Multiple types of cutaneous malignant tumors: A case report

Abstract

Cutaneous malignant tumors are common, prevalent malignancies with high and rising incidence rates. Less attention has been paid to cutaneous malignant tumors because of their wide range of sites, variety of clinical manifestations, and low impact on daily life. In this paper, we report a case of a 57-year-old male who developed multiple cutaneous malignant tumors over a period of 3 years. The patient’s multiple cutaneous lesions did not receive timely intervention when initially identified. Recognition of disease etiological factors and prompt therapeutic intervention upon disease onset are of critical clinical importance.

Introduction

Cutaneous malignant tumors represent the most common worldwide malignancy, and their incidence has been increasing over the past decades. ¹ Common cutaneous malignant tumors mainly include Bowen’s disease, basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. These diseases affect millions of people worldwide; however, skin diseases often receive little attention in daily life, leading to frequent delays in treatment. Herein, we present the case of a 57-year-old male who presented with multiple cutaneous malignant tumors.

Case presentation

The patient is a 57-year-old male who first presented to our hospital in December 2020 with an abdominal skin lesion that had been present for 5 years. As shown in Figure 1, the patient reported that over the course of 5 years, this skin lesion grew in size and was accompanied by itchiness. It is noteworthy that this patient has been engaged in pesticide sales for over 30 years. A histopathological biopsy was taken at the clinic to show that the skin lesion was an early basal cell carcinoma. For further treatment, the patient was hospitalized in the Department of Aesthetic Plastic Surgery, where he underwent extended resection of abdominal basal cell carcinoma and local flap transfer. After the surgery, the skin lesion located on the abdomen was sent for histopathological examination. The pathology report showed that this skin lesion was “basal cell carcinoma.”

Figure 1.

Preoperative photo of abdominal skin lesion.

In August 2023, this patient was readmitted to the Department of Aesthetic Plastic Surgery. This time, the patient reported finding multiple skin lesions on the left thumb, back of the left hand, left wrist, and left face for 2 years, and skin lesions on the anterior chest for 6 months. All of the skin lesions have been increasing in size and are accompanied by pain and itching. The patient had been treated with topical medications, but there was no significant effect. In particular, the skin lesion on the left thumb had repeatedly ulcerated and bled with pus over the past year. After the exclusion of contraindications to surgery, a total of five skin lesions were surgically excised and sent for histopathological examination. The skin lesion located on the left thumb was reported as “keratoacanthoma.” The skin lesions located on the left face and the lower back of the left hand were reported as “squamous cell carcinoma in situ.” The skin lesions located on the left wrist and the anterior chest were reported as “chronic inflammation of the skin and subcutaneous tissue.”

In December 2023, the patient went back to our clinic for further treatment of other skin lesions located on the upper back of the left hand and the back. The patient mentioned that over the past 2 years, these two lesions had been growing continuously. The lesion on the upper back of the left hand was frequently ulcerated and healed slowly. After the exclusion of contraindications to surgery, these two skin lesions were surgically excised and sent for histopathologic examination. In Figure 2, the process of treating the lesion on the upper back of the left hand is shown. The skin lesion located on the upper back of the left hand was reported as “squamous cell carcinoma.” The skin lesion located on the back was reported as “chronic inflammation of skin.”

Figure 2.

Treatment Process of the skin lesion on the upper back of the left hand. (a) Preoperative photo; (b) after an enlarged resection during surgery; (c) compression bandaging after skin grafting; (d) postoperative appearance.

During the 3 years from December 2020 to December 2023, the patient underwent three operations in our clinic to remove a total of eight skin lesions. A summary can be found in Table 1. Among them, four skin lesions were confirmed to be cutaneous malignant tumors (basal cell carcinoma and squamous cell carcinoma), one was confirmed to be a precancerous lesion ² (keratoacanthoma), and three were confirmed to be chronic inflammation of the skin. These lesions had progressed significantly over an extended period before receiving appropriate medical intervention.

Table 1.

Summary of information on treated lesions.

Lesion Information Record	Date of treatment	Location of the lesion	Duration of presence	Diagnosis
The first treatment	December 2020	Abdomen	5 years	Basal cell carcinoma
The second treatment	August 2023	Left thumb	2 years	Keratoacanthoma
		Lower back of left hand	2 years	Squamous cell carcinoma
		Left wrist	2 years	Chronic inflammation
		Left face	2 years	Squamous cell carcinoma
		Anterior chest	6 months	Chronic inflammation
The third treatment	December 2023	Upper back of left hand	2 years	Squamous cell carcinoma
		Back	2 years	Chronic inflammation

Discussion

Cutaneous malignant tumors are seen in people of all races and skin colors and can affect the entire life cycle. Cutaneous malignant tumors mostly occur in exposed areas of the body, 70%–80% occur in the head and face, ³ with basal cell carcinoma and squamous cell carcinoma being the most common.

Risk factors for the disease include ultraviolet light exposure, immunosuppression, infections, chemical carcinogens, genetic disorders, ionizing radiation, and chronic skin ulcers. ⁴

The treatment of cutaneous malignant tumors primarily involves surgical, nonsurgical, and combined approaches. The choice of treatment depends on factors such as the affected area, tumor size, degree of infiltration, tumor characteristics, and the patient’s preferences regarding cosmetic outcomes. The most common clinical treatment is surgical treatment, to completely remove the tumor and reduce the recurrence rate. Particularly, common surgical treatment methods include standard surgical excision and postoperative margin assessment, Mohs micrography, electrodesiccation, and curettage. As people’s demand for appearance is increasing, we are supposed to consider not only the complete removal of the lesion and prevention of tumor recurrence but also how to maximize the restoration of the patient’s appearance after wound repair.

In response to the specificity of this patient’s occupation, we hypothesized that the development of his multiple, multispecies cutaneous malignant tumors was associated with long-term exposure to pesticides. After numerous studies in recent decades, the correlation between pesticides and skin cancer has been established. However, most of the information on pesticide exposure in epidemiological surveys is obtained through questionnaires, so it is difficult to gain strong confidence. ⁵ Various neoplastic diseases have been reported to be associated with occupational exposure to organophosphate pesticides. ⁶ Pesticides act as an initiator in the process of cancer development. ⁷ At this stage, the carcinogenicity risk of chemical substances, including pesticides, to human beings is mainly based on the results of animal studies. Due to the differences between animals and human beings, it is inevitable that there will be bias in extrapolation. Therefore, the association between pesticides and cancer still needs further research.

We also have certain limitations in this case report. First, owing to technical limitations, we were unable to conduct comprehensive genetic testing for this patient. Consequently, we were unable to determine whether the patient harbored genetic predisposition factors or acquired mutations, although such information could be pivotal in elucidating the pathogenesis of multiple primary skin carcinomas. Second, our assessment of pesticide exposure relied predominantly on patient-reported history, lacking objective biomarker analysis (e.g. pesticide metabolite levels in the blood or lesional tissues), which may introduce inaccuracies or omissions in exposure documentation. Third, due to the loss of follow-up, we were unable to obtain subsequent clinical data from this patient, thus precluding assessment of long-term prognosis or tumor recurrence status. Furthermore, as a case report, we can only establish associations rather than causal relationships. The potential link between pesticide exposure and multifocal cutaneous malignancies requires further validation through large-scale epidemiological investigations. Further research is needed to delineate the molecular mechanisms underlying pesticide-induced cutaneous carcinogenesis.

Conclusion

With the increasing incidence of cutaneous malignant tumors, doctors are supposed to have sufficient knowledge of them and master their clinical features, especially for atypical skin lesions. Medical personnel are supposed to enhance public education on cutaneous malignant tumors through various channels to raise awareness about the dangers of these diseases and encourage individuals to prioritize early treatment.