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Year : 2007  |  Volume : 52  |  Issue : 4  |  Page : 206-208
Soft tissue metastasis in basal cell carcinoma

1 Department of Radiotherapy and Oncology, Rural Medical College, Pravara Rural University, Loni, Ahmednagar, India
2 Department of Pathology, Rural Medical College, Pravara Rural University, Loni, Ahmednagar, India

Correspondence Address:
Rajeev Shrivastava
Department of Radiotherapy and Oncology, Rural Medical College, Pravara Rural University, Loni, Ahmednagar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5154.37730

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Basal cell carcinoma (BCC) is the most common of the cutaneous malignancies, accounting for 65-75% of all skin cancers. The natural history of this disease is one of chronic local invasion. Metastatic BCC Is a rare clinical entity, with a reported incidence of only 0.0028-0.5%. Approximately 85% of all metastatic BCCs arise in the head and neck region. We present a case of BCC that spread to the muscles of the cheek and nodes (intraparotid and internal jugular), in a man who had a lesion near the inner canthus of his right eye and adjoining nasal bridge.

Keywords: BCC, chemotherapy, metastatic

How to cite this article:
Shrivastava R, Singh K K, Shrivastava M. Soft tissue metastasis in basal cell carcinoma. Indian J Dermatol 2007;52:206-8

How to cite this URL:
Shrivastava R, Singh K K, Shrivastava M. Soft tissue metastasis in basal cell carcinoma. Indian J Dermatol [serial online] 2007 [cited 2022 Jan 22];52:206-8. Available from:

   Introduction Top

Basal cell carcinoma (rodent ulcer or basal cell epithelioma) is a malignancy derived from the keratinocytes and stroma of the pilosebaceous follicle. [1],[2],[3]

Sixty-six per cent of BCCs occur in the head and neck with increased incidence in those with fair skin and skin type I. [4] Patched gene is thought to be crucial in the pathogenesis of BCC. [5] There are six clinico-pathological subtypes of BCC, namely nodular, pigmented, cystic, morphoeic (sclerosing), superficial and linear BCC. [6],[7],[8]

The course of BCCs is slow and progressive, with local destruction of structure if left untreated. In immunosuppressed patients, tumor may be more aggressive. [8] Metastasis is extremely rare, estimated risk being as low as 0.1%. [9] Metastasis develops in only longstanding lesions and the spread is to regional lymph nodes or lungs. Death may occur by local invasion of tissue such as major blood vessels and brain. Eighty-five per cent of metastatic BCCs arise in the head and neck region. [10] The first reported case of metastatic BCC was published by Beadles in 1894. [11]

In this article, we describe the case of a patient with BCC that spread to the soft tissues of the cheek and nodes (intraparotid and internal jugular), who had a lesion near the inner canthus of his right eye and adjoining nasal bridge.

   Case Report Top

A 68-year-old male came with complaints of recurrent ulcerative lesion near inner canthus of right eye of 13 years duration, operated twice for the same condition. There was 3 4 cm 2 size ulcerative lesion near the inner canthus of the right eye with raised margin, indurated base and serosanguineous discharge with involvement of adjoining nasal bone [Figure - 1]. On histopathological examination, the stained section showed uniform darkly stained basaloid cells with oval nuclei and relatively little cytoplasm. The cells were arranged into well-demarcated islands and strands which appeared to arise from the basal cell layer of the overlying epidermis and invade into the underlying dermal connective tissue. Epithelial island demonstrated palisading of the peripheral cells and showed clear zone of retraction between them and the connective tissue. Based on these facts, it was reported as BCC. He was treated by radiotherapy using Co60 (54 Gy/27#/6 weeks). On follow-up he was asymptomatic apart from bony defect near nasal bridge. After eight months he complained of some mass-like feeling in his right cheek. On examination, there was 4 2 cm 2 size mass present within the muscle of the left cheek with no mucosal or skin involvement without any continuity with primary. Upper cervical node was enlarged and was 1.5 1 cm 2 in size with firm consistency. The USG of cheek and neck revealed lobulated, well-defined, hypoechoic soft tissue mass lesion of size 3.6 1.3 cm 2 in the soft tissue of the left cheek [Figure - 2]. There were multiple left intraparotid enlarged lymph nodes and two internal jugular lymph nodes, the largest measuring 1.2 1.1 cm 2 [Figure - 3]. Left parotid gland was normal. Fine needle aspiration cytology (FNAC) with multiple aspirations from the cheek mass was suggestive of BCC. He was given chemotherapy, cisplatin 20 mg/m 2 D1 to D5 and etoposide 100 mg/m 2 D1, D3 and D5. Patient received four cycles of chemotherapy which were uneventful. Patient was re-evaluated after the fourth cycle of chemotherapy. All routine tests were normal. A repeat USG of cheek and neck showed no evidence of disease [Figure - 4].

   Discussion Top

Metastatic BCC is a rare phenomenon, with a reported incidence of only 0.0028-0.5%. [12],[13] Men are more predisposed to metastatic BCC than women by a ratio of 2 to 1. [14] The median life expectancy after a metastasis is identified as eight months only. [15]

Persistent or recurrent tumor of many years duration predisposes patients to metastatic BCC. The depth of tissue invasion and extension of the tumor into adjacent anatomic structures can also increase the risk of metastasis. [16],[17] In our case the tumor had invaded the nasal bone of the patient. Blewitt reviewed 38 cases of metastatic BCC and noted that the primary tumor was usually located on the scalp or face. [10] In our case too the primary tumor was near the inner canthus of the eye and nasal area, adding to the risk factor for metastasis. In a review of 170 published cases of metastatic BCC, von Domarus and Stevens found that 67.6% of metastases originated in sites on the head and face, mostly on the midface. [15] The BCCs in these regions have been noted to be more aggressive and destructive than lesions at other sites. [7],[18] It has been postulated that the presence of embryonic fusion planes in the midface area results in more occult and distant spread, as well as more difficulty in surgical removal. [19]

Lymphatic and hematogenous channels are the primary routes of metastasis of BCC. Involvement of the parotid or submandibular glands as a result of metastasis to intra- or periglandular lymph nodes has been reported to occur in patients with metastatic BCC that spreads from the head and face. [7],[20],[21],[22],[23],[24] In our case too there was involvement of periglandular lymph node. Common sites of hematogenous dissemination include the lungs and pleura, liver, bone and skin. [21] The underlying molecular mechanisms of tumor invasion and metastasis of BCC have yet to be elucidated. Farmer and Helwig have suggested that tumor metastasis is the result of immunologic alterations between the tumor and host. [25] Recent studies have examined the role of cellular adhesion molecules in tumor metastasis, but no correlation was noted in the expression or distribution of various cellular adhesion molecules by the different histological subtypes of BCC. [26],[27]

Surgery, radiotherapy and chemotherapy, either alone or in combination have been used for treatment of metastatic BCC. Farmer and Helwig reported that postoperative survival was as long as nine years. [25] Several agents are effective, alone or in combination; they include cis -platinum, methotrexate, cyclophosphamide, 5-fluorouracil, bleomycin, vincristine and doxorubicin. [28] As reported by Pfeiffer et al. , [29] the median survival rate with Cisplatinum is better than other regimens (16 vs. 8 months).

It seems most likely that the metastatic disease to the intraparotid and internal jugular node spread from the primary tumor. The spread to the muscles of the cheek may have been due to perinodal spread from the intraparotid nodes but there was no evidence on songraphy for the same. Thus careful examination and evaluation for metastatic potential as well as metastasis will help in better management of patients.

   References Top

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2.Jih DM, Lyle S, Elenitsan R, Elder DE, Cotsarelis G. Cytokine 15 expression in trichoepitheliomas and subset of basal cell carcinomas suggests they originate from hair follicle stem cells. J Cutan Pathol 1999;26:113-8.  Back to cited text no. 2    
3.Kruger K, Blume-Peytavi U, Orfanos CE. Basal cell carcinoma possibly originates from the outer root sheath and/or the bulge region of the vellus hair follicle. Arch Dermatol Res 1999;291:253-9.  Back to cited text no. 3    
4.Aszterbaum M, Beech J, Epstein EH Jr. Ultraviolet radiation mutagenesis of hedgehog pathway genes in basal cell carcinomas. J Investig Dermatol Symp Proc 1999;4:41-5.  Back to cited text no. 4  [PUBMED]  
5.Krudson AG Jr. Hereditary cancer, oncogenes and anti oncogenes. Cancer Res 1985;45:1437-43.  Back to cited text no. 5    
6.Gormley DP, Hirsch P. Aggressive basal cell carcinoma of the scalp. Arch Dermatol 1978;114:782-3.  Back to cited text no. 6    
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8.du Vivier A. Atlas of clinical dermatology, 2 nd ed. Mosby Wolfe: New York; 1993. p. 9.17-9.22.  Back to cited text no. 8    
9.Costanza ME, Dayal Y, Binder S, Nathanson L. Metastatic basal cell carcinoma: Review, report of a case and chemotherapy. Cancer 1974;34:230-5.  Back to cited text no. 9  [PUBMED]  
10.Blewitt RW. Why does basal cell carcinoma metastasize so rarely? Int J Dermatol 1980;19:144-6.  Back to cited text no. 10  [PUBMED]  
11.Beadles CF. Rodent ulcer. Trans Pathol Soc (Lond) 1894;45:176-81.  Back to cited text no. 11    
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19.Levine HL, Bailin PL. Basal cell carcinoma of the head and neck: Identification of the high risk patient. Laryngoscope 1980;90:955-61.  Back to cited text no. 19  [PUBMED]  
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21.Conley J, Sachs ME, Romo T, Labay G, Gillooley J. Metastatic basal cell carcinoma of the head and neck. Otolaryngol Head Neck Surg 1985;93:78-85.  Back to cited text no. 21  [PUBMED]  
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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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