Introduction
Cutaneous squamous cell carcinoma (SCC) is an invasive, malignant tumor with metastatic
potential. This tumor can arise from various precursor lesions, including ulcers,
actinic keratoses, and leukoplakia. A Marjolin ulcer is an aggressive malignancy of
the skin, most commonly SCC, arising in chronic wounds or scars. Transformation from
a chronic wound to SCC is rare and slow with an unknown pathogenesis, although proposed
mechanisms include nonspecific or chronic antigenic stimulation.1, 2 Malignantly transformed
wounds are challenging to differentiate from primary chronic ulcers, so having a high
suspicion for SCC and diagnosis in a timely manner is key.
2
Clinically, it is important to monitor for changes in wound appearance and perform
histologic evaluation early.
1
Chronic osteomyelitis is the clinical condition most frequently associated with Marjolin
ulcers, with other common etiologies being trauma, burns, and diabetes.
2
Although cases of SCC developing in the setting of chronic hidradenitis suppurativa
(HS) or Crohn's disease (CD) have been described in the literature,3, 4 SCC may be
regarded as a rare complication of these diseases. We present a patient with chronic
cutaneous CD that worsened focally on the gluteal cleft and perineum that then became
refractory to multiple immunosuppressive therapies, including biologics and cyclosporine.
After months of failed treatment, she was found to have SCC, and ultimately passed
away approximately 18 months later.
Case
A 55-year-old woman with CD and HS was referred to a dermatology clinic in July 2015
for evaluation of a peristomal rash. On examination, she was also found to have intergluteal
cleft fissuring (Fig 1, A and B) with previous biopsies showing cutaneous CD (Fig
2, A and B). Azathioprine 50 mg once daily was added to her longstanding subcutaneous
injection of adalimumab 80 mg every 2 weeks; then both drugs were replaced with cyclosporine
200 mg twice daily and dapsone 50 mg daily, but she continued to worsen. Despite improvement
of the gluteal cleft ulcers, her HS and gastrointestinal CD worsened, so adalimumab
therapy was restarted. In June 2016, the patient presented with worsening ulceration,
severe perianal pain, bleeding, subjective fevers, and chills. On examination, her
perineum appeared worse and a new, tender ulcer was noted with sanguinous drainage
(Fig 1, C and D). There was concern for a perianal abscess, so the patient was admitted
to the hospital. She also reported intermittent compliance with her immunomodulating
medications in prior months. A computed tomography scan revealed a residual fistulous
tract but no abscess. Despite improved medication compliance after discharge, her
ulcers worsened over the next 2 months. In September, an initial biopsy showed findings
of reactive epidermal hyperplasia at the ulcer edge; however, repeat punch biopsy
results were consistent with SCC (Fig 3). The patient was immediately referred to
gynecology-oncology, but in the meantime, she was readmitted for worsened pain and
drainage of the perineal lesion. During this admission, she underwent wound debridement
and primary chemoradiation with radio-sensitizing cisplatin. Six months later, she
was readmitted for pancytopenia and hypotension. At that time, biopsies of enlarged
regional lymph nodes showed invasive SCC. She was started on a first cycle of carboplatin
and paclitaxel. After a family meeting discussion, the patient elected for a do not
resuscitate/do not intubate status and was discharged with home hospice. Unfortunately,
she succumbed to her disease 2 months later in May 2017.
Fig 1
Clinical images of lesions of the gluteal cleft and perineum. A and B, Intergluteal
cleft fissuring. C and D, Perineal ulceration.
Fig 2
Histologic examination of tissue from patient with cutaneous Crohn's disease (CD).
A, Original peristomal biopsy taken in 2006 showing cutaneous CD. B, Biopsy of skin
showing irregular benign epidermal hyperplasia that embraces collections of epithelioid
histiocytes and multinucleated giant cells. Cultures and special stains were negative
for bacterial, mycobacterial, and fungal pathogens. These alterations are consistent
with cutaneous CD.
Fig 3
Biopsy of skin shows malignant cells infiltrating the dermis in cords and nests. Focal
keratinization and keratin pearl formation are evidence of invasive squamous cell
carcinoma.
Discussion
As observed in this case, a CD patient in whom SCC develops is likely to receive delayed
care because of a low clinical suspicion for malignancy. Clinicians should be wary
of malignancy when caring for immunosuppressed patients with chronic nonhealing ulcers
in whom infection has been excluded. Biopsy should be considered sooner rather than
later. The pathogenesis of SCC in this case is not well understood but could be related
to poor wound healing, constant cell turnover in areas of inflammation and trauma,
or chronic immunosuppression.
5
Another mechanism could be decreased immunologic reactivity to tumor cells in scar
tissue; also, a lack of vasculature for defense against metastases could permit tumors
growing to a critical size.
6
There have also been case reports on the development of SCC in patients on long-term
tumor necrosis factor (TNF)-inhibitor therapy for rheumatoid arthritis, psoriasis,
and ankylosing spondylitis.7, 8 Such cases raise the question of whether nonmelanoma
skin cancer surveillance in patients on TNF-inhibitors should be further investigated,
and whether there is a need for identifying patients at high risk for malignancy.
9
Because cure of SCC is possible through a combination of both surgical and oncologic
methods, early diagnosis and intervention is crucial.
10
Chronic wounds in patients with CD are common, so suspicion for malignancy is low,
and subsequent patient outcomes are poor given delayed surgical management.
5
Ulcers or wounds that do not heal normally within 2-3 weeks despite adequate treatment
are particularly worrisome and warrant consideration for biopsy.
6
Clinicians need to be aware of any change or worsening in clinical symptoms of existing
perineal disease, such as refractory pain, discharge, or bleeding that is resistant
to medical treatment.
11
In the event of biopsy-proven SCC, first-line treatment is local excision with consideration
for lymph node evaluation in locally advanced disease. As seen here, adjuvant chemoradiation
is an option in more advanced cases. The most important prognostic indicator is lymph
node metastases. Close follow-up is imperative as risk for local recurrence is high.
1
In summary, vigilance for SCC in patients with a history of longstanding cutaneous
CD is encouraged through identification of risk factors and maintaining a lower threshold
for biopsy.
1