ARTICLE
Auteur(s) : Kahena Jaber, Houda Hammami, Soumaya Youssef,
Feriel Robbana, Mohamed Raouf Dhaoui, Nejib Doss
Dermatology department, Military Hospital of Tunis, 1089
Tunis, Tunisia
Multiple primary malignant tumours are a well-known phenomenon.
The incidence of a second tumor is elevated, between 2-10%, in
patients previously affected by another tumor [1]. In this report,
a case of ungueal melanoma and basal cell carcinoma on the face in
a man with a history of hepatocellular carcinoma (HCC) is
presented.
Case report
A 70-year-old man was referred to our dermatology department for
evaluation of an ungueal tumor. Medical history was notable for a
hepatocarcinoma secondary to hepatic cirrhosis, diagnosed in
November 1996 at stage C Child-Pugh. The patient was treated
by alcohol embolization. The evolution was marked by necrosis of
the majority of nodules.
He presented in December 2004 with a history of a 2-month
non-healing wound of the right forefinger which bled with minor
trauma. Clinical examination revealed a 2 cm,
ulceroproliferative tumor on the nail bed and a pigmented lesion
extending onto the soft tissues surrounding the nail, the proximal
nail fold and the periungueal skin. A 1 cm nodular tumor
of 3 months’ duration with central ulceration and a raised
translucent ring-like border was observed on the left cheek.
A punch biopsy was performed from the distal matrix of the
right second fingernail. Histological examination concluded a
malignant melanoma. Median Breslow thickness was 4 mm. Clark’s
level was IV. The patient was treated with amputation through the
distal interphalangeal joint. He underwent sentinel lymph node
biopsy and subsequent sentinel lymph node dissection.
A homolateral axillary lymphadenectomy was also performed. The
histopathological study showed features of invasive melanoma.
Immunohisto-chemistry showed positive staining for HMB45, S-100
protein and negative for Vimentin, cytokeratin and EMA.
Histological examination of the tumor of the cheek confirmed a
basal cell carcinoma. Surgical excision of this tumor was
performed. The patient has healed well, without evidence of
recurrence at short-term follow-up visits.
Discussion
Several studies have been conducted to clarify the association
between HCC and second primary malignancies. In a consecutive
series of patients with pathologically documented HCC, 2 to 6% were
found to have a second primary malignancy elsewhere. Cutaneous
neoplasms associated to HCC were rarely reported [2]. On the other
hand, it has long been suggested that subjects diagnosed with
cutaneous melanoma have an higher rate of non-cutaneous
malignancies such as cancers of the breast, colon, Hodgkin’s
lymphoma and an increased risk for BCC/SCC. In addition, cancer
registries have reported an increased incidence of melanoma and
certain non-cutaneous cancers following non-melanoma skin cancer.
Several studies suggest that the etiology of multiple primary
malignant tumors is complex, and includes environmental factors,
aging processes, genetic predisposition, previous medical treatment
(radio- or chemotherapy), hormonal factors, intensified medical
surveillance and interactions of these factors. Calzavara-Pinton P
et al., report the case of a woman with a 20-year history of plaque
stage mycosis fungoides who developed 34 BCCs in a short time
period after systemic bexarotene therapy [3]. The pathogenesis of
skin cancers in our patient may be related to genetic
predisposition. In fact, high fibroblast growth factor receptor 4
expression [4], an over-expression of an oncofetal antigen glypican
3 [5], and reduced expression of TANGO gene [6] have been recently
associated with the progression of cutaneous melanoma and HCC. BCC,
which is the most frequent skin cancer, is probably due to sun
exposure in our patient. This case stresses the importance of
carefully monitoring skin lesions in persons previously diagnosed
with HCC.
Acknowledgements
Financial support: none. Conflict of interest: none.
References
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