CASE REPORT
Atypical Fibroxanthoma Arising in a Scar of Discoid Lupus Erythematosus Vincenzo De Francesco, Enzo Errichetti, Enrico Pegolo, and Giuseppe Stinco
Background: M a lig n a n t cha ng e in th e scars o f d is c o id lu p u s e ry th e m a to s u s IDLE) is a w e ll-k n o w n e ve n t. In m o s t cases, tu m o rs are o f e p ith e lia l o rig in , p a rtic u la rly sq u a m o u s cell carcin o m a s and, less fre q u e n tly , basal cell c a rcin o m a s an d k e ra to a ca n th o m a s. The o n s e t o f s o ft tis s u e s a rco m a s in a DLE scar is a ve ry rare e ve n t, h o w e v e r, because o n ly on e case o f m a lig n a n t fib ro u s h is tio c y to m a has been d e sc rib e d in th e lite ra tu re .
O bjective: W e d e scrib e th e fir s t d o c u m e n te d re p o rt o f a ty p ic a l fib ro x a n th o m a (AFX) a ris in g in an o ld scar o f DLE. Results: A lth o u g h w e c a n n o t e xclu d e an a ccid e n ta l a sso cia tio n b e tw e e n AFX an d DLE, o u r case em p h a size s th a t p a tie n ts w ith DLE m a y d e v e lo p AFX in th e c o n te x t o f an o ld scar.
Conclusion: O u r fin d in g fu rth e r u n d e rlin e s th e im p o rta n c e o f s tric t an d lo n g -te rm s u rve illa n ce o f p e o p le w ith DLE to id e n tify and re m o v e e v e n tu a l tu m o rs a t an e a rly stage.
Contexte: La tra n s fo rm a tio n m a lig n e des cica trice s de lu p u s e ry th e m a te u x d is c o id e (LED) e st un f a it bie n co n n u . Dans la p lu p a rt des cas, les tu m e u rs s o n t d 'o rig in e e p ith e lia le ; il s 'a g it en p a rtic u lie r de ca rcin o m e s sq u a m e u x, m a is aussi de ca rcin o m e s ba so ce llu la ire s e t de k e ra to a c a n th o m e s , bie n qu e le u r fre q u e n ce s o it m o in d re . T o u te fo is , il e st tre s rare q u e des sarco m es des tis s u s m o u s p re n n e n t naissance da ns des cica trice s de LED; en e ffe t, la d o c u m e n ta tio n ne fa it e ta t qu e d 'u n seul cas d 'h is tio c y to m e fib re u x m a lin .
O bjectif: L 'e tu d e vise a d e crire le p re m ie r cas d o c u m e n ts de fib ro x a n th o m e a ty p iq u e (FA) q u i a p ris naissance dans un e an cie n n e c ic a tric e de LED. Resultats. Bien qu un e a sso c ia tio n a c c id e n te lle e n tre le FA e t le LED ne p u isse e tre ecartee, le cas d e c rit ici fa it re s s o rtir la p o s s ib ility d e v o lu tio n du LED ve rs le FA da ns le c o n te x te d 'u n e an cie n n e cica trice.
Conclusion: Les re s u lta ts de l'e tu d e f o n t re s s o rtir d a va n ta g e I'im p o rta n c e d 'u n s u iv i rig o u re u x e t p ro lo n g e chez les p a tie n ts a tte in ts de LED a fin de p e rm e ttre I'id e n tific a tio n e t I'exerese precoces d 'e v e n tu e lle s tu m e u rs .
typical fibroxanthoma (afx) is an uncom mon cutaneous neoplasm of fibrocytic or myofibrocytic differentiation that usually develops rapidly over several m onths on the sun-exposed skin of elderly individuals as a painless, firm, skin-colored or brownred, frequently ulcerated, usually immovable nodule. Ultraviolet (UV) light exposure, irradiation, and im mu nosuppression would be the most likely risk factors for its development. Despite the malignant appearance
A
From the Department o f Experimental and Clinical Medicine, DISM, Institute o f Dermatology, University o f Udine, and Department o f Medical and Biological Sciences, Institution o f Anatom ic Pathology, Azienda Ospedaliero-Univeristaria S. Maria della Misericordia, Udine, Italy. Address reprint requests to: Enzo Errichetti, MD, Institute o f Dermatology, University o f Udine, Ospedale '‘San Michele," Piazza Rodolone, 1, 33013Gemona del Friuli (Udine), Italy; e-mail:[email protected].
DOI 10.2310/7750.2013.13144 © 2014 Canadian Dermatology Association
histopathologically, AFX generally follows a benign clinical course, although in some cases, it may metastasize. Local excision is curative in most patients.1 Here we report an exceptional case of AFX arising in a discoid lupus erythematosus (DLE) scar.
Case Report A 69-year-old male who was under periodic follow-up at our clinic for a histologically confirmed DLE mainly localized on his head, started about 20 years previously and stabilized with hydroxychloroquine 200 mg/d for the last 7 years (Figure 1A), presented 3 months after the last visit for evaluation of a new asymptomatic lesion arising on a previous DLE scar on the left temporal region. The neoformation appeared about 2 months earlier and had increased rapidly in size. Physical examination revealed a violaceous, firm, irregular nodule 8 mm in diameter (Figure IB). Except for DLE scars, no other significant skin or mucosal lesions were seen and no lymphadenopathy was present. The lesion was excised with
DECKER^ Canadian Dermatology Association I Journal o f Cutaneous Medicine and Surgery, Vol 18, No 5 (September/October), 2014: pp 353-355
353
De Francesco et al
Figure 1. A, Discoid lupus erythematosus (DLE) scar on the left temporal region (photograph dating back 6 m onths earlier). B, Violaceous, firm, irregular nodule 8 mm in diameter on the same DLE scar shown in A.
a margin of 1 cm and submitted to histologic examination, which revealed dermal cell proliferation of bizarre spindle cells with pleomorphic and hyperchromatic nuclei and atypical mitoses (Figure 2). There was no vascular or perineural invasion or necrosis. On immunohistochemistry, tumor cells were positive for CD68, CD 10, vimentin, and smooth muscle actin (focal positivity) and negative for CD34, S-100 protein, melan-A, desmin, pancytokeratin (clone AE1/ AE3), CD99, and CD117. Based on the clinical, histologic, and immunochemical data, we made a diagnosis of AFX. A sonogram of locoregional lymph nodes and the abdomen and a chest radiograph were negative. There was no evidence of local recurrence or distant metastasis during a 4-month follow-up period.
Discussion There have been several case studies indicating an increased risk of malignancy associated with connective tissue disorders.2,3 In particular, malignant change in the scars of DLE is a well-known event, with a latency period that may vary widely, from a few years to decades. In most cases, tumors are of epithelial origin, particularly squa mous cell carcinomas and, less frequently, basal cell carcinomas and keratoacanthomas.4,3 Instead, the onset of soft tissue sarcomas in a DLE scar is a very rare event because only one case of “malignant fibrous histiocytoma” (MFH) has been described in the literature/’ Regarding this last report, dating back to 1988, the authors described a dermal lesion mainly consisting of a dense infiltrate of spindle cells with moderate pleomorphism and a high mitotic rate that showed no stain for cytokeratin or epithelial membrane antigens by the immunoperoxidase method.6 In our opinion, these findings, in association with the lack of a complete im m unohistochemical
Figure 2. A, Dermal massive proliferation in an expansile and welldemarcated fashion (hematoxylin-eosin stain; original magnification X 100). B, Bizarre spindle cells with pleomorphic and hyperchromatic nuclei in the dermis; atypical mitoses are also seen (hematoxylin-eosin stain; original magnification X200). C, Magnification (X400) o f the previous image.
evaluation, do not allow us to exclude an AFX, which is the most likely diagnosis because the key histologic indicators for MFH, including deep invasion (deep subcutis/fascia), necrosis, and perineural/perivascular invasion,7 were not present.6 The exact etiology of the development of malignancies in DLE scars is still not completely clear, but several hypotheses have been suggested. With regard to epithelial tumors, the most widespread theory emphasizes that UV light exposure plays a primary causal role, compounded by the decrease in protective melanin in DLE with hypopigmentation.5,8 However, this explicative model is hardly applicable in those cases in which the tum or arises in
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 5 (September/October), 2014: pp 353—355
Atypical Fibroxanthoma and DLE
lesions of DLE in a sun-protected area.9 Genetic predis position, severity of DLE, and human papillomavirus infection of discoid lesions are other hypothesized secondary factors.4,8,9 Furthermore, some authors have also speculated on a hypothetical, but indeterminate, contribution of the chronic scarring process. 8 This, together with chronic inflammation per se, has also been considered a possible causal factor for the development of soft tissue sarcomas from DLE, by unknown mechanisms.6 In general, scars of various origin are common vulnerable areas for the subsequent development of cutaneous tumors, including AFX, 10,11 and according to recent studies, such an event would be due to the interruption of the normal innervation and lymphatic network occurring in scarring sites, with a consequent imbalance of lymphatic circulation and release of neuromediators. 12 These changes would lead to an alteration of local cutaneous immunity, which would favor hyperreactivity and, consequently, immune disorders or immunosuppression that would facilitate the onset of skin infections or cancer. 12,13 Based on the foregoing, it is likely that in our case, local immunosuppression, indirectly induced by scarring, and UV exposure, which are both known risk factors for the development of AFX, could be the causal factors under lying the malignant change.
Conclusion Although we cannot exclude an accidental association between AFX and DLE, our case emphasizes that patients with DLE, even though it may be clinically inactive for many years, may develop AFX in the context of an old scar. This possibility further underlines the importance of strict and long-term surveillance of people with DLE to identify and remove eventual tumors at an early stage to avoid possible distant diffusion.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References 1. Ziemer M. Atypical fibroxanthoma. J Dtsch Dermatol Ges 2012;10: 537-50. 2. Parodi PC, Riberti C, Draganic Stinco D, et al. Squamous cell carcinoma arising in a patient with long-standing pansclerotic morphea. Br J Dermatol 2001;144:417-9, doi: 10.1046/i.13652133.2001.04041.x. 3. Ragnarsson O, Grondal G, Steinsson K. Risk of malignancy in an unselected cohort of Icelandic patients with systemic lupus erythematosus. Lupus 2003;12:687-91, doi:10.1191/0961203303 lu443oa. 4. Dhingra M, Bhalla M, Tharm GP, Mittal P. Metastasizing squamous cell carcinoma arising from chronic discoid lupus erythematosus plaque of recent onset. Indian J Dermatol Venereol Leprol 2011;77:626, doi: 10.4103/0378-6323.84078. 5. Minicucci EM, Weber SA, Stolf HO, et al. Keratoacanthoma of the lower lip complicating discoid lupus erythematosus in a 14-yearold boy. Pediatr Dermatol 2007;24:329-30, doi:10.1111/j.l5251470.2007.00419.x. 6. Farber JN, Koh HK. Malignant fibrous histiocytoma arising from discoid lupus erythematosus. Arch Dermatol 1988;124:114-6, doi:10.1001/archderm. 1988,01670010078025. 7. Withers AH, Brougham ND, Barber RM, Tan ST. Atypical fibroxanthoma and malignant fibrous histiocytoma. J Plast Reconstr Aesthet Surg 2011;64:e273-8, doi:10.1016/j.bips.2011.05.004. 8. Ee HL, Ng PP, Tan SH, Goh CL. Squamous cell carcinoma developing in two Chinese patients with chronic discoid lupus erythematosus: the need for continued surveillance. Clin Exp Dermatol 2006;31:542-4, doi:10.1111/j.l365-2230.2006.02154.x. 9. Alsanafi S, Werth VP. Squamous cell carcinomas arising in discoid lupus erythematosus scars: unusual occurrence in an AfricanAmerican and in a sun-protected area. J Clin Rheumatol 2011;17: 35-6, doi:10.1097/RHU.0b013e3182051928. 10. Ergtin SS, Biiyiikbabani N, Su 6 . Atypical fibroxanthoma in a chronic burn scar of the cheek. J Dermatol 2011;38:1000-3, doi:10.1Ul/j.l346-8138.2010.01193.x. 11. Ito A, Yamada N, Yoshida Y, et al. Myofibroblastic differentiation in atypical fibroxanthomas occurring on sun-exposed skin and in a burn scar: an ultrastructural and immunohistochemical study. J Cutan Pathol 2011;38:670-6, doi: 10.1111/j, 1600-0560.2011,01708.x. 12. Ruocco V, Brunetti G, Puca RV, Ruocco E. The immunocom promised district: a unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites. J Eur Acad Dermatol Venereol 2009;23:1364-73, doi:10.111l/j.1468-3083. 2009.03345.x. 13. Errichetti E, Piccirillo A, Ricciuti F, Ricciuti F. Multiple actinic keratoses and squamous carcinomas at the site of prior herpes zoster. J Dermatol 2013;40:219-20, doi:l0.1111/1346-8138.12038.
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 5 (September/October), 2014: pp 353-355
355
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Atypical Fibroxanthoma Arising in a Scar of Discoid Lupus Erythematosus Vincenzo De Francesco, Enzo Errichetti, Enrico Pegolo, and Giuseppe Stinco
Background: M a lig n a n t cha ng e in th e scars o f d is c o id lu p u s e ry th e m a to s u s IDLE) is a w e ll-k n o w n e ve n t. In m o s t cases, tu m o rs are o f e p ith e lia l o rig in , p a rtic u la rly sq u a m o u s cell carcin o m a s and, less fre q u e n tly , basal cell c a rcin o m a s an d k e ra to a ca n th o m a s. The o n s e t o f s o ft tis s u e s a rco m a s in a DLE scar is a ve ry rare e ve n t, h o w e v e r, because o n ly on e case o f m a lig n a n t fib ro u s h is tio c y to m a has been d e sc rib e d in th e lite ra tu re .
O bjective: W e d e scrib e th e fir s t d o c u m e n te d re p o rt o f a ty p ic a l fib ro x a n th o m a (AFX) a ris in g in an o ld scar o f DLE. Results: A lth o u g h w e c a n n o t e xclu d e an a ccid e n ta l a sso cia tio n b e tw e e n AFX an d DLE, o u r case em p h a size s th a t p a tie n ts w ith DLE m a y d e v e lo p AFX in th e c o n te x t o f an o ld scar.
Conclusion: O u r fin d in g fu rth e r u n d e rlin e s th e im p o rta n c e o f s tric t an d lo n g -te rm s u rve illa n ce o f p e o p le w ith DLE to id e n tify and re m o v e e v e n tu a l tu m o rs a t an e a rly stage.
Contexte: La tra n s fo rm a tio n m a lig n e des cica trice s de lu p u s e ry th e m a te u x d is c o id e (LED) e st un f a it bie n co n n u . Dans la p lu p a rt des cas, les tu m e u rs s o n t d 'o rig in e e p ith e lia le ; il s 'a g it en p a rtic u lie r de ca rcin o m e s sq u a m e u x, m a is aussi de ca rcin o m e s ba so ce llu la ire s e t de k e ra to a c a n th o m e s , bie n qu e le u r fre q u e n ce s o it m o in d re . T o u te fo is , il e st tre s rare q u e des sarco m es des tis s u s m o u s p re n n e n t naissance da ns des cica trice s de LED; en e ffe t, la d o c u m e n ta tio n ne fa it e ta t qu e d 'u n seul cas d 'h is tio c y to m e fib re u x m a lin .
O bjectif: L 'e tu d e vise a d e crire le p re m ie r cas d o c u m e n ts de fib ro x a n th o m e a ty p iq u e (FA) q u i a p ris naissance dans un e an cie n n e c ic a tric e de LED. Resultats. Bien qu un e a sso c ia tio n a c c id e n te lle e n tre le FA e t le LED ne p u isse e tre ecartee, le cas d e c rit ici fa it re s s o rtir la p o s s ib ility d e v o lu tio n du LED ve rs le FA da ns le c o n te x te d 'u n e an cie n n e cica trice.
Conclusion: Les re s u lta ts de l'e tu d e f o n t re s s o rtir d a va n ta g e I'im p o rta n c e d 'u n s u iv i rig o u re u x e t p ro lo n g e chez les p a tie n ts a tte in ts de LED a fin de p e rm e ttre I'id e n tific a tio n e t I'exerese precoces d 'e v e n tu e lle s tu m e u rs .
typical fibroxanthoma (afx) is an uncom mon cutaneous neoplasm of fibrocytic or myofibrocytic differentiation that usually develops rapidly over several m onths on the sun-exposed skin of elderly individuals as a painless, firm, skin-colored or brownred, frequently ulcerated, usually immovable nodule. Ultraviolet (UV) light exposure, irradiation, and im mu nosuppression would be the most likely risk factors for its development. Despite the malignant appearance
A
From the Department o f Experimental and Clinical Medicine, DISM, Institute o f Dermatology, University o f Udine, and Department o f Medical and Biological Sciences, Institution o f Anatom ic Pathology, Azienda Ospedaliero-Univeristaria S. Maria della Misericordia, Udine, Italy. Address reprint requests to: Enzo Errichetti, MD, Institute o f Dermatology, University o f Udine, Ospedale '‘San Michele," Piazza Rodolone, 1, 33013Gemona del Friuli (Udine), Italy; e-mail:[email protected].
DOI 10.2310/7750.2013.13144 © 2014 Canadian Dermatology Association
histopathologically, AFX generally follows a benign clinical course, although in some cases, it may metastasize. Local excision is curative in most patients.1 Here we report an exceptional case of AFX arising in a discoid lupus erythematosus (DLE) scar.
Case Report A 69-year-old male who was under periodic follow-up at our clinic for a histologically confirmed DLE mainly localized on his head, started about 20 years previously and stabilized with hydroxychloroquine 200 mg/d for the last 7 years (Figure 1A), presented 3 months after the last visit for evaluation of a new asymptomatic lesion arising on a previous DLE scar on the left temporal region. The neoformation appeared about 2 months earlier and had increased rapidly in size. Physical examination revealed a violaceous, firm, irregular nodule 8 mm in diameter (Figure IB). Except for DLE scars, no other significant skin or mucosal lesions were seen and no lymphadenopathy was present. The lesion was excised with
DECKER^ Canadian Dermatology Association I Journal o f Cutaneous Medicine and Surgery, Vol 18, No 5 (September/October), 2014: pp 353-355
353
De Francesco et al
Figure 1. A, Discoid lupus erythematosus (DLE) scar on the left temporal region (photograph dating back 6 m onths earlier). B, Violaceous, firm, irregular nodule 8 mm in diameter on the same DLE scar shown in A.
a margin of 1 cm and submitted to histologic examination, which revealed dermal cell proliferation of bizarre spindle cells with pleomorphic and hyperchromatic nuclei and atypical mitoses (Figure 2). There was no vascular or perineural invasion or necrosis. On immunohistochemistry, tumor cells were positive for CD68, CD 10, vimentin, and smooth muscle actin (focal positivity) and negative for CD34, S-100 protein, melan-A, desmin, pancytokeratin (clone AE1/ AE3), CD99, and CD117. Based on the clinical, histologic, and immunochemical data, we made a diagnosis of AFX. A sonogram of locoregional lymph nodes and the abdomen and a chest radiograph were negative. There was no evidence of local recurrence or distant metastasis during a 4-month follow-up period.
Discussion There have been several case studies indicating an increased risk of malignancy associated with connective tissue disorders.2,3 In particular, malignant change in the scars of DLE is a well-known event, with a latency period that may vary widely, from a few years to decades. In most cases, tumors are of epithelial origin, particularly squa mous cell carcinomas and, less frequently, basal cell carcinomas and keratoacanthomas.4,3 Instead, the onset of soft tissue sarcomas in a DLE scar is a very rare event because only one case of “malignant fibrous histiocytoma” (MFH) has been described in the literature/’ Regarding this last report, dating back to 1988, the authors described a dermal lesion mainly consisting of a dense infiltrate of spindle cells with moderate pleomorphism and a high mitotic rate that showed no stain for cytokeratin or epithelial membrane antigens by the immunoperoxidase method.6 In our opinion, these findings, in association with the lack of a complete im m unohistochemical
Figure 2. A, Dermal massive proliferation in an expansile and welldemarcated fashion (hematoxylin-eosin stain; original magnification X 100). B, Bizarre spindle cells with pleomorphic and hyperchromatic nuclei in the dermis; atypical mitoses are also seen (hematoxylin-eosin stain; original magnification X200). C, Magnification (X400) o f the previous image.
evaluation, do not allow us to exclude an AFX, which is the most likely diagnosis because the key histologic indicators for MFH, including deep invasion (deep subcutis/fascia), necrosis, and perineural/perivascular invasion,7 were not present.6 The exact etiology of the development of malignancies in DLE scars is still not completely clear, but several hypotheses have been suggested. With regard to epithelial tumors, the most widespread theory emphasizes that UV light exposure plays a primary causal role, compounded by the decrease in protective melanin in DLE with hypopigmentation.5,8 However, this explicative model is hardly applicable in those cases in which the tum or arises in
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 5 (September/October), 2014: pp 353—355
Atypical Fibroxanthoma and DLE
lesions of DLE in a sun-protected area.9 Genetic predis position, severity of DLE, and human papillomavirus infection of discoid lesions are other hypothesized secondary factors.4,8,9 Furthermore, some authors have also speculated on a hypothetical, but indeterminate, contribution of the chronic scarring process. 8 This, together with chronic inflammation per se, has also been considered a possible causal factor for the development of soft tissue sarcomas from DLE, by unknown mechanisms.6 In general, scars of various origin are common vulnerable areas for the subsequent development of cutaneous tumors, including AFX, 10,11 and according to recent studies, such an event would be due to the interruption of the normal innervation and lymphatic network occurring in scarring sites, with a consequent imbalance of lymphatic circulation and release of neuromediators. 12 These changes would lead to an alteration of local cutaneous immunity, which would favor hyperreactivity and, consequently, immune disorders or immunosuppression that would facilitate the onset of skin infections or cancer. 12,13 Based on the foregoing, it is likely that in our case, local immunosuppression, indirectly induced by scarring, and UV exposure, which are both known risk factors for the development of AFX, could be the causal factors under lying the malignant change.
Conclusion Although we cannot exclude an accidental association between AFX and DLE, our case emphasizes that patients with DLE, even though it may be clinically inactive for many years, may develop AFX in the context of an old scar. This possibility further underlines the importance of strict and long-term surveillance of people with DLE to identify and remove eventual tumors at an early stage to avoid possible distant diffusion.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References 1. Ziemer M. Atypical fibroxanthoma. J Dtsch Dermatol Ges 2012;10: 537-50. 2. Parodi PC, Riberti C, Draganic Stinco D, et al. Squamous cell carcinoma arising in a patient with long-standing pansclerotic morphea. Br J Dermatol 2001;144:417-9, doi: 10.1046/i.13652133.2001.04041.x. 3. Ragnarsson O, Grondal G, Steinsson K. Risk of malignancy in an unselected cohort of Icelandic patients with systemic lupus erythematosus. Lupus 2003;12:687-91, doi:10.1191/0961203303 lu443oa. 4. Dhingra M, Bhalla M, Tharm GP, Mittal P. Metastasizing squamous cell carcinoma arising from chronic discoid lupus erythematosus plaque of recent onset. Indian J Dermatol Venereol Leprol 2011;77:626, doi: 10.4103/0378-6323.84078. 5. Minicucci EM, Weber SA, Stolf HO, et al. Keratoacanthoma of the lower lip complicating discoid lupus erythematosus in a 14-yearold boy. Pediatr Dermatol 2007;24:329-30, doi:10.1111/j.l5251470.2007.00419.x. 6. Farber JN, Koh HK. Malignant fibrous histiocytoma arising from discoid lupus erythematosus. Arch Dermatol 1988;124:114-6, doi:10.1001/archderm. 1988,01670010078025. 7. Withers AH, Brougham ND, Barber RM, Tan ST. Atypical fibroxanthoma and malignant fibrous histiocytoma. J Plast Reconstr Aesthet Surg 2011;64:e273-8, doi:10.1016/j.bips.2011.05.004. 8. Ee HL, Ng PP, Tan SH, Goh CL. Squamous cell carcinoma developing in two Chinese patients with chronic discoid lupus erythematosus: the need for continued surveillance. Clin Exp Dermatol 2006;31:542-4, doi:10.1111/j.l365-2230.2006.02154.x. 9. Alsanafi S, Werth VP. Squamous cell carcinomas arising in discoid lupus erythematosus scars: unusual occurrence in an AfricanAmerican and in a sun-protected area. J Clin Rheumatol 2011;17: 35-6, doi:10.1097/RHU.0b013e3182051928. 10. Ergtin SS, Biiyiikbabani N, Su 6 . Atypical fibroxanthoma in a chronic burn scar of the cheek. J Dermatol 2011;38:1000-3, doi:10.1Ul/j.l346-8138.2010.01193.x. 11. Ito A, Yamada N, Yoshida Y, et al. Myofibroblastic differentiation in atypical fibroxanthomas occurring on sun-exposed skin and in a burn scar: an ultrastructural and immunohistochemical study. J Cutan Pathol 2011;38:670-6, doi: 10.1111/j, 1600-0560.2011,01708.x. 12. Ruocco V, Brunetti G, Puca RV, Ruocco E. The immunocom promised district: a unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites. J Eur Acad Dermatol Venereol 2009;23:1364-73, doi:10.111l/j.1468-3083. 2009.03345.x. 13. Errichetti E, Piccirillo A, Ricciuti F, Ricciuti F. Multiple actinic keratoses and squamous carcinomas at the site of prior herpes zoster. J Dermatol 2013;40:219-20, doi:l0.1111/1346-8138.12038.
Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 5 (September/October), 2014: pp 353-355
355
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
