Multiple Squamous Cell Carcinomas and Eruptive Keratoacanthomas in an Arc Welder

Abstract

The authors have indicated no significant interest with commercial supporters. W e report an arc welder who developed 51 squamous cell carcinomas (SCCs) on the dorsal upper extremities after 10 years of unprotected arc welding. SCCs began to appear 27 years after he started welding. Mohs surgery and acitretin were necessary to control his disease. Case ReportA 52-year-old Caucasian man, Fitzpatrick skin type III, was referred to our clinic in 2007 for three eruptive SCCs adjacent to two recent surgical sites in which tumor-free margins were confirmed. Past history was negative for carcinogenic exposure and immunosuppression. As a child and teenager, he participated in outdoor activities on the weekends and summers and had occasional sunburns. Other sources of significant sun exposure were not identified. He had received multiple tattoos on his upper extremities beginning approximately 30 years before his initial visit. Occupational history revealed that he had worked as a metal arc welder indoors in a boiler plant beginning 27 years before the eruption of his first SCC. He welded approximately 4 hours per day for 10 years and reported not wearing protective clothing. Typical work attire included a sleeveless shirt, jeans, and leather boots. He reported multiple small burns from molten metal spatter and feeling "sunburned" on his upper extremities after welding. Initial examination revealed multiple small circular scars and ultraviolet radiation (UVR) damage, which consisted of spotty depigmentation, hyperpigmentation, and mild erythema of the exposed face, neck, and upper extremities. A small number of fine actinic keratoses were noted on the upper extremities. Multiple multicolored and black tattoos were noted on his dorsal upper extremities. Mohs surgery was used to treat the three SCCs and two additional SCCs found on initial examination (Figure 1), with suspected metal fragments found intraoperatively. Acitretin was started at his initial visit in 2007. He continued to develop multiple keratoacanthomas (KAs) adjacent to surgical sites and SCCs at distant sites, with a halt of tumor formation in 2009. Acitretin was discontinued in 2010 after a 1-year tumor-free period. In 2012, tattoo application over preexisting tattoos (Figure 2) resulted in the formation of new eruptive SCCs and KAs within these tattoos (Figure 3). Of 54 total lifetime skin cancers, all were SCCs-51 on the dorsal upper extremities and three on the face. The location and associated factors for the 51 SCCs are depicted in Figure 4. All sites were treated using Mohs surgery. Examination for occult malignancy was negative.

Skin cancer and welding

“…Four case reports indicated that the welder or an assistant had not worn proper protective clothing such as shields and gloves. [15][16][17][18] In addition, five case-control studies have been published concerning the potential link between welding and skin cancer ( Table 2). 9,[19][20][21][22] Four of the five studies did not find an increased prevalence of skin cancer in welders.…”

“…Skin cancer type n Currie and Monk, 2000 16 Basal cell carcinoma 3 Donoghue and Sinclair, 1999 17 1 Ewing et al, 1971 23 1 Goetze and Elsner, 2014 24 1 Ratner et al, 2001 25 1 Currie and Monk, 2000 16 Squamous cell carcinoma 2 Wolfe et al, 2013 18 1 Caroe TK et al, 2013 26 Unknown or mixed types 5 Dixon et al, 2007 15 1 Similarly, Zamanian et al 19 found no significant differences in skin cancers in welders vs. nonwelders, yet the mean age of welders in their study was only 36 years. The patient populations in these studies may have been too young to appropriately investigate skin cancer risk.…”

Metal arc welding and the risk of skin cancer

“…Another casuistic study reported a woman who had presented with numerous SCC on her hands and forearms after assisting her son with welding business (Dixon 2007 ). Three other case reports depicted welders developing SCC and BCC after unprotected arc welding (Donoghue and Sinclair 1999 ; Kristensen and Sorensen 2015 ; Wolfe et al 2013 ). Although casuistic studies have demonstrated a potential risk of NMSC due to welding, the epidemiological evidence for an association between long-term arc welding and skin cancer is limited.…”

“…The suspicion linking welding with skin cancer originates from reports. Several case reports have been published of BCC and SCC occurring after years of arc welding (Currie and Monk 2000 ; Dixon 2007 ; Donoghue and Sinclair 1999 ; Kristensen and Sorensen 2015 ; Wolfe et al 2013 ). Currie et al reported on five cases of welders with non-melanoma skin cancer (NMSC) whose mean age at presentation was 52 years (Currie and Monk 2000 ).…”

Skin cancers arising within tattoos: A systematic review

“…A total of 20 cases of squamous cell carcinoma arising in a tattoo are described in the literature. 7 , 39 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 The cases were reported most frequently in males (50%) followed by females (40%) ( Table I ). Most of the lesions were located on the extremities (71.4%) ( Table I ).…”