Metastasizing basal cell carcinoma

To the editor: Basal cell carcinoma, the most common skin cancer, rarely metastasizes; the frequency of metastasis is less than 0.1 % .. Among some 10000 patients with basal cell carcinoma seen at the Princess Margaret Hospital, Toronto since 1958, only 1 appears to have had metastatic disease. Case report A 79-year-old debilitated man presented with a painful ulcer on his upper lip of 3 years' duration. The ulcer had destroyed much of the lip and had spread to the dental alveolus. A biopsy confirmed the clinical impression of basal cell carcinoma. Roentgenograms of the jaw and chest were normal. Because the patient refused surgical treatment the tumour was irradiated: 5000 rad was given in 14 fractions in 3 weeks. There was some improvement, but a large deficit remained, and 18 months later a mass was evident in the right submaxillary triangle (Fig. 1). A needle biopsy showed the same histologic pattern of basal cell carcinoma as had been seen in the lip. All treatment was declined and the patient died 8 months later of senesence. No autopsy was performed, but there was no evidence of further metastasis. Comments Basal cell carcinoma is a lowgrade skin cancer that can develop anywhere on the body surface. It is most common on the exposed areas of the head and neck in per-

Sons whose skin is weather-beaten or fair. The synonym "rodent ulcer" describes the characteristic gnawing at surrounding tissues. The tumours are frequently multiple, and the rate of cure with any method of treatment is about 95% .. The criteria for the diagnosis of metastasizing basal cell carcinoma are that the primary tumour is localized to the skin, that there are metastases in lymph nodes or viscera, and that the histologic features of both the primary tumour and the metastases are those typical of basal cell carcinoma, without signs of epidermoid differentiation.3 A review of the world literature in 1970 revealed only 76 cases of metastatic basal cell carcinoma.4 The lesions were characteristic, long-standing, large, ulcerated and refractory to surgery, treatment or irradiation. On the basis of my clinical experience, I believe that patients with cachexia may have an immunologic deficit severe enough to tolerate distant implants of a tumour that ordinarily grows only in the skin. PETER FITZPATRICK, MB, BS, FRcP[c], FRCR

Consultant radiation oncologist Princess Margaret Hospital Toronto, Ont.

References 1. COTRAN RS: Metastasizing basal cell carcinomas. Cancer 14: 1036, 1961 2. FITZPATRICK

PJ,

JAMIEsON

DM,

THOMPSON GA, et al: Tumors of the eyelids and their treatment by radiotherapy. Radiology 104: 661, 1972 3. DAHLGREN S, MXRTENSSON B: Meta-

stasizing basal-cell carcinoma. A cta Pathol Microbiol Scand 59: 335, 1963 4. WERMUTH BM, FAJARDO LF: Meta-'

static basal cell carcinoma. Arch Pathol 90: 458, 1970

Second international congress on child abuse

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4

FIG. 1-Metastatic basal cell carcinoma in submaxillary lymph nodes.

To the editor: Without wanting to detract from an otherwise excellent review of the second international congress on child abuse (Can Med Assoc 1 120: 86, 1979), I do want to dispute its introductory contention that there is an increased frequency of child abuse in the "industrialized world". The reasoning

522 CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121

supporting that contention is as fallacious as it is attractive. The underlying assumption is that child abuse is a more or less rational act that is indulged in when children become a burden on their family and refrained from when children are a prime economic asset to the family. This may be a feature of child abuse by clearly deviant parents (a very small proportion), but it is certainly not a feature of the child abuse most of us see in medical practice. Immaturity, impulsivity and an inability both to tolerate frustration and to rein in outbursts of anger are the characteristics associated with most incidents of child abuse. A raging parent doesn't stop to count the registered retirement savings plan certificates before throwing a crying baby down the stairs. If child abuse is worse in industrial society, then we should find less evidence of it in preindustrial society - both historically and anthropologically. Even before there was a proverb that cautioned that sparing the rod spoils the child, there was a stringent Levitical prohibition of the sacrifice of children to Moloch, which suggests the prevalence of such a cult in ancient Canaan. My cursory knowledge of the anthropologic literature does not bring to mind any specific articles dealing with child abuse in primitive people, but my general impression of the literature suggests that primitive and preindustrial peoples are distressingly similar to ourselves. My experience as a physician among the Tiv tribe in central Nigeria confirms that child abuse is at least as prevalent here as it is in Canada. When I have spoken with various native informants about the subject, the impression of its incidence has been conservative. The Tiv is a preindustrial African tribe 2 million strong, 90% of whom are subsistence farmers. Children are the main significant family asset. They are beaten for a variety of indiscretions, and occasionally a child is maimed or dead before a parent's wrath is spent. Much more common is parental neglect. Most of the time it is a neglect of ignorance; however, I find distressingly often the fatalistic