CAMEO
MULTIPLE BONE METASTASES FROM BASAL CELL CARCINOMA ROBERT E. BEER, JOSEPH ALCALAY, M.D., AND LEONARD H. GOLDBERG, M.D., E.R.C.P.
A 43-year-old Caucasian man presented with a lesion on the left ear, tbe posterior auricular sulcus, and post-auricular scalp in November of 1987. The lesion measuring 9.9 x 7 cm was ulcerated and covered by a tbick black crust (Fig. 1). Tbe tumor bad been neglected for several years. The patient now sought treatment because of pain and the request of bis family. He also bad basal cell carcinoma (BCC) lesions of bis rigbt forehead (1.5 x 1.5 cm), rigbt pre-auricular cheek (2.0 X 2.0 cm), rigbt cbest, left upper back (4.5 x 6.8 cm), and right lower back (2.5 x 2.3 cm). The left ear BCC was initially excised in tbree stages using tbe Mobs micrograpbic surgery technique. Mobs surgery was terminated after the tbird stage because tbe outer border of the cartilaginous postauricular canal was positive for BCC. The patient was referred to bead and neck surgery for furtber resection. Head CT showed normal underlying bony structures. Chest x-ray was normal, EKG was unremarkable. Tbe left auricle was excised with a sleeve resection of the external canal and superficial parotidectomy. Tbe defect was closed using rotation flaps and a skin graft. Over the next 6 months the patient's otber BCC lesions were all completely excised using Mohs micrographic surgery. Figure 1. The primary lesion originating from the left ear and post-auricular sulcus.
In March 1989, tbe patient presented with the chief complaint of "trouble walking." He had been unable to walk without assistance over the past 10 days. He had sharp pain in the interscapular region of bis back tbat radiated bilaterally around eacb scapula to tbe lateral portion of tbe ribs. Tbe patient bad noted parasthesia in his lower legs that spread to his upper legs 2 days earlier. On pbysical examination, be had a broad gait, taking short steps with slight circumduction of eacb bip. He was unable to rise on his toes and beels. Reflexes were 3+ and symmetrical at the knees. Vibration and proprioception were intact to both great toes. Pin and cold sensation were diminished to the T8 sensory level. Tbe patient was taken to the OR for a posterior surgical decompression of the cord on the next day following preoperative radiologic studies. The bone marrow of the seventh thoracic vertebra was essentially replaced by tumor. Several osteoclasts were noted, but only a rare osteoblast could be found. Tbe tumor was a primitive basosquamous BCC witb a dense fibrous component (Fig. 2). The pathology specimen was compared to the slides from the left ear. The diagnosis of metastatic BCC to the spine was confirmed. The preoperative
CT scan showed lytic destruction in multiple skeletal sites including: the 7th and 8th thoracic vertebral bodies, posterior portion of several ribs, and both iliac crests. The patient's neurologic status continued to deteriorate after the first operation. Eight days later he was taken to surgery for an anterior decompression through the cbest wall for progressive paralysis syndrome. He received radiotherapy of 3000 rads to the thoracic spine T4-T11. A postoperative bone scan showed increased uptake in the skull, both scapulae, the 6th, 7th, and 8th thoracic vertebrae, the lumbar spine, the right 4th and 7th ribs, the left 3rd, 5th and 6tb ribs, the bony pelvis, and the greater trochanter of the right femur. The patient refused further chemotherapy after receiving two cycles of adriamycin and cis-platinum, which induced anemia and fatigue. The patient was able to ambulate well with tbe use of a walker. Metastases in the heart, lungs, liver, and kidneys were not found. In October 1989, the patient returned with worsening neurologic status. Harrington rods were placed for stabilization of the thoracic spine. Tbe patient became paraplegic and died 3 months later.
From the Department of Dermatology, Baylor Gollege of Medicine, Houston, Texas. DISCUSSION
Address for correspondence: Mr. Robert E. Beer, Department of Dermatology, Baylor Gollege of Medicine, One Baylor Plaza, Houston, TX 77030.
Basal cell carcinotna (BCC) is the most cotntnon type of cancer in the world today with ati incidence of 500,000 637
Intern.itional Journal of Dermatology Vol. 31, No. 9, September t992
•y.
>
•
'
Figure 2. Histologic specimen showing biopsy from the seventh thoracic vertebra with invasive basal cell carcinoma, (hematoxylin and eosin stain, original magnification x 100) new cases per year in the U.S.A.' Although BCC is considered a carcinoma of low metastatic potential, the prevalence of metastasis from BCC has been reported to vary frotn 0.0028% to 0.55%.^-' Metastasis to bone occurs in 20 to 30% of the cases.'-'' One hundred and seventy cases of metastatic basal cell carcinoma were reviewed by Domarus et al.' The median age at onset of the primary tumor was 45 years, with a ratige of 14-84.' The tnedian interval between onset of the primary tumor and first sign of metastasis was 9 years.^ The longest interval reported was 45 years.-' The median survival after first sign of metastasis has been reported from 8 to 14 months.'-'' There is a man to woman preponderance of 2.1:1.^ Several cases have presented with spinal cord compression.'' Only two were initially discovered in the thoracic vertebrae. Lumbar metastases being slightly more common than cervical. The cheek was the most comtnon site of the primary lesion. The mean interval between primary and metastatic lesion is 9 years. The mean survival following discovery of the spinal metastases is 11 months. Our patient was 45-years-old when he presented with signs of cord cotnpression due to BCC metastasis to the 6th, 7th, and 8th thoracic vertebrae. Multiple bony metastatic sites includitig the skull, vertebrae, the right 4th and 7th ribs, the left 3rd, 5th and 6th ribs, the scapulae, pelvis, and right fetnur were found. The presumed primary lesion was on his left ear. In our patient the interval between excision of the primary le-
sion and metastasis was only 16 months. This time interval may be artificially short since the primary lesion in our patient had been neglected for so long. Pathologic examination showed BCC with some keratin differentiation in both the 7th vertebra and the left ear. Our patient lived 10 months after the discovery of spinal metastases. Therapy for spinal metastases of BCC has not been firmly established. Sotne report radiation as efficacious as laminectomy and radiation.'' Chemotherapy, laminectomy, and radiation have all been effective single modalities. We chose to use all three tnodalities due to the severity and extent of malignancy in our patient. Factors which contribute to developtnent of metastasis are size and depth of tumor, inadequate resection, and resistance to surgical radiation therapy.*"-^ Sotne authors report the basosquamous type of BCC is more likely to metastasize than others.**"" One report estimates the incidence of tnetastasis of basosquamous BCC is 4 to 5% over 20 years." Lungs and the bony skeleton are the two most likely sites of hematogenous spread.' Metastasis of BCC remains a rare event. Both local and distant BCC metastases do infrequently occur. BCC metastasis tnay occur more often with the basosquamous type of BCC. Metastasizing BCC can be severely debilitating or fatal to the patient.
REFERENCES
1. 2.
3. 4.
5.
6.
7. 8.
9. 10.
11.
Silberbery E, Lubera JA. Gancer statistics. GA 1988; 38:5-22. Paver K, Poyzer K, Burry N, Deakin M. The incidence of basal cell carcinoma and their metastases in Australia and New Zealand. Australas J Dermatol 1973; 14:53. Domarus H, Stevens PJ. Metastatic basal cell carcinoma. J Am Acad Dermatol 1984; 113:1043-1060. Weshler Z, Leviatan A, Peled I, Wexler M. Spinal metastases of basal cell carcinoma. J Surg Oncol 1984; 25:28-33. Gonley J, Sachs ME, Romo T, et al. Metastatic basal cell carcinoma of the head and neck. Otolaryngol Head Neck Surg 1985; 93:79-85. Ghristensen M, Briggs RM, Goblenz MG. Metastatic basal cell carcinoma: a review of the literature and report of two cases. Am Surg 1978; 44:382-387. Kord JP, Gottel WI, Proper S. Metastatic basal cell carcinoma. J Dermatol Surg Oncol 1982; 8: 604-608. Farmer ER, Helwig EB. Metastatic basal cell carcinoma: a clinical pathologic study of seventeen cases. Gancer 1980; 46:748-757. Dierberg WJ, Shcpard GH, Davis FG. Metastasis from basal cell carcinoma. Va Med 1988; 115:584-587. Ambros RA, Standiford SB, Sobel HJ, et al. Rapid development of metastases from basal cell carcinoma presenting as cranial nerve palsies. J Dermatol Surg Oncol 1988; 14:1410-1412. Lopes de Faria J, Nunes PH. Basosquamous cell carcinoma of the skin with metastases. Histopathology 1988; 12:85-94. • '
MULTIPLE BONE METASTASES FROM BASAL CELL CARCINOMA ROBERT E. BEER, JOSEPH ALCALAY, M.D., AND LEONARD H. GOLDBERG, M.D., E.R.C.P.
A 43-year-old Caucasian man presented with a lesion on the left ear, tbe posterior auricular sulcus, and post-auricular scalp in November of 1987. The lesion measuring 9.9 x 7 cm was ulcerated and covered by a tbick black crust (Fig. 1). Tbe tumor bad been neglected for several years. The patient now sought treatment because of pain and the request of bis family. He also bad basal cell carcinoma (BCC) lesions of bis rigbt forehead (1.5 x 1.5 cm), rigbt pre-auricular cheek (2.0 X 2.0 cm), rigbt cbest, left upper back (4.5 x 6.8 cm), and right lower back (2.5 x 2.3 cm). The left ear BCC was initially excised in tbree stages using tbe Mobs micrograpbic surgery technique. Mobs surgery was terminated after the tbird stage because tbe outer border of the cartilaginous postauricular canal was positive for BCC. The patient was referred to bead and neck surgery for furtber resection. Head CT showed normal underlying bony structures. Chest x-ray was normal, EKG was unremarkable. Tbe left auricle was excised with a sleeve resection of the external canal and superficial parotidectomy. Tbe defect was closed using rotation flaps and a skin graft. Over the next 6 months the patient's otber BCC lesions were all completely excised using Mohs micrographic surgery. Figure 1. The primary lesion originating from the left ear and post-auricular sulcus.
In March 1989, tbe patient presented with the chief complaint of "trouble walking." He had been unable to walk without assistance over the past 10 days. He had sharp pain in the interscapular region of bis back tbat radiated bilaterally around eacb scapula to tbe lateral portion of tbe ribs. Tbe patient bad noted parasthesia in his lower legs that spread to his upper legs 2 days earlier. On pbysical examination, be had a broad gait, taking short steps with slight circumduction of eacb bip. He was unable to rise on his toes and beels. Reflexes were 3+ and symmetrical at the knees. Vibration and proprioception were intact to both great toes. Pin and cold sensation were diminished to the T8 sensory level. Tbe patient was taken to the OR for a posterior surgical decompression of the cord on the next day following preoperative radiologic studies. The bone marrow of the seventh thoracic vertebra was essentially replaced by tumor. Several osteoclasts were noted, but only a rare osteoblast could be found. Tbe tumor was a primitive basosquamous BCC witb a dense fibrous component (Fig. 2). The pathology specimen was compared to the slides from the left ear. The diagnosis of metastatic BCC to the spine was confirmed. The preoperative
CT scan showed lytic destruction in multiple skeletal sites including: the 7th and 8th thoracic vertebral bodies, posterior portion of several ribs, and both iliac crests. The patient's neurologic status continued to deteriorate after the first operation. Eight days later he was taken to surgery for an anterior decompression through the cbest wall for progressive paralysis syndrome. He received radiotherapy of 3000 rads to the thoracic spine T4-T11. A postoperative bone scan showed increased uptake in the skull, both scapulae, the 6th, 7th, and 8th thoracic vertebrae, the lumbar spine, the right 4th and 7th ribs, the left 3rd, 5th and 6tb ribs, the bony pelvis, and the greater trochanter of the right femur. The patient refused further chemotherapy after receiving two cycles of adriamycin and cis-platinum, which induced anemia and fatigue. The patient was able to ambulate well with tbe use of a walker. Metastases in the heart, lungs, liver, and kidneys were not found. In October 1989, the patient returned with worsening neurologic status. Harrington rods were placed for stabilization of the thoracic spine. Tbe patient became paraplegic and died 3 months later.
From the Department of Dermatology, Baylor Gollege of Medicine, Houston, Texas. DISCUSSION
Address for correspondence: Mr. Robert E. Beer, Department of Dermatology, Baylor Gollege of Medicine, One Baylor Plaza, Houston, TX 77030.
Basal cell carcinotna (BCC) is the most cotntnon type of cancer in the world today with ati incidence of 500,000 637
Intern.itional Journal of Dermatology Vol. 31, No. 9, September t992
•y.
>
•
'
Figure 2. Histologic specimen showing biopsy from the seventh thoracic vertebra with invasive basal cell carcinoma, (hematoxylin and eosin stain, original magnification x 100) new cases per year in the U.S.A.' Although BCC is considered a carcinoma of low metastatic potential, the prevalence of metastasis from BCC has been reported to vary frotn 0.0028% to 0.55%.^-' Metastasis to bone occurs in 20 to 30% of the cases.'-'' One hundred and seventy cases of metastatic basal cell carcinoma were reviewed by Domarus et al.' The median age at onset of the primary tumor was 45 years, with a ratige of 14-84.' The tnedian interval between onset of the primary tumor and first sign of metastasis was 9 years.^ The longest interval reported was 45 years.-' The median survival after first sign of metastasis has been reported from 8 to 14 months.'-'' There is a man to woman preponderance of 2.1:1.^ Several cases have presented with spinal cord compression.'' Only two were initially discovered in the thoracic vertebrae. Lumbar metastases being slightly more common than cervical. The cheek was the most comtnon site of the primary lesion. The mean interval between primary and metastatic lesion is 9 years. The mean survival following discovery of the spinal metastases is 11 months. Our patient was 45-years-old when he presented with signs of cord cotnpression due to BCC metastasis to the 6th, 7th, and 8th thoracic vertebrae. Multiple bony metastatic sites includitig the skull, vertebrae, the right 4th and 7th ribs, the left 3rd, 5th and 6th ribs, the scapulae, pelvis, and right fetnur were found. The presumed primary lesion was on his left ear. In our patient the interval between excision of the primary le-
sion and metastasis was only 16 months. This time interval may be artificially short since the primary lesion in our patient had been neglected for so long. Pathologic examination showed BCC with some keratin differentiation in both the 7th vertebra and the left ear. Our patient lived 10 months after the discovery of spinal metastases. Therapy for spinal metastases of BCC has not been firmly established. Sotne report radiation as efficacious as laminectomy and radiation.'' Chemotherapy, laminectomy, and radiation have all been effective single modalities. We chose to use all three tnodalities due to the severity and extent of malignancy in our patient. Factors which contribute to developtnent of metastasis are size and depth of tumor, inadequate resection, and resistance to surgical radiation therapy.*"-^ Sotne authors report the basosquamous type of BCC is more likely to metastasize than others.**"" One report estimates the incidence of tnetastasis of basosquamous BCC is 4 to 5% over 20 years." Lungs and the bony skeleton are the two most likely sites of hematogenous spread.' Metastasis of BCC remains a rare event. Both local and distant BCC metastases do infrequently occur. BCC metastasis tnay occur more often with the basosquamous type of BCC. Metastasizing BCC can be severely debilitating or fatal to the patient.
REFERENCES
1. 2.
3. 4.
5.
6.
7. 8.
9. 10.
11.
Silberbery E, Lubera JA. Gancer statistics. GA 1988; 38:5-22. Paver K, Poyzer K, Burry N, Deakin M. The incidence of basal cell carcinoma and their metastases in Australia and New Zealand. Australas J Dermatol 1973; 14:53. Domarus H, Stevens PJ. Metastatic basal cell carcinoma. J Am Acad Dermatol 1984; 113:1043-1060. Weshler Z, Leviatan A, Peled I, Wexler M. Spinal metastases of basal cell carcinoma. J Surg Oncol 1984; 25:28-33. Gonley J, Sachs ME, Romo T, et al. Metastatic basal cell carcinoma of the head and neck. Otolaryngol Head Neck Surg 1985; 93:79-85. Ghristensen M, Briggs RM, Goblenz MG. Metastatic basal cell carcinoma: a review of the literature and report of two cases. Am Surg 1978; 44:382-387. Kord JP, Gottel WI, Proper S. Metastatic basal cell carcinoma. J Dermatol Surg Oncol 1982; 8: 604-608. Farmer ER, Helwig EB. Metastatic basal cell carcinoma: a clinical pathologic study of seventeen cases. Gancer 1980; 46:748-757. Dierberg WJ, Shcpard GH, Davis FG. Metastasis from basal cell carcinoma. Va Med 1988; 115:584-587. Ambros RA, Standiford SB, Sobel HJ, et al. Rapid development of metastases from basal cell carcinoma presenting as cranial nerve palsies. J Dermatol Surg Oncol 1988; 14:1410-1412. Lopes de Faria J, Nunes PH. Basosquamous cell carcinoma of the skin with metastases. Histopathology 1988; 12:85-94. • '
