Acta Chir Belg, 2008, 108, 269-272
Metastatic Basal Cell Carcinoma
M. Akinci*, S. Aslan*, F. Markoç**, B. Cetin*, A. Cetin*
Department of General Surgery*, Department of Pathology**, Oncology Hospital, Ankara, Turkey.
Key words. Basal cell carcinoma ; metastasis ; non-melanoma skin cancer.
Introduction
Basal cell carcinoma (BCC) is one of the most prevalent
forms of cancer worldwide. Despite the large number of
BCCs diagnosed each year, the rate of metastatic BCC
ranges from 0.003-0.5% (1). Metastatic BCC typically
occurs in middle-aged men with a history of a recalcitrant BCC that has been refractory to conventional methods of treatment. The median age of onset of the primary
BCC is approximately 45 years. Although the time
interval between tumour onset and metastasis is approximately 9-12 years, once metastasis has been identified,
the average life expectancy is around 8 months (2).
Metastasis is usually to regional lymph nodes (60%),
lung (42%), bone (20%), skin (10%), and other sites
(2%).
In this article, we present a case with metastatic basal
cell carcinoma.
Case report
A 67-year-old man was admitted to the oncological surgery ward for basal cell carcinoma (BCC). He was diagnosed during 2000 in another hospital when a total excisional biopsy from a 30*25 cm partially ulcerated lesion
in the back, with a 5-year history, showed BCC. His skin
was closed with a graft. He came to our hospital two
years later in June 2002 with a recurrence of the lesion in
his back. When he was first seen in our hospital, he had
a 3*5 cm ulcerated, hard, cream-white colored lesion
with elevated borders in the right scapular region. The
patient was in good health without any symptoms except
the lesion in his back. There was no family history of
skin cancer and no personal basal cell nevus syndrome.
Abdominal ultrasonography was normal but thorax computed tomography showed mediastinal, carinal, subcarinal, aorticopulmonary lymphadenopathy. Chronic nodular changes were observed in lung parenchyma and inhomogeneous infiltrations were present in the right lower
lobe anterior segment. Peribronchial and septal thickening were observed in the basal portions of the lungs.
Fig. 1
Computerised Tomography showing defective area after
scapulectomy.
Follow-up with thoracic computed tomographies was
planned because of these findings. His lesion was
excised with at least 2 cm of disease-free margins plus
scapulectomy (Fig. 1). Pathology from this 21*16*8 cm
specimen revealed basal cell carcinoma of the kerototic
type. Microscopically, the tumour was composed of
nodular masses of basoloid cell groups with spiky outlines, displaying a rather uniform, large, oval, elongated
nucleus (Fig. 2). In the centre of the cell groups, there
were horn cysts with fully keratinized cells, which were
surrounded by parakeratotic nuclei. The cell groups had
irregular infiltrating edges, while peripheral palisading
and clefting was obvious. There were also large strands
of cells in a desmoplastic stroma. The tumour was ulcerative, had invaded the scapular bone and was metastatic
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Fig. 3
Computerised Tomography showing pulmonary metastatic
deposits.
Fig. 2
Skin tumour on the back showing features of a basal cell carcinoma (HE, 40).
to the lung. Tissue obtained from the scapular bone and
bronchial wall showed tumour with features similar to
those described in the primary tumour.
The tumour had invaded to the bone inferolaterally,
and was positive at the margins in the bone. Two of the
three subcapular lymphadenopathies were positive for
metastasis. Radiotherapy was started. The operation site
was closed with a free skin graft, 40 days later.
At his admission to our surgical ward in February
2003, he had a new, ulcerated lesion with a serous
discharge on 10 cm*8 cm area on the controlateral left
axilla. Ten days before this admission, this lesion had
been excisionally biopsied in a peripheral hospital,
showing basal cell carcinoma. All the previous biopsies
were reviewed in our pathology department and keratotic basal cell carcinoma was confirmed with virtually
identical histology to that seen in the right scapular
region. The patient was complaining of cough, dyspnea,
weakness and weight loss. Physical examination
revealed the lesion on the axilla, the operation scar on the
back and bilateral rhonchi. His admission chest X-ray
showed bilateral nodular infiltrations and thorax computed tomography revealed a striking increase in inhomogeneous infiltrations with pleural retractions compared
to the previous tomography suggesting pulmonary
metastasis (Fig. 3). His forced vital capacity (FVC) was
1.41 liters (44% predicted), forced expiratory volume at
1 second (FEV1) was 0.97 liters (38% predicted), peak
expiratory flow (PEF) was 3.95 liters/sec (55% predicted) and FEV1/FVC was 69% (91% predicted). Arterial
blood gas analysis, complete blood count and serum
biochemistry were within normal limits. Bronchoscopy
revealed hyperemic mucosa starting from the right
main bronchus. Middle lobe lateral segment ostium
was narrowed and its mucosa was oedematous. Punch
biopsy from the right lung also showed the malignant
epithelial tumour with a similar histologic structure to
the primary basal cell carcinoma. Chemotherapy was
started with Cisplatin 125 mg/m2/day and 5-fluorouracil
1000 mg/m2/day for 3 days once in every 21 days.
Hospital discharge was possible on the twenty-fifth
postoperative day. However, the patient suffered from
progressive haemoptysis and died of pulmonary metastases after six months.
Discussion
Metastasis from basal cell carcinoma is extremely rare,
unlike that from squamous cell carcinoma (3). According
to Latess’ and Kessler’s guidelines for establishing the
diagnosis of metastatic BCC, the primary lesion must be
a basal cell carcinoma originating from the skin, not
from mucous membrane. Metastasis must be to a distant
site and not due to extensive local growth of the primary
tumour, and finally the primary and metastatic lesion
must have a similar histologic structure (3, 4).
The size and site of the tumour, depth of invasion,
duration and recurrence of the disease, play important
roles in predicting metastasis from basal cell carcinoma (3). SNOW et al. analysed the size and distribution of
tumours of 45 patients with metastatic BCC. They found
the mean diameter of the primary BCC to be 8.7 cm and
that large (T2 and T3) and deep (T4) BCC accounts for
approximately 75% of metastatic tumours (2). In a
review of 78 metastatic BCC cases, the site of the primary tumour was mainly in the head and neck region.
Insufficient non-radical excision and radiation therapy of
the primary lesion may lead to the occurrence of metastasis (3, 5). Our patient had a large, deep lesion in the
back and suffered direct bone invasion that led to distant
metastasis. Deeply invasive trunk BCC and genital BCC
Metastatic Basal Cell Carcinoma
also appear to have a relatively high rate of metastasis,
given the low incidence of BCC originating from these
general lesions compared with the facial region (2). Our
patient had recurrence, lymph node metastasis, contralateral axilla skin metastasis and pulmonary metastasis two
years after excision of the primary lesion with a 5-year
history. In a cumulated series by Sakula of 30 cases with
pulmonary metastatic BCC, the average duration of the
disease was 11.4 years when metastasis occurred (6).
In previous case reports, good outcome was reported
after resection of the solitary pulmonary metastasis from
BCC (3, 7). In our case, the metastatic nodules were
bilateral and were not appropriate for surgical resection.
Metastatic BCC has been described with many histologic subtypes of BCC. There is no consensus as to
whether any histologic subtype of the primary tumour
predisposes to metastatic BCC (1). Nodular, micronodular, morpheaform, metatypical or basosquamous, and
keratotic histologies have all been reported (8). But BCC
which contains keratotic foci, as reported here, has a
prevalence of aggressive feature of 39%, and is observed
in 78% of basosquamous carcinomas (9). In the present
case, microscopically infiltrative tumour nests in the
desmoplastic stroma showed an aggressive growth pattern, peripheral palisading and clefting. In the centre of
the cell groups, there were horn cysts with fully keratinized cells. In the present case there was also a severe
clinical course. In the literature, squamous differentiation is reported to be more frequent in the metastasizing,
than in the non-metastasizing BCC (10). The keratotic
foci found in the present case support this concept.
In conclusion, metastatic BCC is a complication of
BCC with high morbidity and mortality rates. Patients
with metastatic BCC often begin with long-standing primary BCCs that are either large or recurrent and have a
higher incidence of the more aggressive histologic
patterns (morpheic, infiltrating, metatypical and
basosquamous) (1, 11, 12). Perineural spread, blood vessel invasion and squamous differentiation were found to
be evident in the primary lesions of metastatic cases (13).
Conventional surgical treatment of basal cell cancer is
an important issue, since inadequately excised basal cell
cancer may be a cause of recurrence and the recurring
tumour is a prognostic parameter of metastatic potential (1, 11). Two distinct surgical approaches are practiced in BCC excisions : en bloc excision and Mohs
micrographic surgery. A 4-mm surgical margin of clinically normal skin is the current standard for elliptical
excision of basal cell carcinomas (14). Histologic studies
have confirmed that the sub-clinical extension of disease
varies from 1-6 mm (15). Prior studies have shown a
recurrence rate as high as 35-38% for inadequately
excised tumours (16, 17). BISSON et al. have shown that,
given a 3 mm margin, 96% of lesions would have been
excised completely (18). However, a 4-mm surgical
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margin is often not feasible on lesions which are large,
recurrent and have deep structural invasion.
Tumours larger than 2 cm have wider sub-clinical
invasion than smaller lesions ; therefore, a tumour smaller than 2 cm would require a margin of only 4 mm to
achieve adequate clearance. Larger morpheaform BCC
requires a resection margin of 1-2 cm. The incidence of
recurrence following surgical excision is 30% for
patients with a positive margin, 12% with a close margin,
and less than 5% for complete excision (15). To avoid
repetitive operations and the risk of recurrence these
tumours should be treated with standard wide margins.
The principal aim of surgical treatment should be to
obtain complete excision of the tumour with uninvolved
margins. Cosmetic and functional concerns are secondary. The extent of the surgical margin required depends
on the histological type, and the clinician should expect
deeper and/or wider infiltration in patients with recurrent
tumours.
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M. Akinci et al.
M. Akinci, M.D
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Ankara, Turkey
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