Malignant fibrous histiocytoma, malignant melanoma and squamous cell carcinoma arising from different areas in an adult.

To the Editor: Malignant fibrous histiocytoma (MFH) is a well-defined and common malignant mesenchymal tumor of soft tissue occurring in late adult life. (1) It usually involves the deep soft tissue and skeletal muscles of the proximal part of the extremities, especially the thigh. (1) Skin cancers, such as basal cell carcinomas, squamous cell carcinomas (SCC) and melanomas represent the most frequent human malignancies. However, the presentation of all three types of cancer (MFH, SCC, and melanoma) in the same patient is very rare. This unique association was reported in a patient with burn scar. (2) Herein, we report a case of MFH, SCC, and malignant melanoma arising in different areas over the course of fifteen years without a history of burn scar.

A 31-year-old man was admitted to the hospital for complaints of painful swelling in his left thigh in November 1990. He was treated with above knee amputation with the diagnosis of a stage IIB MFH of soft tissue around the proximal tibia. The patient had been given 10 cycles of combined chemotherapy with epirubicin, cyclophosphamide, and vincristine. He remained clinically well until January 1998. At this time pigmented, acneiform lesion at his lateral lumbar region appeared. Excisional biopsy was performed and histopathologic examination was consistent with malignant melanoma of Clark level V, Breslow depth 11 mm. There were 17 mitoses at 10 high powered field and several small necrotic foci through the lesion. The surgical margin was clear of tumor. The computed tomography of the chest and abdomen did not reveal any metastatic lesion. The patient used interferon-[alpha] in an adjuvant manner for one year.

He remained well until 2004, when he was admitted to the hospital with an unhealed wound at the left side of the nose. This lesion was also resected widely and skin grafted. Histologic diagnosis was SCC with safety margin. He had a history of smoking 23 packs of cigarettes per year. When his father was 75 years old, he was diagnosed and treated for colon cancer.

This case illustrates three different tumors in the patient. Our patient is currently in good health without any tumor. To our knowledge, this unique association has not been described previously in the literature. Skin phototypes, genetic predisposition, viruses, and immunosuppressive therapy may predispose to cutaneous malignancies. DNA repair systems play a crucial role in maintaining the genetic integrity against genotoxic attacks and in protecting us from tumoral progress. The tumor suppressor gene p53 plays a crucial role in the cellular response to DNA damage, by way of causing cell cycle arrest in the G1 phase or apoptosis. (3) This raises the issue of a possible association of this mutation, as a carcinogenic trigger, with the occurrence of the skin and soft tissue cancers, as seen in our case. The p53 mutation was documented previously in all SCC, MFH, and malignant melanomas; however nuclear p53 over expression in these tumors had no prognostic implication. (3-5) Those tumors may also be associated with the radiotherapy and combined chemotherapy. In our patient, it is unlikely that radiation played a role in either malignant melanoma or SCC development as the patient was not treated with radiotherapy. The exact reason for occurrence of those tumors in different areas in the same patient is obscure and needs to be examined further.

Mevlut Kurt, MD

Department of Internal Medicine

Hacettepe University Faculty of Medicine

Ankara, Turkey

Sadettin Kilickap, MD

Sercan Aksoy, MD

Gulten Tekuzman, MD

Department of Medical Oncology

Hacettepe University Institute of Oncology

Ankara, Turkey

References

1. Rooser B, Willen H, Gustafson P, et al. Malignant fibrous histiocytoma of soft tissue. A population-based epidemiologic and prognostic study of 137 patients. Cancer 1991;67:499-505.

2. Alconchel MD, Olivares C, Alvarez R. Squamous cell carcinoma, malignant melanoma and malignant fibrous histiocytoma arising in burn scars. Br J Dermatol 1997;137:793-798.

3. Nakanishi H, Tomita Y, Yoshikawa H, et al. Frequent p53 gene mutations in soft tissue sarcomas arising in bum scar. Jpn J Cancer Res 1999;90:276-279.

4. Giglia-Mari G, Sarasin A. TP53 mutations in human skin cancers. Hum Mutat 2003;21:217-228.

5. Rhim KJ, Hong SI, Hong WS, et al. Aberrant expression of p53 gene product in malignant melanoma. J Korean Med Sci 1994;9:376-381.