Scandinavian Journal of Plastic and Reconstructive Surgery
ISSN: 0036-5556 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iphs18
Metastasizing Basal Cell Carcinoma Torben Lildholdt & Helmer Søgaard To cite this article: Torben Lildholdt & Helmer Søgaard (1975) Metastasizing Basal Cell Carcinoma, Scandinavian Journal of Plastic and Reconstructive Surgery, 9:2, 170-173, DOI: 10.3109/02844317509022784 To link to this article: http://dx.doi.org/10.3109/02844317509022784
Published online: 08 Jul 2009.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iphs18 Download by: [Flinders University of South Australia]
Date: 22 March 2016, At: 20:20
Scand J Plast Reconstr Surg 9: 170-173, 1975
METASTASIZING BASAL CELL CARCINOMA Case Report
Torben Lildholdt and Helmer Sergaard From the Department of Plastic Surgery (Head: N . C. Petersen), the Department of Pathology (Heads: S. Olsen, J. Hastrup, E. Sommer Hansen and H. Sogaard), and the Radium Centre for Jurland (Heady: S. Kaae and A . P. Andersen), Arhus Kommunehospital, Arhus, Danmark
Downloaded by [Flinders University of South Australia] at 20:20 22 March 2016
(Submitted for publication March 25, 1975)
Abstract. Three cases of metastasizing basal cell carcinoma are presented. Metastases to regional lymph nodes occurred in 2 cases, and to both the humerus and the brain in the third. In all 3 patients, local recurrence developed in spite of apparently radical surgical removal of the primary tumour, and histological examination revealed distinct aggressive growth. The presence of metastases provides further evidence of the existence of an aggressive variety of the basal cell carcinoma. In these cases it is of particular importance that initial radical treatment is performed, and that the follow-up of the patients includes a check of the regional lymph nodes.
Ever since the first report on metastasizing basal cell carcinoma appeared in 1894, metastases from this type of neoplasm has for various reasons been the subject of discussion. First, the common basal cell carcinoma reveals a highly varying histological picture (Montgomery, 1967; Andersen, 1970). Accordingly, this neoplasm may be confused with other frequently metastasizing tumours arising, e.g., from epidermal appendages. Secondly, the metastases may, per se, give rise to misdiagnosis. As pointed out by Lattes & Kessler (1951), some of the previously reported cases have actually been carcinomata of the mixed basal cell and squamous cell type, while, in others, extensive invasive growth has been mistaken for a metastasis. In the reports published during recent years (Conway & Hugo, 1965; Assor, 1967; Wermuth & Fajardo, 1970), the criteria for the diagnosis of metastasizing basal cell carcinoma set up by Lattes & Kessler have been widely accepted. It is emphasized that a histological similarity between the primary tumour and the metastasis must exist, i.e., neoplastic proliferation of epithelial cells resembling those of the basal layer of the epidermis or hair matrix must Scand J Plast Reconstr Surg 9
have occurred, whereas areas with squamous cell differentiation must not be present. The sprzad must not have occurred by simple extension. Only 93 cases of metastasizing basal cel I carcinoma are on record in the literature (Costanza, Dayal, Binder & Nathanson, 1974). During recent years we have treated 3 patients with this rare condition. Case I Fig. 1. In 1962, a 55-year-old man was treated for a rightsided retro-auricular tumour, measuring 5 # 5 cm, which had developed over the previous 2 years. A biopsy specimen revealed basal cell carcinoma. Radiation therapy (200 kV' FSD 50 cm, 4 500 R) was followed by complete regression of the tumour. I n 1970, a recurrence in the scar was treated surgically with apparent success. In 1973, a rapidly growing neoplasm recurred both i n front and behind the right ear, with invasive growth into the underlying bone. The tumour was excised together with the lamina externa of the cranial bone, and the defect was covered with a skin flap from the occipital region. Histological examination revealed diffusely growing basal cell carcinoma, and, in certain areas, it seemed doubtful whethe. radical removal had been achieved. For psychological :easons, further surgical treatment was impossible at that)'. ie. A check-up examination 2 months :waled a f : ' - ' lump, measuring 2 x 1 cm, just above I -alien o' common carotid artery. Radical lymph .tion performed, and histological examinat on suspicion of metastases from a basal cell At the time of writing, the patient G signs of further metastases, but local : u n around the right auditory meatus. h w negative attitude of the patient a success, further treatment has been
Case 2 Fig. 2. A 53-year-old mentally retardeir the first time in October, 1973., For 25 yed
Downloaded by [Flinders University of South Australia] at 20:20 22 March 2016
Metastasizing basal cell carcinotna 171
Fig. 1. Case I . (a) Primary tumour at the upper attachment of the right ear. ( b ) Lymph node from the neck, containing metastases from the retro-auricular basal cell carcinoma.
There is no keratinization or spindle-shaped cells suggesting the presence of poorly differentiated squamous cell carcinoma, as is often seen after radiation therapy. y 25.
from recurrent ulcerations on the left leg; for the preceding 3 years these lesions had been treated conservatively by dermatologists. Physical examination revealed an ulcer, measuring 15 11 cm, on the lower left leg and a similar lesion, 5 x 5 cm, on the medial aspect of the left thigh. Biopsy specimens from the ulcerations showed basal cell carcinoma. A number of firm lymph nodes, of a diameter of up to 2.5 cm, were palpable in the left inguinal region. Both ulcers were excised and the defects covered with free skin grafts. Block dissection of the ilio-inguinal lymph nodes revealed further enlarged nodes, which, however, extended beyond the reach of surgery. Histological examination showed metastases from a basal cell carcinoma. At follow-up examination 6 months later, five ulcerations were observed outside the treated area on the left leg, but there were no signs of distant metastases. The ulcerations were excised and the defects covered with free skin grafts. Histologically, the removed tissue showed basal cell carcinoma of an aggressive appearance.
Case 3
rgz, ulcerated basal cell carcinomata on wrgicil removal.
Fig. 3. A 24-year-old woman was first seen in our hospital in 1966. The patient presented a scar of suspicious appearance in the right supra-orbital region, measuring 3 x 5 cm. It originated from a burn by a curling iron sustained at the age of 3 years. A biopsy specimen showed a highly aggressive basal cell carcinoma-an unusual form of tumour in a Marjolin’s ulcer (Giblin, Pickrell, Pitts & Armstrong, 1965). The area involved, including part of the underlying bone, was excised and covered with a skin flap from the arm. I n 1968, a rapidly progressing recurrence had arisen in the right upper eyelid and the orbit, with displacement of the eyeball. Evisceration of the orbit with excision of the adjacent skin was performed. The histological diagnosis was basal cell carcinoma. Scand J Plasl Reconslr Surg 9
Downloaded by [Flinders University of South Australia] at 20:20 22 March 2016
112
T. Lildholdt and H . S0guurd
Fig. 3. Case 3. Basal cell carcinoma in a burn scar. (a) 20 years after the accident, Marjolin's ulcer. (b) Photomicrograph of tissue from the primary tumour. x 51. ( c ) Needle biopsy specimen of the humerus showing metastases from the basal cell carcinoma. The bone structure is destroyed by the densely fibrous tumour stroma. ( 51).
In 1973, the patient complained OF pain which had persisted for a couple of months. Radiographs of the right humerus revealed a fracture of its proximal end in a suspicious area suggestive of metastases. A biopsy specimen from this area showed a metastasis from basal cell carcinoma. In 1974, the patient repeatedly had seizures of symptomatic epilepsy and complained of lumbar pain. Brain scanning and electroencephalography aroused suspicion of metastases involving the left hemisphere, and radiographs showed metastases to the lumbar vertebrae and the head of the right femur. Palliative irradiation was given, but the condition is progressing rapidly.
DISCUSSION It is a characteristic feature in the clinical course of our 3 patients that the metastases arose from tumows which had been present for several years. The tumours had been subjected to inadequate irradiation or surgical treatment, or they had been neglected in spite of their considerable size. Metastases most frequently occur in the regional Scand J Plasr Reronstr Surg 9
lymph nodes, and, as in our case 3, distant metastases may involve the brain and skeletal bones. In addition, metastases to the lungs and liver have been described (Conway & Hugo). The occurrence of metastases carries a grave prognosis, in all probability leading to a fatal outcome. Similar characteristic clinical features have been reported by Conway & Hugo, Werrnuth & Fajardo, Costanza et al., and others. ~ical In none of our three cases did h i ~ t ~ ~ n ~examination reveal any evidence of s q i r lo differentiation, but the tumcrur.i ,--og destructive infiltration of the -id In cases 2 and 3, the spread of 'W '.. wb. occurred along the nerves. A 5. ggiossive histological picture was described h y It is typical of our three cases i h t 7 the group of aggressive basal CAI
ISSN: 0036-5556 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iphs18
Metastasizing Basal Cell Carcinoma Torben Lildholdt & Helmer Søgaard To cite this article: Torben Lildholdt & Helmer Søgaard (1975) Metastasizing Basal Cell Carcinoma, Scandinavian Journal of Plastic and Reconstructive Surgery, 9:2, 170-173, DOI: 10.3109/02844317509022784 To link to this article: http://dx.doi.org/10.3109/02844317509022784
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 6
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iphs18 Download by: [Flinders University of South Australia]
Date: 22 March 2016, At: 20:20
Scand J Plast Reconstr Surg 9: 170-173, 1975
METASTASIZING BASAL CELL CARCINOMA Case Report
Torben Lildholdt and Helmer Sergaard From the Department of Plastic Surgery (Head: N . C. Petersen), the Department of Pathology (Heads: S. Olsen, J. Hastrup, E. Sommer Hansen and H. Sogaard), and the Radium Centre for Jurland (Heady: S. Kaae and A . P. Andersen), Arhus Kommunehospital, Arhus, Danmark
Downloaded by [Flinders University of South Australia] at 20:20 22 March 2016
(Submitted for publication March 25, 1975)
Abstract. Three cases of metastasizing basal cell carcinoma are presented. Metastases to regional lymph nodes occurred in 2 cases, and to both the humerus and the brain in the third. In all 3 patients, local recurrence developed in spite of apparently radical surgical removal of the primary tumour, and histological examination revealed distinct aggressive growth. The presence of metastases provides further evidence of the existence of an aggressive variety of the basal cell carcinoma. In these cases it is of particular importance that initial radical treatment is performed, and that the follow-up of the patients includes a check of the regional lymph nodes.
Ever since the first report on metastasizing basal cell carcinoma appeared in 1894, metastases from this type of neoplasm has for various reasons been the subject of discussion. First, the common basal cell carcinoma reveals a highly varying histological picture (Montgomery, 1967; Andersen, 1970). Accordingly, this neoplasm may be confused with other frequently metastasizing tumours arising, e.g., from epidermal appendages. Secondly, the metastases may, per se, give rise to misdiagnosis. As pointed out by Lattes & Kessler (1951), some of the previously reported cases have actually been carcinomata of the mixed basal cell and squamous cell type, while, in others, extensive invasive growth has been mistaken for a metastasis. In the reports published during recent years (Conway & Hugo, 1965; Assor, 1967; Wermuth & Fajardo, 1970), the criteria for the diagnosis of metastasizing basal cell carcinoma set up by Lattes & Kessler have been widely accepted. It is emphasized that a histological similarity between the primary tumour and the metastasis must exist, i.e., neoplastic proliferation of epithelial cells resembling those of the basal layer of the epidermis or hair matrix must Scand J Plast Reconstr Surg 9
have occurred, whereas areas with squamous cell differentiation must not be present. The sprzad must not have occurred by simple extension. Only 93 cases of metastasizing basal cel I carcinoma are on record in the literature (Costanza, Dayal, Binder & Nathanson, 1974). During recent years we have treated 3 patients with this rare condition. Case I Fig. 1. In 1962, a 55-year-old man was treated for a rightsided retro-auricular tumour, measuring 5 # 5 cm, which had developed over the previous 2 years. A biopsy specimen revealed basal cell carcinoma. Radiation therapy (200 kV' FSD 50 cm, 4 500 R) was followed by complete regression of the tumour. I n 1970, a recurrence in the scar was treated surgically with apparent success. In 1973, a rapidly growing neoplasm recurred both i n front and behind the right ear, with invasive growth into the underlying bone. The tumour was excised together with the lamina externa of the cranial bone, and the defect was covered with a skin flap from the occipital region. Histological examination revealed diffusely growing basal cell carcinoma, and, in certain areas, it seemed doubtful whethe. radical removal had been achieved. For psychological :easons, further surgical treatment was impossible at that)'. ie. A check-up examination 2 months :waled a f : ' - ' lump, measuring 2 x 1 cm, just above I -alien o' common carotid artery. Radical lymph .tion performed, and histological examinat on suspicion of metastases from a basal cell At the time of writing, the patient G signs of further metastases, but local : u n around the right auditory meatus. h w negative attitude of the patient a success, further treatment has been
Case 2 Fig. 2. A 53-year-old mentally retardeir the first time in October, 1973., For 25 yed
Downloaded by [Flinders University of South Australia] at 20:20 22 March 2016
Metastasizing basal cell carcinotna 171
Fig. 1. Case I . (a) Primary tumour at the upper attachment of the right ear. ( b ) Lymph node from the neck, containing metastases from the retro-auricular basal cell carcinoma.
There is no keratinization or spindle-shaped cells suggesting the presence of poorly differentiated squamous cell carcinoma, as is often seen after radiation therapy. y 25.
from recurrent ulcerations on the left leg; for the preceding 3 years these lesions had been treated conservatively by dermatologists. Physical examination revealed an ulcer, measuring 15 11 cm, on the lower left leg and a similar lesion, 5 x 5 cm, on the medial aspect of the left thigh. Biopsy specimens from the ulcerations showed basal cell carcinoma. A number of firm lymph nodes, of a diameter of up to 2.5 cm, were palpable in the left inguinal region. Both ulcers were excised and the defects covered with free skin grafts. Block dissection of the ilio-inguinal lymph nodes revealed further enlarged nodes, which, however, extended beyond the reach of surgery. Histological examination showed metastases from a basal cell carcinoma. At follow-up examination 6 months later, five ulcerations were observed outside the treated area on the left leg, but there were no signs of distant metastases. The ulcerations were excised and the defects covered with free skin grafts. Histologically, the removed tissue showed basal cell carcinoma of an aggressive appearance.
Case 3
rgz, ulcerated basal cell carcinomata on wrgicil removal.
Fig. 3. A 24-year-old woman was first seen in our hospital in 1966. The patient presented a scar of suspicious appearance in the right supra-orbital region, measuring 3 x 5 cm. It originated from a burn by a curling iron sustained at the age of 3 years. A biopsy specimen showed a highly aggressive basal cell carcinoma-an unusual form of tumour in a Marjolin’s ulcer (Giblin, Pickrell, Pitts & Armstrong, 1965). The area involved, including part of the underlying bone, was excised and covered with a skin flap from the arm. I n 1968, a rapidly progressing recurrence had arisen in the right upper eyelid and the orbit, with displacement of the eyeball. Evisceration of the orbit with excision of the adjacent skin was performed. The histological diagnosis was basal cell carcinoma. Scand J Plasl Reconslr Surg 9
Downloaded by [Flinders University of South Australia] at 20:20 22 March 2016
112
T. Lildholdt and H . S0guurd
Fig. 3. Case 3. Basal cell carcinoma in a burn scar. (a) 20 years after the accident, Marjolin's ulcer. (b) Photomicrograph of tissue from the primary tumour. x 51. ( c ) Needle biopsy specimen of the humerus showing metastases from the basal cell carcinoma. The bone structure is destroyed by the densely fibrous tumour stroma. ( 51).
In 1973, the patient complained OF pain which had persisted for a couple of months. Radiographs of the right humerus revealed a fracture of its proximal end in a suspicious area suggestive of metastases. A biopsy specimen from this area showed a metastasis from basal cell carcinoma. In 1974, the patient repeatedly had seizures of symptomatic epilepsy and complained of lumbar pain. Brain scanning and electroencephalography aroused suspicion of metastases involving the left hemisphere, and radiographs showed metastases to the lumbar vertebrae and the head of the right femur. Palliative irradiation was given, but the condition is progressing rapidly.
DISCUSSION It is a characteristic feature in the clinical course of our 3 patients that the metastases arose from tumows which had been present for several years. The tumours had been subjected to inadequate irradiation or surgical treatment, or they had been neglected in spite of their considerable size. Metastases most frequently occur in the regional Scand J Plasr Reronstr Surg 9
lymph nodes, and, as in our case 3, distant metastases may involve the brain and skeletal bones. In addition, metastases to the lungs and liver have been described (Conway & Hugo). The occurrence of metastases carries a grave prognosis, in all probability leading to a fatal outcome. Similar characteristic clinical features have been reported by Conway & Hugo, Werrnuth & Fajardo, Costanza et al., and others. ~ical In none of our three cases did h i ~ t ~ ~ n ~examination reveal any evidence of s q i r lo differentiation, but the tumcrur.i ,--og destructive infiltration of the -id In cases 2 and 3, the spread of 'W '.. wb. occurred along the nerves. A 5. ggiossive histological picture was described h y It is typical of our three cases i h t 7 the group of aggressive basal CAI
