
Naylor MF, Boyd A, Smith DW, : High sun protection factor sunscreens in the suppression of actinic neoplasia. Arch Dermatol 131:170-5,1995.
Neilson D, Dundas S, Page RE: Carcinoma cuniculatum of the hand. J Hand Surg 13B:218-20,1988.
Rayner CRW: The results of treatment of two hundred and seventy-three carcinomas of the hand. The Hand 13:183-6,1981.
Reed WB, College J, Jr, Francis MJ, : Epidermolysis bullowsa dystrophica with epidermal neoplasms. Arch Dermatol 110:894-902,1974.
Robinson JK, Rigel DS, Amonette RA: Trends in sun exposure knowledge, attitudes, and behaviors: 1986 to 1996. J Am Acad Dermatol 37:179-86,1997.
Rowe DE, Carroll RJ, Day CL: Prognostic factors for local recurrence, metastasis and survival rates in squamous cell carcinoma of the skin, ear, and lip. J Am Acad Dermatol 26:976-90,1992.
Schroven I, Hulse G, Saligson D: Squamous cell carcinoma of the foot. Two case reports. Clin Orthop 328:227-30,1996.
Schwartz RA, Birnkrant AP, Rubenstein DJ, : Squamous cell carcinoma in dominant type epidermolysis bullosa dystrophica. Cancer 47:615-20,1981.
Smith JB, Fenske NA: Cutaneous manifestations and consequences of smoking. J Am Acad Dermatol 34:717-32,1996.
Stadelmann WK, Javaheri S, Cruse CW, Reintgen DS: The use of selective lymphadenectomy in squamous cell carcinoma of the wrist: a case report. J Hand Surg 22A:726-31,1997.
Staples M, Marks R, Giles G: Trends in the incidence of non-melanocytic skin cancer (NMSC) treated in Australia 1985-1995: are primary prevention programs starting to have an effect? Int J Cancer 78:144-8,1998.
Stokes R, Diffey B: How well are sunscreen users protected? Photodermatol Photoimmunol Photomed 13:186-8,1997.
Strom SS, Yamamura Y: Epidemiology of nonmelanoma skin cancer. Clin Plast Surg 24:627-36,1997.
Thompson SC, Jolley D, Marks R: Reduction of solar keratoses by regular sunscreen use. N Engl J Med 329:1147-51,1993.
Weinstock MA: Death from skin cancer among the elderly: Epidemiological patterns. Arch Dermatol 133:1207-9,1997.
Weistock MA: Nonmelanoma skin cancer mortality in the United States, 1969 through 1988. Arch Dermatol 129:1286-90,1993.
Weinstock MA, Bogaars HA, Ashley M, : Nonmelanoma skin cancer mortality. A population-based study. Arch Dermatol 127:1194-7,1991.
Wechsler HL, Krugh FJ, Domonkos AN, Scheen SR, Davidson DL, Jr: Polysysplastic epidermolysis bullosa and development of epidermal neoplasms. Arch Dermatol 102:374-80,1970.
Weinstock MA: Epidemiology of nonmelanoma skin cancer. Clinical issues, definitions, and classifications. J Invest Dermatol 102(Suppl):4s-5s,1994.