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Sep 23 2017

Pathology Outlines – Basal cell carcinoma (BCC) #basal #cell #carcinoma #treatment #options


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  • Associated with UV light exposure (particularly intermittent intense exposure), history of radiation treatment
  • Associated with various syndromes: basal cell nevus syndrome; Bazex syndrome; xeroderma pigmentosum
  • Clinical appearance often parallels the histologic subtype
  • Most common appearance is a papule or nodule with telangiectasias, which may be eroded or ulcerated (ulcus rodens / rodent ulcer)
  • Papules of BCC may clinically resemble a nevus, fibroma or folliculitis
  • Basal cell carcinoma may also manifest as an erythematous patch, papule, nodule or plaque, which is often eroded, ulcerated or indurated
  • Usually only local growth; may be locally destructive with significant morbidity depending on location and size
  • Pigmented BCC may mimic a melanocytic neoplasm
  • Metastases are exceedingly rare (preferred sites: lymph nodes, lung, bones)

Variants.

  • Common subtypes important to distinguish for management purposes:
    • Nodular:
      • Large tumor nodules in the dermis
      • Generally circumscribed
    • Superficial:
      • Tumor nests growing multifocally from the epidermis
      • Minimal to no component detached in the dermis
      • Generally multicentric and grows radially / laterally
      • Arises in skin of trunk and other sites with sparse fine hairs and thin epidermis
      • Has high recurrence rate, tumors may also regress; candidate for topical treatment
    • Infiltrative / Morpheaform:
      • Angulated narrow tumor nests growing in an infiltrative manner at the leading edge of the tumor
      • Higher recurrence rate
      • More likely to find perineural invasion
      • Indication for Moh’s microsurgery
    • Basosquamous (metatypical) carcinoma:
      • Basal cell carcinoma plus admixed foci indistinguishable from squamous cell carcinoma (NOT the same as focal squamous differentiation in BCC, which is commonly seen)
      • More aggressive than classic basal cell carcinoma (J Am Acad Dermatol 2009;60:137 )
      • May metastasize

Basal cell nevus syndrome.

  • Also called Gorlin’s syndrome
  • Due to mutations in PTCH (patched) gene on 9q22.3
  • Autosomal dominant, young patients with multiple basal cell carcinomas (with more varied histologic types than normal, often superficial and multicentric, often with osteoid), palmar pits (in situ basal cell carcinomas), dural calcification, keratinous cysts of jaws, skeletal abnormalities, occasional abnormalities of CNS, mesentery and endocrine organs (medulloblastoma, ovarian fibromas)
  • Histologic subtypes: infiltrative, morpheaform, micronodular, basosquamous
  • Dense fibrous stroma and loss of peripheral palisading
  • Reduced expression of syndecan-1 and BCL2
  • Greater expression of p53 and aneuploidy
  • Perineurial invasion
  • Positive margins
  • 56 year old man with malignant basomelanocytic tumor manifesting as metastatic melanoma (Am J Surg Pathol 2004;28:1393 )
  • 56 year old man with basal cell carcinoma of penis (Case Rep Urol 2014;2014:173076 )
  • 68 year old man with multiple, brown-colored macules and plaques of varying sizes on face and throughout body (Case of the Week #251 )
  • Surgical: saucerization, standard full thickness excision, Mohs micrographic surgery, curettage with or without electrodesiccation, cryosurgery
  • Medical: topical 5-fluorouracil, imiquimod
  • Radiation

Images hosted on other servers:

A basal cell carcinoma on the back

Raised border and central ulceration

Nodular with telangiectasias

Atrophy and friability

Nodular (left) and pigmented (right)

BCC in 75 year old man

Red, waxy nodule with visible telangiectasias

BCC “rodent ulcer” in a sun exposed area

  • Reddish tan to pink papules or nodules, with or without central ulceration, often with telangiectasia (prominent subepidermal vessels)
  • Atrophic to indurated, scar-like lesions typically will show an infiltrative histologic pattern

Microscopic (histologic) description

  • Basaloid cells with scant cytoplasm and elongated hyperchromatic nuclei, peripheral palisading, peritumoral clefting and mucinous alteration of surrounding stroma
  • Also mitotic figures, apoptotic bodies
  • The presence of myxoid stroma and peripheral clefting has been suggested to be most helpful to distinguish BCC from other basaloid tumors
  • Many secondary features may occur, such as dystrophic calcification, amyloid deposition or inflammatory reactions with or without partial regression

Other variants of histopathologic interest.

  • Clear cell basal cell carcinoma:
    • Tumor cells with prominent cytoplasmic vacuoles or signet ring morphology
  • Fibroepithelial tumor:
    • Also called Pinkus’ tumor, fibroepithelioma
    • Polypoid variant, often on back, with abundant stroma
  • Granular basal cell carcinoma:
    • Contains tumor cells resembling granular cell tumor
    • No clinical significance
  • Infundibulocystic basal cell carcinoma:
    • Hair follicle differentiation

Microscopic (histologic) images

Images hosted on PathOut server:

Superficial tumor
contributed by
Dr. Amy Lynn,
Toledo, Ohio

Images hosted on other servers:

Area of ulceration

BCC below epidermis

Superficial, various images

Cystic basal cell carcinoma

Micronodular basal cell carcinoma

Superficial basal cell carcinoma

Micrograph of a basal cell carcinoma,
showing characteristic histomorphologic
features (peripheral palisading, myxoid
stroma, artefactual clefting); H E stain

Infiltrative BCC, courtesy of Sara Shalin, M.D. Ph.D.



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