A Thing of Beauty

 •60 yo woman with few year history LLL lesion

•Full-time care-giver to disabled son

•2-cm liner lesion Left Lower Lid with a central groove

•3 mm punch bx: nodular & infiltrative BCC

Clinical Images:

Pathology (Courtesy of Dr. David Jones, Berkshire Medical Center)

Diagnosis: Linear Basal Cell Carcinoma

Presented for interest and comments.

References:

•Linear basal cell carcinoma occurs most commonly on the lower eyelid  G L Becher, et. al. Clin Exp Dermatol. 2011 Apr;36(3):311-2.

•Linear basal cell carcinoma: a distinct condition?                              Al-Niaimi, C C Lyon. Clin Exp Dermatol. 2011 Apr;36(3):231-4.

•Linear Basal cell carcinoma in an asian patien. Kinoshita Shinsuke  et. al. Open Ophthalmol J. 2007 Dec 17;1:20  Free Full Text PMC

Infiltrating BCC of the Ala

The patient is a 58 yo man in fair health.  He suffers from anxiety and depression as well as diabetes and coronary heart disease and is status past CABG.  He was brought in by his female companion who noticed a lesion of the left ala.

O/E There is a nine mm indurated lesion with some surface erosion.

Image:

A 3 mm punch biopsy was difficult because of his severe agitation.  The pathology showed a deeply infiltrating basal cell.

Questions:

Given this patient’s pervasive anxieties, should one consider XRT over Mohs surgery?  The latter might also cause some deformity and may require a complicated reconstruction.  Of course, I will lay out the choices to the patient and his companion; but I thought this was a good question for our members to consider and weigh in on.  Some great unknown medical sage said, “Sometimes, it is may be more important to treat the patient who has the lesion, than it is to simply treat the lesion the patient has.”

Post-Auricular Basal Cell

The patient is an 84 year-old man with a one to two week history of bleeding from a lesion in the sulcus behind the left ear and overlying the mastoid process.  He had noticed a tumor there for a longer period of time and has covered that with a Band-aid.  The area was recently traumatized and he was seen at the Dermatology Clinic. He has a history of basal cell carcinoma of the glabella.

O/E:  There is a 2 cm erosive lesion behind the left ear that extends over the mastoid bone. 

A shave biopsy was taken from two representative areas.

Clinical Photo:

Pathology:  Basal cell carcinoma. Probably nodular, but deeper areas may show other features

Diagnosis:  The pathology confirms the clinical impression of basal cell carcinoma.

Discussion:  This is a particularly worrisome area.  While some nonmelanoma skin cancers in octogenarians can be observed, lesions in this area can be invasive into the underlying bone.  For this reason, we will recommend Mohs micrographic surgery.

Reference:
Invasive basal cell carcinoma of the temporal bone.
Gussack GS et. al.
Abstract: Basal cell carcinomas involving the ear represent a spectrum of diseases, from a small superficial auricular lesion to an advanced destructive malignancy invading the temporal bone. The biologic activity of the morphea-form basal cell carcinoma variant of tumor and a postauricular location predispose to an aggressive biologic pattern. Management requires a thorough evaluation with determination of the degree of cranial and possible intracranial invasion. These lesions usually can be managed with partial temporal bone resections, although prognosis for patients with advanced lesions may be poor.
(No proof of bone invasion in this case; however, this is a setting where one needs to consider it)

Recurrent BCC with Perineural Invasion

The patient is a 56 yo woman who had micrographic surgery for a BCC on the tip of the nose in August of 2008. The initial typing could not be done b/c the specimen was a superficial shave and deeper component could not be appreciated.

She presented in March 2012 with a subtle area of hypopigmentation at the site of the tumor. Because of the firmness of the nasal tip, induration could not be appreciated. The patient was worried that this might be a recurrence.

Clinical Photo:

A 3 mm punch biopsy showed "infiltrating BCC with perineural invasion (PNI)."

Photomicrographs courtesy of Dr. Jag Bhawan. Please click on Picasa for more images.
Teaching point: The initial shave bx was not adequate to type the lesion and this was also not commented on by Mohs surgeon. Complex BCCs of the nasal tip pose special problems. Dr. highlight some of these.

Questions to Mohs surgeons: How would you approach this woman who is concerned about cosmetic appearance of nose after second Mohs procedure? Is it likely that after almost four years of insidious growth this tumor may pose special problems for closure and necessitate plastic surgical reconstruction?

View Dr. Michael Albom's Comments on this patient.

References:
1. Leibovitch I, et. al, Basal cell carcinoma treated with Mohs surgery in Australia III. Perineural invasion. J Am Acad Dermatol 2005 Sep;53(3):458-63.
Abstract Conclusion: PNI is an uncommon feature of BCC. When present, PNI is associated with larger, more aggressive tumors, and the risk of 5-year recurrence is higher. This emphasizes the importance of tumor excision with margin control and long-term patient monitoring.

2. Geist DE et. al. Perineural invasion of cutaneous squamous cell carcinoma and basal cell carcinoma: raising awareness and optimizing management. Dermatol Surg: 2008 Dec;34(12):1642-51. Division of Dermatology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA. david.geist@umassmemorial.org

ABSTRACT: BACKGROUND: Perineural invasion (PNI) by cutaneous squamous cell carcinoma (CSCC) and basal cell carcinoma (BCC) is an infrequent but not rare complication of traditionally low-morbidity skin cancers that can lead to catastrophic sequelae; 2.5% to 14% of CSCC and approximately 3% of BCC exhibit PNI. Tumors with PNI tend to be larger, have greater subclinical extension, have a higher rate of recurrence, and have a greater risk of metastases. Tumors with PNI may result in major neurologic deficits.

OBJECTIVE: To review current recommendations for the management of PNI and to evaluate a treatment strategy involving excision using Mohs micrographic surgery (MMS) followed by adjunctive radiotherapy.

MATERIALS AND METHODS:Cases of PNI treated with MMS and radiotherapy were reviewed for recurrence, disease-free follow-up, and adverse events.

RESULTS:Twelve patients with incidental PNI treated with MMS and adjunctive radiotherapy are presented. After 3 to 32 months of follow-up, there had been no recurrences. Adverse events from radiotherapy were minor and self-limited.

CONCLUSIONS: The use of adjunctive radiotherapy in these patients remains controversial. When managing superficial skin tumors with PNI, a multidisciplinary team including a cutaneous surgeon and a radiation oncologist familiar with PNI is recommended.

Tumor in Vaccination Site

Abstract: 59 yo woman with six month history of tumor l. arm
HPI: The patient, a kindergarten teacher, was bitten on the hand by a child on March 20, 2011. School policy did not allow the child to be tested for hepatitis or HIV. Therefore, it was recommended that she receive hepatitis B vaccination. She had three shots ( March, June and December 2010) in the left deltoid area. In late January or early February 2011 she developed a tumor at the site of the vaccination.
O/E: There is a 1.2 cm. slightly friable tumor in the above-mentioned area. Dermoscopic exam shows some arborizing blood vessels.

Clinical Photograph:

Pathology: Basal Cell Carcinoma: Nodular and Infiltrating. No epidermal connection is apparent in submitted specimens.

Diagnosis: Basal Cell Carcinoma in Vaccination site.

Discussion: There have been sporadic reports of skin cancer developing at the sites of vaccination, but never one in a hepatitis B site. The latent period here is short. It's unclear what the initiating factor is. Our patient is a light-complected Caucasian, so has another risk factor, too. We plan to investigate this area further and present a case report with a review of the literature. Your thoughts will be helpful.

BCC Tip Nose

The patient is a 70 yo woman who had a nasal bulb lesion biopsied in September 2010. This was an ill-defined area and two, 2-mm biopsies were taken. One showed a superficial and nodular BCC ang the other a melanocytic nevus. This was probably a collision lesion. The patient elected to wait and see what developed.

Today, April 29, 2010, the exam shows a residual lesion with arborizing blood vessels on dermoscopy. This lesion requires definitive treatment either with micrographic surgery or radiotherapy and the patient is leaning towards the former.

Question: With re: Moh's surgery, what kind of closure you you recommend?