Metastatic basal cell carcinoma of the upper extremity
C. Wayne Cruse, MD, Tampa, Fla., William O'Neill, MD, Houston, Texas, and John Rayhack, MD, Tampa, Fla.
Basal cell carcinoma comprises 65% to 75% of malignant skin lesions, making it the most common skin cancer. Although metastasis was first reported in 1894 by Beadles, I basal cell carcinoma is generally locally invasive rather than metastatic. The incidence of metastasis varies from 0.1 %2 to 0.0028%.3 According to Cotrarr' and Lattes and Kessler," the criteria for metastases are as follows: (I) The primary neoplasm must arise in the skin, not in the mucosa; (2) metastasis must be demonstrated at a site distant from the primary lesion (local extensions of the primary lesion, even farflung implantations, are not metastatic); and (3) both the primary and the metastatic lesions must be histologically the same, without any component of squamous cell carcinoma. Case report A 73-year-old woman noticed an enlarging lesion on her right forearm, and incisional biopsy of this 4 cm lesion showed basal cell carcinoma. The patient refused a wide excision. Five years later the lesion was 15 X 8 em, ulcerated, and bleeding (Fig. I). Upper extremity function was markedly impaired, with loss of finger extension and diminished grip strength. There was no axillary adenopathy. X-ray films showed a soft tissue mass with erosion of ulnar and radial cortices. An above-the-elbow amputation was performed. Twenty-two months later the patient had a 3.3 X 4.5 x 3 em axillary mass, and a right axillary dissection was performed after an evaluation for other metastatic disease was negative. Histologically, the metastatic lesion was From the Divisions of Plastic Surgery and Orthopaedics, University of South Florida College of Medicine. Tampa, Fla., and the Division of Plastic Surgery, Baylor University, Houston, Texas. Received for publication May 8,1991; accepted in revised form Jan. 15, 1992. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: C. Wayne Cruse, MD, Division of Plastic Surgery, Harboursidc Medical Tower #730, Four Columbia Cr., Tampa, FL 33606.
3/1/36744
Fig. 1. Basal cell carcinoma of right upper extremity. a typical basal cell carcinoma (Fig. 2). There were 10 other tumor-free nodes in the specimen. The patient remained free of disease 18 months after axillary dissection.
Discussion A large, ulcerated, locally invasive lesion is the typical setting for metastatic basal cell carcinoma, The average time from primary diagnosis to metastasis is 6 years. Two thirds of the metastases occur in regional lymph nodes, but hematogenous spread to bone, lung, pleura, and skin can occur. Hematogenous spread withTHE JOURNAL OF HAND SURGERY
1093
1094
The Journal of HAND SURGERY
Cruse et al.
rise to large tumor emboli," Basal cell carcinoma, unlike squamous cell carcinoma, may be dependent on its stroma for metastasis' because in vitro autologous transplantation cannot take place without stroma in the transplant. It may, however, be grown in tissue culture without its stroma. The treatment of metastatic basal cell carcinoma is not well defined, but clearly spread to a regional node without further spread should be treated surgically. Although earlier reports on chemotherapy are not hopeful, Coker et al. 7 have suggested that combination chemotherapy with cisplatinum and bleomycin may be helpful. The prognosis for metastatic disease is poor, with a median survival time of 10 to 14 months from the time of diagnosis of metastatic disease." REFERENCES I. Beadles CF. Rodent ulcer. Pathol Soc London Trans 1894;45: 176-81.
2. Cotran RS. Metastasizing basal cell carcinomas. Cancer 1961; 14:1036-40.
3. Paver K, Poyzcr K, Burry N, et al. The incidence of basal cell carcinoma and their metastases in Australia and New Zealand [letter]. Aust J Dermatol 1973; 14:53. 4. Lattes R, Kessler RW. Metastasizing basal cell epithelioma of the skin. Cancer 1951;4:866-78. 5. Mikhail GR, Nims LP, Kelly AP, Ditmars DM, Eyler WR. Metastatic basal cell carcinoma. Arch Dcrmatol 1977;113:1261-9. Fig. 2. Peripheral palisading of metastasis in axillary lymph
node. out regional lymph node metastasis is very rare. Metastasis from all histologic types can take place. s Some think that for metastases to occur the primary tumor must be large with invasion of deeper structures giving
6. Amonette RA. Metastatic basal cell carcinoma. J Dermatol Surg Oncol 1981;7:397-400. 7. Coker DO, Elias EG, Viravathana T, McCrea E, Hafiz M. Chemotherapy for metastatic basal cell carcinoma. Arch Derrnatol 1983;119:44-50. 8. Conway H, Hugo NE. Metastatic basal cell carcinoma. Am J Surg 1965;[ 10:620.
C. Wayne Cruse, MD, Tampa, Fla., William O'Neill, MD, Houston, Texas, and John Rayhack, MD, Tampa, Fla.
Basal cell carcinoma comprises 65% to 75% of malignant skin lesions, making it the most common skin cancer. Although metastasis was first reported in 1894 by Beadles, I basal cell carcinoma is generally locally invasive rather than metastatic. The incidence of metastasis varies from 0.1 %2 to 0.0028%.3 According to Cotrarr' and Lattes and Kessler," the criteria for metastases are as follows: (I) The primary neoplasm must arise in the skin, not in the mucosa; (2) metastasis must be demonstrated at a site distant from the primary lesion (local extensions of the primary lesion, even farflung implantations, are not metastatic); and (3) both the primary and the metastatic lesions must be histologically the same, without any component of squamous cell carcinoma. Case report A 73-year-old woman noticed an enlarging lesion on her right forearm, and incisional biopsy of this 4 cm lesion showed basal cell carcinoma. The patient refused a wide excision. Five years later the lesion was 15 X 8 em, ulcerated, and bleeding (Fig. I). Upper extremity function was markedly impaired, with loss of finger extension and diminished grip strength. There was no axillary adenopathy. X-ray films showed a soft tissue mass with erosion of ulnar and radial cortices. An above-the-elbow amputation was performed. Twenty-two months later the patient had a 3.3 X 4.5 x 3 em axillary mass, and a right axillary dissection was performed after an evaluation for other metastatic disease was negative. Histologically, the metastatic lesion was From the Divisions of Plastic Surgery and Orthopaedics, University of South Florida College of Medicine. Tampa, Fla., and the Division of Plastic Surgery, Baylor University, Houston, Texas. Received for publication May 8,1991; accepted in revised form Jan. 15, 1992. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: C. Wayne Cruse, MD, Division of Plastic Surgery, Harboursidc Medical Tower #730, Four Columbia Cr., Tampa, FL 33606.
3/1/36744
Fig. 1. Basal cell carcinoma of right upper extremity. a typical basal cell carcinoma (Fig. 2). There were 10 other tumor-free nodes in the specimen. The patient remained free of disease 18 months after axillary dissection.
Discussion A large, ulcerated, locally invasive lesion is the typical setting for metastatic basal cell carcinoma, The average time from primary diagnosis to metastasis is 6 years. Two thirds of the metastases occur in regional lymph nodes, but hematogenous spread to bone, lung, pleura, and skin can occur. Hematogenous spread withTHE JOURNAL OF HAND SURGERY
1093
1094
The Journal of HAND SURGERY
Cruse et al.
rise to large tumor emboli," Basal cell carcinoma, unlike squamous cell carcinoma, may be dependent on its stroma for metastasis' because in vitro autologous transplantation cannot take place without stroma in the transplant. It may, however, be grown in tissue culture without its stroma. The treatment of metastatic basal cell carcinoma is not well defined, but clearly spread to a regional node without further spread should be treated surgically. Although earlier reports on chemotherapy are not hopeful, Coker et al. 7 have suggested that combination chemotherapy with cisplatinum and bleomycin may be helpful. The prognosis for metastatic disease is poor, with a median survival time of 10 to 14 months from the time of diagnosis of metastatic disease." REFERENCES I. Beadles CF. Rodent ulcer. Pathol Soc London Trans 1894;45: 176-81.
2. Cotran RS. Metastasizing basal cell carcinomas. Cancer 1961; 14:1036-40.
3. Paver K, Poyzcr K, Burry N, et al. The incidence of basal cell carcinoma and their metastases in Australia and New Zealand [letter]. Aust J Dermatol 1973; 14:53. 4. Lattes R, Kessler RW. Metastasizing basal cell epithelioma of the skin. Cancer 1951;4:866-78. 5. Mikhail GR, Nims LP, Kelly AP, Ditmars DM, Eyler WR. Metastatic basal cell carcinoma. Arch Dcrmatol 1977;113:1261-9. Fig. 2. Peripheral palisading of metastasis in axillary lymph
node. out regional lymph node metastasis is very rare. Metastasis from all histologic types can take place. s Some think that for metastases to occur the primary tumor must be large with invasion of deeper structures giving
6. Amonette RA. Metastatic basal cell carcinoma. J Dermatol Surg Oncol 1981;7:397-400. 7. Coker DO, Elias EG, Viravathana T, McCrea E, Hafiz M. Chemotherapy for metastatic basal cell carcinoma. Arch Derrnatol 1983;119:44-50. 8. Conway H, Hugo NE. Metastatic basal cell carcinoma. Am J Surg 1965;[ 10:620.
