Climcal and Experimental Dermatology 1992; 17: 360-362.
Perianal basal cell carcinoma A.ESPANA, P.REDONDO, M.A.IDOATE*, M.J.SERNA AND E.QUINTANILLA Departments of Dermatology and *Pathology, University Clinic, School of Medicine, Navarras' University, Pamplona, Spain Accepted for publication 3 October 1991
copy Up to 30 cm did not reveal any pathology except diverticula in the sigmoid region. Perianal basal cell carcinoma (BCC) is a rare tumour and The lesion was surgically removed with a wide excision only a few case reports can be found in the literature. In margin. Histopathological study revealed an epithelial this location, it is important to differentiate a BCC from a tumour located in the dermis and subcutaneous fat. It basaloid cloacogenic carcinoma, as the first is an invasive consisted of cords of uniform basaloid cells (some highly but localized tumour, while the second has a high capacity pigmented), dispersed within a fibrous stroma. An for metastasis. adenoid pattern was evident. The tumour cells had a clear basophilic cytoplasm with melanin pigment and a vesicular nucleus. There was a tendency towards palisade Basal cell carcinoma (BCC) is a common malignant skin formation. The stroma surrounding the tumour cells was tumour, and ultraviolet irradiation has been incriminated fibrous and contained scanty lymphocytic infiltrate with as one of the most important factors in its pathogenesis. occasional melanophages (Fig. 2). Nevertheless, several patients have been reported who develop this tumour on non-sun-exposed skin, indicating that there are other aetiological factors. Discussion We report a patient who presented with a BCC of the BCC occur most often in elderly patients on the sunperianal area. This is a very rare location for this tumour; exposed skin of the face and neck with a frequency of 85only occasional reports have been identified in the 90%.' dermatological literature. We discuss the possible aetioloHolubar^ reported that 80-90% occur on the upper gical factors in our patient. two-thirds of the face, 2% on scalp, 2% on the occipital area and neck, 2% on the limbs and 5% on the trunk. The remainder develop around the anus and perineum. Case report Dulanto and Armijo^ documented a series of 1238 A 72-year-old female reported a 5-year history of an patients with BCC; 96% arose on the face, 2-7% on the asymptomatic perianal tumour. She had noted a slow scalp and occipital areas, and 12% on the trunk and enlargement of the lesion and denied spontaneous bleed- limbs. They noted that BCCs arising in the perianal and ing. The patient gave a past history of a uterine tumour that was surgically removed followed by radiotherapy 35 years previously. The dosage and number of sessions of radiotherapy received were unknown. Physical examination of the perianal region revealed a 15 cm hard, round tumour with well defined margins and hyperpigmented areas which was situated on the right hand side of the anus, 0-5 cm from its orifice. There was a small erosion at its centre, and some superficial telangiectasia were present (Fig. 1). The surrounding skin showed isolated angiokeratomata and external haemorrhoids. There were no other lesions on the surrounding skin or the rest of the body surface. There was no evidence of lymphadenopathy or hepatosplenomegaly. SigmoidosSummary
Correspondence: Dr A.Espana, Departtnent of Dermatology, University Clinic, P.O. Box 192, 31080 Pamplona, Spain.
360
Figure 1. Basal cell carcinoma localized in perianal area.
PERIANAL BASAL CELL CARCINOMA
Figure 2. ilasalold cell cords, .some of them highly pigmented. The ceils had a clear basophil cytoplasm with melanin pigment and clear nucleus, and the> tend to group in palisades. They are surrounded by mucinous stroma. There are several melanophages and some retraction of the stroma from the tumour islands (I [&E x 200).
361
Figure 3. Solid tumour showing basaloid and squamous cells that produce horn pearls. The tumour masses show no palisade and there is no mucin in the siroma (II&l. x7I).
Upwards from the dentate line. It is covered by transitional or stratified columnar epithelium,'- and may perineal regions is unusual. Reports of BCCs arising on extend onto the periana! skin.'' Cloacogenic carcinoma non-sun-exposed skin arc infrequent.*' BCCs may pres- tends to mctastasize early and has a high mortality in ent at a variety of unusual sites including the palms and contrast ro ihe more indolent perianal BCC. The histopathological features of a cloacogenic carcisoles,"*' penis,'*-*' scrotum,'" \-ulva,"'- subungal region,'^'* external auditory meatus,'' intraoral and noma, that differentiate It from a BCC are: the wide mandibular gingiva,'"'' nipples'"'•* and axillae-" but these variation in histological appearances, the predominant pattern of basaloid and transitional masses, combined occurrences are rare. BCC of the anus and perianal region has been reported with focal mucoepidermoid and squamous differentiavery rarely in the dermatological literature. To our tion." Moreover, cloacogenic carcinoma does not show knowledge, only four such cases have been pub- prominent peripheral nuclear palisading and retraction lished.''•^'•" An additional case is described by Demis et artifact" " (l-ig. 3). In conclusion, it is important to differentiate BCC al}^ in a I-'igure in his textbook. Occasional reports are from cloacogenic carcinoma in order that the correct described in surgical journals.^"*"' therapy be instituted. I'\)r superficial and small cloacogeThe precise aetiology of BCC is not fully understood. nic carcinomas ItK-al excision is normally adequate, but Despite its usual location on sun-exposed skin, BCC may for lesions over 2 cm in diameter, pelvic lymph-node also arise on covered sites. Additonal aetiological factors excision combined with radiotherapy should be included have been implicated: genetic factors, immunodeficiency, in the treatment regimen." For perianal BCC complete viruses, arsenic exposure, ionizing radiation, trauma, excision is all that is necessary.'**-^ thermal burns, vaccination, pre-existing skin diseases, and sharp or blunt physical injury.'" Nodleman and Pollack-^' have reported that skin previously sensitized to References tumour development (BBC) by pre-existing carcinogens, 1 I jng PG, .Maize }C. Basal cell carcinoma. In: Friedman RJ, Rigel may then progress to tumour formation as a consequence DS, Kopl" AW. Harris MN, Baker D, eds. Cancer of the skin. of trauma (co-carcinogen). The interval between trauma Philadelphia: WB Saunders Company, 199], ,15-7.V and subsequent tumour development varies greatly, 2. llolubar K. Das Basaliom. In: Jadassohn J, ed. Handhuch der ranging from weeks to decades. In our patient, radiohatit-iind geschlechtskrankheiten. Ergdnzungswerk. Bd 3, Toil .1 A, S 2.S.1, Berlin, Heidelberg, New York: Springer Verlag, I97.S. therapy to rhe pelvis, combined with trauma from 3. Duliinio I', Armijo M. ICpiicliomas basocelulares. l.n: Dulanto F, hygiene or clothing around the perianal area, may have Armijo .M, Camacho I", Naranjd R, eds. Dermalologia medicotjiiirstimulated the development of this tumour, even though lirgica, 1" edn. (iranada; I'.diciones Anel, 1981, 439-456. radiodermatitis was not observed.'" 4. Robins P, Rabinovitz IIS, Rigel D. Basal-cell carcinoma on covered ()r unusual sites of the body. Journal of Dermatologie It is important to differentiate true BCC of the anus Surgery and Oncotogy 1981; 7: 803-806. and perianal skin from the basaloid-appearing cloacoge5. Rahbari It, Mehrcgan AH. Basal cell epitheliomas in usual and nic carcinoma. The latter originates from the anal unusual sites. The Journal of Cutaneous Pathology 1979; 6: 425transitional zone, which normallv extends about 1 cm 431.
A.ESPANA et al.
362
6. Hyman AB, Barsky AJ. Basal cell epithelioma of palm. Archives of 22. Dermatology 1965; 92: 571-573. 7. Robinson JK. A gigant basal cell carcinoma on the plantar arch of a foot. The Journal of Dermatologie Surgery and Oncology 1979; 5: 23. 958-960. 8. Goldminz D, Scott G, Klaus S. Penile basal cell carcinoma. Journal of the American Academy of Dermatology 1989; 20: 1094— 24. 1097.
25. 9. Hartman DL. Basal cell epithelioma of the penis. Archives of Dermatology 1966; 94: 326-327. 26. 10. McEleney DA. Basal cell carcinoma of the scrotum. Cutis 1976; 18: 227. 11. Bean SF, Becker FT. Basal cell carcinoma of the vulva. Archives of 27. Dermatology 1968; 98: 284-286. 12. Goldberg DJ. Multiple basal-cell carcinoma of the \VL\\2L. Journal 28. of Dermatologie Surgery and Oncology 1984; 10: 615-617. 13. Hoffman S. Basal cell carcinoma of the nail bed. Archives of 29. Dermatology 1973; 108: 828. 14. Alpert LI, Zak FG, Wertbamer S. Subungual basal cell epithe30. lioma. Archives of Dermatology 1972; 106: 599. 15. Stell PM. Basal cell carcinoma of the external auditory meatus. 31. Clinical Otolaryngology 1984; 9: 187-190. 16. Williamson JJ, Cohney BC, Henderson BM. Basal cell carcinoma of the mandibular gingiva. Archives of Dermatology 1967; 95: 7632. 80. 17. Edmondson HD, Browne RM, Potts AJC. Intraoral basal cell 33. carcinoma. British Journal of Oral Surgery 1982; 20: 239-247. 18. Sauven P, Roberts A. Basal cell carcinoma of the nipple. Journal of the Royal Society of Medicine 1983; 76: 699. 19. Lupton GP, Goette DK. Basal cell carcinoma of the nipple. 34. Archives of Dermatology 1978; 114: 1845. 20. Susong CR, Ratz JL. Basal carcinoma occurring in a axilla: A case presenting and a review of factors related to tumor development. The Journal of Dermatologie Surgery and Oncology 1985; 11: 526-35. 530. 2L Kraus KW. Perianal basal cell carcinoma. Archives of Dermatology 1978, H4: 460-461.
Crippa D, Beneggi M, Sala GP, Calcinati M, Albanese G. EpkhehomzbAsoceWularepenanaXcGiornaleltalianodi Dermatologia e Venereologia 1983; H8: 175-177. Clendenning WE. Basal cell carcinoma. In: Demis DJ, ed. Clinicat Dermatology, Vol. 4. Philadelphia: JB Lippincott Company, 1988,21-18. Armitage G, Smith I. Rodent ulcer of anus. British Journal oj' Surgery 1955; 42: 395-398. Matt JG, Dilger JT. Basal cell carcinoma of the anus. American Surgeon 1956; 22: 886-893. Wittoesch JH, Woolner LB, Jackman RJ. Basal cell epithelioma and basaloid lesions of the anus. Surgery Gynecology and Ohstetrics 1957; 104: 75-80. Bunstock WH. Basal cell carcinoma of the anus. American Journal of Surgery 1958; 95: 822-825. Rosenthal D. Basal cell carcinoma of the anus: Report of two cases. Diseases of the Colon and Rectum 1967; 10: 397-400. Beahrs OH, Wilson SM. Carcinoma of the anus. American Surgeon 1976; 184: 422-428. Moller C, Saksela E. Cancer of the anus and anal canal. Acta Chtrurgica Scandinavica 1970; 136: 340-348. Nodleman FR, Pollack SV. Trauma as a possible etiologic factor in basal cell carcinoma. The Journat of Dermatologie Surgery and Oncology 1986; 12: 841-846. Fenger C. Histology of the anal canal. American Journat of Surgical Pathology 1988; 12: 41-55. Lee K-Ch, Daniel Su WP, Muller SA. Multicentric cloacogenic carcinoma: Report of a case with anogenital pruritus at presentation. Journal of the American Academy of Dermatology 1990; 23: 1005-1008. White WB, Schneiderman H, Sayre JT. Basal cell carcinoma of the anus: clinical and pathological distinction from cloacogenic. Journat of Clinical Gastroenterology 1984; 6: 441-446. Pang LSC, Morson BC. Basaloid carcinoma of the anal canal. Journal of Clinical Pathology 1967; 20: 128-135.
Perianal basal cell carcinoma A.ESPANA, P.REDONDO, M.A.IDOATE*, M.J.SERNA AND E.QUINTANILLA Departments of Dermatology and *Pathology, University Clinic, School of Medicine, Navarras' University, Pamplona, Spain Accepted for publication 3 October 1991
copy Up to 30 cm did not reveal any pathology except diverticula in the sigmoid region. Perianal basal cell carcinoma (BCC) is a rare tumour and The lesion was surgically removed with a wide excision only a few case reports can be found in the literature. In margin. Histopathological study revealed an epithelial this location, it is important to differentiate a BCC from a tumour located in the dermis and subcutaneous fat. It basaloid cloacogenic carcinoma, as the first is an invasive consisted of cords of uniform basaloid cells (some highly but localized tumour, while the second has a high capacity pigmented), dispersed within a fibrous stroma. An for metastasis. adenoid pattern was evident. The tumour cells had a clear basophilic cytoplasm with melanin pigment and a vesicular nucleus. There was a tendency towards palisade Basal cell carcinoma (BCC) is a common malignant skin formation. The stroma surrounding the tumour cells was tumour, and ultraviolet irradiation has been incriminated fibrous and contained scanty lymphocytic infiltrate with as one of the most important factors in its pathogenesis. occasional melanophages (Fig. 2). Nevertheless, several patients have been reported who develop this tumour on non-sun-exposed skin, indicating that there are other aetiological factors. Discussion We report a patient who presented with a BCC of the BCC occur most often in elderly patients on the sunperianal area. This is a very rare location for this tumour; exposed skin of the face and neck with a frequency of 85only occasional reports have been identified in the 90%.' dermatological literature. We discuss the possible aetioloHolubar^ reported that 80-90% occur on the upper gical factors in our patient. two-thirds of the face, 2% on scalp, 2% on the occipital area and neck, 2% on the limbs and 5% on the trunk. The remainder develop around the anus and perineum. Case report Dulanto and Armijo^ documented a series of 1238 A 72-year-old female reported a 5-year history of an patients with BCC; 96% arose on the face, 2-7% on the asymptomatic perianal tumour. She had noted a slow scalp and occipital areas, and 12% on the trunk and enlargement of the lesion and denied spontaneous bleed- limbs. They noted that BCCs arising in the perianal and ing. The patient gave a past history of a uterine tumour that was surgically removed followed by radiotherapy 35 years previously. The dosage and number of sessions of radiotherapy received were unknown. Physical examination of the perianal region revealed a 15 cm hard, round tumour with well defined margins and hyperpigmented areas which was situated on the right hand side of the anus, 0-5 cm from its orifice. There was a small erosion at its centre, and some superficial telangiectasia were present (Fig. 1). The surrounding skin showed isolated angiokeratomata and external haemorrhoids. There were no other lesions on the surrounding skin or the rest of the body surface. There was no evidence of lymphadenopathy or hepatosplenomegaly. SigmoidosSummary
Correspondence: Dr A.Espana, Departtnent of Dermatology, University Clinic, P.O. Box 192, 31080 Pamplona, Spain.
360
Figure 1. Basal cell carcinoma localized in perianal area.
PERIANAL BASAL CELL CARCINOMA
Figure 2. ilasalold cell cords, .some of them highly pigmented. The ceils had a clear basophil cytoplasm with melanin pigment and clear nucleus, and the> tend to group in palisades. They are surrounded by mucinous stroma. There are several melanophages and some retraction of the stroma from the tumour islands (I [&E x 200).
361
Figure 3. Solid tumour showing basaloid and squamous cells that produce horn pearls. The tumour masses show no palisade and there is no mucin in the siroma (II&l. x7I).
Upwards from the dentate line. It is covered by transitional or stratified columnar epithelium,'- and may perineal regions is unusual. Reports of BCCs arising on extend onto the periana! skin.'' Cloacogenic carcinoma non-sun-exposed skin arc infrequent.*' BCCs may pres- tends to mctastasize early and has a high mortality in ent at a variety of unusual sites including the palms and contrast ro ihe more indolent perianal BCC. The histopathological features of a cloacogenic carcisoles,"*' penis,'*-*' scrotum,'" \-ulva,"'- subungal region,'^'* external auditory meatus,'' intraoral and noma, that differentiate It from a BCC are: the wide mandibular gingiva,'"'' nipples'"'•* and axillae-" but these variation in histological appearances, the predominant pattern of basaloid and transitional masses, combined occurrences are rare. BCC of the anus and perianal region has been reported with focal mucoepidermoid and squamous differentiavery rarely in the dermatological literature. To our tion." Moreover, cloacogenic carcinoma does not show knowledge, only four such cases have been pub- prominent peripheral nuclear palisading and retraction lished.''•^'•" An additional case is described by Demis et artifact" " (l-ig. 3). In conclusion, it is important to differentiate BCC al}^ in a I-'igure in his textbook. Occasional reports are from cloacogenic carcinoma in order that the correct described in surgical journals.^"*"' therapy be instituted. I'\)r superficial and small cloacogeThe precise aetiology of BCC is not fully understood. nic carcinomas ItK-al excision is normally adequate, but Despite its usual location on sun-exposed skin, BCC may for lesions over 2 cm in diameter, pelvic lymph-node also arise on covered sites. Additonal aetiological factors excision combined with radiotherapy should be included have been implicated: genetic factors, immunodeficiency, in the treatment regimen." For perianal BCC complete viruses, arsenic exposure, ionizing radiation, trauma, excision is all that is necessary.'**-^ thermal burns, vaccination, pre-existing skin diseases, and sharp or blunt physical injury.'" Nodleman and Pollack-^' have reported that skin previously sensitized to References tumour development (BBC) by pre-existing carcinogens, 1 I jng PG, .Maize }C. Basal cell carcinoma. In: Friedman RJ, Rigel may then progress to tumour formation as a consequence DS, Kopl" AW. Harris MN, Baker D, eds. Cancer of the skin. of trauma (co-carcinogen). The interval between trauma Philadelphia: WB Saunders Company, 199], ,15-7.V and subsequent tumour development varies greatly, 2. llolubar K. Das Basaliom. In: Jadassohn J, ed. Handhuch der ranging from weeks to decades. In our patient, radiohatit-iind geschlechtskrankheiten. Ergdnzungswerk. Bd 3, Toil .1 A, S 2.S.1, Berlin, Heidelberg, New York: Springer Verlag, I97.S. therapy to rhe pelvis, combined with trauma from 3. Duliinio I', Armijo M. ICpiicliomas basocelulares. l.n: Dulanto F, hygiene or clothing around the perianal area, may have Armijo .M, Camacho I", Naranjd R, eds. Dermalologia medicotjiiirstimulated the development of this tumour, even though lirgica, 1" edn. (iranada; I'.diciones Anel, 1981, 439-456. radiodermatitis was not observed.'" 4. Robins P, Rabinovitz IIS, Rigel D. Basal-cell carcinoma on covered ()r unusual sites of the body. Journal of Dermatologie It is important to differentiate true BCC of the anus Surgery and Oncotogy 1981; 7: 803-806. and perianal skin from the basaloid-appearing cloacoge5. Rahbari It, Mehrcgan AH. Basal cell epitheliomas in usual and nic carcinoma. The latter originates from the anal unusual sites. The Journal of Cutaneous Pathology 1979; 6: 425transitional zone, which normallv extends about 1 cm 431.
A.ESPANA et al.
362
6. Hyman AB, Barsky AJ. Basal cell epithelioma of palm. Archives of 22. Dermatology 1965; 92: 571-573. 7. Robinson JK. A gigant basal cell carcinoma on the plantar arch of a foot. The Journal of Dermatologie Surgery and Oncology 1979; 5: 23. 958-960. 8. Goldminz D, Scott G, Klaus S. Penile basal cell carcinoma. Journal of the American Academy of Dermatology 1989; 20: 1094— 24. 1097.
25. 9. Hartman DL. Basal cell epithelioma of the penis. Archives of Dermatology 1966; 94: 326-327. 26. 10. McEleney DA. Basal cell carcinoma of the scrotum. Cutis 1976; 18: 227. 11. Bean SF, Becker FT. Basal cell carcinoma of the vulva. Archives of 27. Dermatology 1968; 98: 284-286. 12. Goldberg DJ. Multiple basal-cell carcinoma of the \VL\\2L. Journal 28. of Dermatologie Surgery and Oncology 1984; 10: 615-617. 13. Hoffman S. Basal cell carcinoma of the nail bed. Archives of 29. Dermatology 1973; 108: 828. 14. Alpert LI, Zak FG, Wertbamer S. Subungual basal cell epithe30. lioma. Archives of Dermatology 1972; 106: 599. 15. Stell PM. Basal cell carcinoma of the external auditory meatus. 31. Clinical Otolaryngology 1984; 9: 187-190. 16. Williamson JJ, Cohney BC, Henderson BM. Basal cell carcinoma of the mandibular gingiva. Archives of Dermatology 1967; 95: 7632. 80. 17. Edmondson HD, Browne RM, Potts AJC. Intraoral basal cell 33. carcinoma. British Journal of Oral Surgery 1982; 20: 239-247. 18. Sauven P, Roberts A. Basal cell carcinoma of the nipple. Journal of the Royal Society of Medicine 1983; 76: 699. 19. Lupton GP, Goette DK. Basal cell carcinoma of the nipple. 34. Archives of Dermatology 1978; 114: 1845. 20. Susong CR, Ratz JL. Basal carcinoma occurring in a axilla: A case presenting and a review of factors related to tumor development. The Journal of Dermatologie Surgery and Oncology 1985; 11: 526-35. 530. 2L Kraus KW. Perianal basal cell carcinoma. Archives of Dermatology 1978, H4: 460-461.
Crippa D, Beneggi M, Sala GP, Calcinati M, Albanese G. EpkhehomzbAsoceWularepenanaXcGiornaleltalianodi Dermatologia e Venereologia 1983; H8: 175-177. Clendenning WE. Basal cell carcinoma. In: Demis DJ, ed. Clinicat Dermatology, Vol. 4. Philadelphia: JB Lippincott Company, 1988,21-18. Armitage G, Smith I. Rodent ulcer of anus. British Journal oj' Surgery 1955; 42: 395-398. Matt JG, Dilger JT. Basal cell carcinoma of the anus. American Surgeon 1956; 22: 886-893. Wittoesch JH, Woolner LB, Jackman RJ. Basal cell epithelioma and basaloid lesions of the anus. Surgery Gynecology and Ohstetrics 1957; 104: 75-80. Bunstock WH. Basal cell carcinoma of the anus. American Journal of Surgery 1958; 95: 822-825. Rosenthal D. Basal cell carcinoma of the anus: Report of two cases. Diseases of the Colon and Rectum 1967; 10: 397-400. Beahrs OH, Wilson SM. Carcinoma of the anus. American Surgeon 1976; 184: 422-428. Moller C, Saksela E. Cancer of the anus and anal canal. Acta Chtrurgica Scandinavica 1970; 136: 340-348. Nodleman FR, Pollack SV. Trauma as a possible etiologic factor in basal cell carcinoma. The Journat of Dermatologie Surgery and Oncology 1986; 12: 841-846. Fenger C. Histology of the anal canal. American Journat of Surgical Pathology 1988; 12: 41-55. Lee K-Ch, Daniel Su WP, Muller SA. Multicentric cloacogenic carcinoma: Report of a case with anogenital pruritus at presentation. Journal of the American Academy of Dermatology 1990; 23: 1005-1008. White WB, Schneiderman H, Sayre JT. Basal cell carcinoma of the anus: clinical and pathological distinction from cloacogenic. Journat of Clinical Gastroenterology 1984; 6: 441-446. Pang LSC, Morson BC. Basaloid carcinoma of the anal canal. Journal of Clinical Pathology 1967; 20: 128-135.
