SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2023 | VOLUME 21 | ISSUE 1 | 23 Dermatological examination revealed multiple hypertrophic, ulcerated skin lesions involving sun- exposed areas in the preauricular (5 × 10mm), post auricular (5 × 5mm) and V-neckline (6 × 5mm). No other suspicious lesions were noted. Furthermore, general clinical examination was unremarkable. Dermatology was consulted and curettage and cautery of all three lesions was performed. Histopathological examination of the pre- auricular and post auricular lesions revealed invasive SCC. Lympho-vascular and perineural invasion were absent. The lesion on the anterior aspect of the chest revealed a BCC with a nodular growth pattern. In addition, a staging whole- body computed tomography protocol did not reveal any other malignant focus elsewhere. Plastic surgery was consulted, and local excision of these lesions were performed followed by local cryotherapy. Azathioprine was stopped, and she was placed on subcutaneous methotrexate (15mg weekly). Her CD remained in clinical remission. The subsequent three- and six-monthly skin surveillance follow-up visits revealed macroscopic evidence of recurrence of these prior lesions which confirmed histopathological recurrence of BCC and SCC. Over the course of 2 years and 3 months, she was diagnosed with and treated for disease recurrence including new non-melanoma skin cancers involving the scalp, right aspect of the neck, forehead and shoulder and anterior aspect of the chest (Table 1 and Figure 2). Left side of the neck and anterior aspect of the chest. Table 1: History of procedures and histopathological diagnoses Date Site of skin lesion Procedure Diagnosis Nov 2020 1. Left side of neck 2. Left cheek 3. Anterior aspect of chest Cautery and curettage of all three lesions SCC SCC BCC Feb 2021 1. Scalp 2. Left side of neck Punch biopsy Punch biopsy BCC BCC & SCC in situ (Fig 2B) Mar 2021 1. Left side of neck 2. Left cheek 3. Skin of scalp 4. Anterior aspect of chest Excisional biopsies of all four lesions BCC & SCC Actinic keratosis BCC BCC May 2021 1. Left side of forehead 2. Left side of neck 3. Right side of neck Punch biopsy Cautery and curettage Cautery and curettage BCC BCC BCC Jun 2021 Right side of neck Cautery and curettage BCC Jul 2021 Right leg, lateral aspect Cautery and curettage BCC Aug 2021 1. Left side of forehead 2. Left shoulder Excisional biopsies of both lesions BCC (Fig 2A) BCC Feb 2023 Left side of neck x 2 lesions Punch biopsies of both lesions BCC x 2 BCC, basal cell carcinoma; SCC, squamous cell carcinoma Figure 2. Histopathology. A. Basal cell carcinoma of the left side of the forehead with an infiltrative growth pattern and overlying ulceration (haematoxylin and eosin, magnification 20x). B. Basal cell carcinoma of the left side of the neck with squamous cell carcinoma in situ in the overlying epidermis (haematoxylin and eosin, 20X magnification). Discussion Crohn’s disease (CD) forms part of the spectrum of inflammatory bowel disease (IBD) which is characterized by chronic relapsing inflammation involving the gastrointestinal tract resulting in significant morbidity related to recurrent hospitalisations, inherent risk for surgical intervention, immunosuppressive adverse effects, and independently increases the risk for both intestinal and extra-intestinal malignancy. Malignancies related to IBD, and chronic immune suppression include lymphomas, urinary tract cancers, acute myeloid leukaemia’s and skin cancers. Well described risk factors for skin cancers include high ultraviolet radiation exposure, high doses and prolonged duration of immunosuppression, prior history of skin cancer, lighter skin complexion, elderly, male gender, history of smoking and human papilloma viral infection. 1 The main therapeutic goal in the management of IBD is to induce and maintain clinical remission which can be achieved with the appropriate choice of immunosuppressive therapy. 2,3,4 Thiopurines, which consists of azathioprine and 6-mercaptopurine, are immunomodulators considered to be the backbone of immunosuppressive therapy capable of inducing and maintaining clinical remission in CD. Both agents are also effectively utilized in several autoimmune disorders including the improvement of patient survival by preventing tissue graft rejection in solid organ transplantation. 4 Concerns related to the carcinogenic effects of thiopurines were highlighted in 1987 by the International Agency for Research on Cancer which identified azathioprine as a human carcinogen as it has been associated with an increased risk for the development of non-melanoma skin cancer (NMSC) in organ transplant recipients, especially in patients on higher doses for a prolonged duration. 5 In the most recent South African National Cancer Registry, published in 2019, BCC and SCC were reported as being part of the top five cancers, representing 18% and 9% of all reported cancers respectively. The inherent malignancy risk related to IBD, and the mutagenic effects of azathioprine CASE REPORT