An unusual case of multiple melanoma and non-melanoma skin cancers of the leg.

Dear Editors, Skin cancers are a very common malignancy. According to American Cancer Society estimates, more than 70 000 new cases of invasive melanoma and more than 53 000 new cases of melanoma in situ will have occurred in the USA by the end of 2011 (1). However, the annual incidence of non-melanoma skin cancers, such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is more difficult to estimate. Early diagnosis and treatment provide the best chance for survival and reduced morbidity. In patients with BCC, the prognosis is relatively good, but some BCC forms, such as infiltrative and morpheaform BCC, are associated with the highest recurrence rates and greatest morbidity (2). A rare and often misdiagnosed complication is the malignant transformation of chronic ulcers of the lower limbs. In the majority of these cases, the malignancy consists of a rare, but highly aggressive SCC which has an average of three decades of latency before malignant transformation (3). We report a case of a 72-year-old woman who presented to our facility complaining of a chronic wound on the ventral lower side of the right leg. Ten years prior the patient had reported for surgical excision of a skin lesion histologically identified as melanoma. Physical examination of the right leg skin revealed a shallow ulcer of 4× 2 cm diameter and skin lesions with mean diameter ranging 0.5–1.5 cm. The ulcer had a well-defined border and a plain wound bed appearing as granulation tissue with no necrosis (Figure 1). Signs of chronic venous insufficiency were found on both legs and feet. The patient reported that the ulcer had surfaced 3 years before. After 2 months of daily topical treatment with various dressings, including disinfection with sodium hypoclorite 0.05% (Amukine Med® 0,05%, Amuchina S.p.A.; Genova, Italy) and iodopividone 0.5% (Betadine®, Meda Pharma S.p.A.; Milano, Italy), the ulcer healed. Six months after healing, a new wound arose on the scar (Figure 2). Several biopsy specimens were obtained from the margin of the ulcer and a diagnosis of BCC of the lower leg was established. The patient received a total excision of the lesion and the defect was covered with a split-thickness skin graft. Surgical excision of the remaining skin lesions, histologically identified as BCC, was then performed. The excision margins were free of tumour and the patient has been symptom-free ever since. Skin cancers are associated with significant morbidity, especially in patients with recurrent or multiple simultaneous tumours, burdened by years of surgeries and the resultant economic, social and emotional costs of treatment and possibly, disfigurement. The hope for such patients is to develop Figure 1 First observation: shallow ulcer on the lower third of the right leg.