Basal cell carcinoma

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Basal cell carcinoma
Diagnosis in short

Basal cell carcinoma. H&E stain.

LM "basaloid cells", nests with peripheral palisading of cells, artefactual clefting, myxoid stroma
Subtypes superficial pattern, nodular pattern, morpheaform (sclerosing) pattern, infiltrative pattern, fibroepitheliomatous pattern, infundibulocystic pattern, adenoidal pattern
LM DDx trichoepithelioma, adenoid cystic carcinoma, eccrine poroma, reticulated seborrheic keratosis (for BCC, fibroepitheliomatous pattern), basaloid squamous cell carcinoma, basosquamous carcinoma
IHC Ber-EP4 +ve, EMA -ve
Gross pearly nodule with telangiectasias
Site skin

Syndromes Bazex syndrome, nevoid basal cell carcinoma syndrome, xeroderma pigmentosum

Prevalence very common
Prognosis good
Clin. DDx solar elastosis with ectatic blood vessels
Basal cell carcinoma
External resources
EHVSC 10187 (BCC with dermal scar from bx)

Basal cell carcinoma, abbreviated BCC, is an extremely common form of skin cancer.

General

  • Very common.
  • Sun exposed skin.
  • Hair bearing area; tumour derived from hair follicle - a more appropriate name might be trichoblastic carcinoma.[1]
  • Very rarely metastasizes:
    • Dermatopathologists might see a couple in their career.
    • There are only ~ 300 literature reports of metastatic BCC.[2]
  • Uncommon in patients less than 35 years old.[3]

Clinical

  • Telangiectasias.
  • Raised pearly nodule.

As part of a syndrome

Microscopic

Features:[5][6]

  1. Basaloid cells - similar in appearance to basal cells:
    • Moderate blue/grey cytoplasm.
    • Dark ovoid/ellipsoid nucleus with uniform chromatin.
  2. Palisading of cells at the edge of the cell nests.
  3. Artefactual separation of cells (forming the nests) from the underlying stroma - key feature.
  4. Surrounded by blue (myxoid) stroma - key feature.

May be present:[6]

Notes:

  • Palisading = the long axes of the cells are alined and the axes are perpendicular to the interface between the (basaloid cell) nests and stroma.
  • Key elements in a list: Artefactual clefting (of nests), Basaloid cells, Peripheral palisading, Myxoid stroma.
    • Memory device PAM: palisading, artefactual clefts, myxoid stroma.

DDx:

Images

Basal cell carcinoma with mucin production Basal cell carcinoma with mucin production Basal cell carcinoma with mucin production

Basal cell carcinoma with mucin production in the left nasal bridge of a 59 year old man, presenting as a presumptive lacrimal cyst. Because of the location, immunohistochemical stains were needed to exclude eccrine tumors and salivary gland type tumors. A. A spheroidal, well circumscribed mass shows intertwining nests (green arrow), isles with cribriforming (yellow arrows), and large acini (cyan arrows), with good circumscription. B. Round to ovoid nuclei show > 4:1 nuclear size variation in some adjacent pairs (black arrows) and occasional pyknotic nuclei (green arrows). Lumens show mucinous material with vacuoles (yellow arrows); the color argues against adenoid cystic carcinoma, but certainty in that respect could not be maintained without immunostains. Note lining up of nuclei suggestive of palisades (blue arrows). C. Nuclei are P63 positive, not shown are the negative stains for SOX10, CK7, and CD117.


www:

Basal cell carcinoma subtypes/unique features

  • Many patterns exist.
  • Recurrence higher in morpheaform (sclerosing), infiltrative, micronodular, and superficial patterns.[11]
  • DG says the prognosis is similar for all BCC subtypes, except for sclerosing pattern and infiltrative pattern.[12]

The subtypes:[13]

Pattern Key histologic feature Other histologic features Other Image
Superficial pattern connected to epidermis
Nodular pattern nodules partial detachment from epidermis subgroup micronodular = nests equal size ~ 0.2 mm dia., >=25% of lesion
Morpheaform (sclerosing) pattern stroma sclerosis often seen with infiltrative pattern, DDx: desmoplastic trichoepithelioma[14]
Infiltrative pattern small irregular cell aggregates often also sclerosing or morpheaform
Fibroepitheliomatous pattern cords and columns of basaloid cells fibrous stroma name of pattern comes from fibroepithelioma of Pinkus; DDx: reticulated seborrheic keratosis
Infundibulocystic pattern small keratocysts (keratin cysts) usu. small, often in cords usu. indolent
Adenoidal pattern cribriform / pseudoglandular arch. myxoid stroma, peripheral palisading DDx: adenoid cystic carcinoma Adenoidal BCC (nih.gov)

Unique features/differentiation:[13]

Differentiation / unique cell Key histologic feature Other histologic features Other
Pigmented cells any pattern can have pigmentation pigment may be in malignant cell DDx: collision lesion with melanocytic lesion
Squamous differentiation (metatypical BCC) pink cytoplasm, keratinization assoc. with ulceration/tumour recurrence
Eccrine differentiation focal duct formation very rare, DDx: BCC engulfing sweat ducts
Clear cells (Clear cell BCC) clear cytoplasm due to glycogen

IHC

Squamous cell carcinoma versus basal cell carcinoma:

  • BerEP4 +ve.
    • SCC usually negative.[16]
  • EMA -ve.
    • SCC usually positive.[17]
  • SMA +ve.[18]
    • SCC usually negative.

Other:

Sign-out

SKIN LESION, RIGHT EAR, EXCISION: 
- BASAL CELL CARCINOMA. 
- MARGINS NEGATIVE FOR BASAL CELL CARCINOMA. 
- EXTENSIVE SOLAR ELASTOSIS.
SKIN LESION, RIGHT TEMPLE, RE-EXCISION:
- BASAL CELL CARCINOMA, NODULAR, MARGINS NEGATIVE.
- DERMAL SCAR.
- EXTENSIVE SOLAR ELASTOSIS.

Electrodesiccation and curettage

SKIN LESION, SHAVE BIOPSY WITH ELECTRODESICCATION AND CURETTAGE (EDC): 
- BASAL CELL CARCINOMA, MARGIN STATUS ASSESSED CLINICALLY DURING EDC. 
- EXTENSIVE SOLAR ELASTOSIS.
SKIN LESION, RIGHT UPPER BACK, SHAVE BIOPSY WITH ELECTRODESICCATION AND CURETTAGE (EDC):
- BASAL CELL CARCINOMA, MARGIN STATUS ASSESSED CLINICALLY DURING EDC.
- SOLAR ELASTOSIS.

COMMENT:
The tumour is clear of the edges of the tissue in the planes of section.

Close margin

SKIN LESION, SCALP, EXCISION:
- BASAL CELL CARCINOMA, NODULAR.
-- LATERAL MARGIN CLEARANCE LESS THAN 0.2 MILLIMETRES, SEE COMMENT.
-- DEEP MARGIN NEGATIVE FOR BASAL CELL CARCINOMA.
- SOLAR ELASTOSIS.

COMMENT:
The lesion is focally very close to the green inked margin in block A5
(3 o'clock to 6 o'clock margin).

The lateral margins elsewhere are 2-3 millimetres.
The deep margin is approximately 3 millimetres.

Positive lateral margin

SKIN LESION, LOWER MID BACK, EXCISION:
- BASAL CELL CARCINOMA, NODULAR, LATERAL MARGIN POSITIVE.
-- DEEP MARGIN NEGATIVE.
- SOLAR ELASTOSIS.

Infiltrative BCC

SKIN LESION, RIGHT EAR, SHAVE BIOPSY:
- INFILTRATIVE BASAL CELL CARCINOMA WITH FOCAL SCLEROSIS, DEEP AND LATERAL
  MARGINS POSITIVE.
- ACTINIC KERATOSIS.
- ULCERATION.

COMMENT:
The tumour stains as follows:
POSITIVE: CK34betaE12, Ber-EP4.
NEGATIVE: S-100, EMA.

Micro

The sections show hair-bearing skin with nests of basaloid cells in the dermis. The basaloid nests have peripheral palisading of the nuclei, have numerous mitoses, and are surrounded by a myxoid stroma. The nests are well demarcated from the stroma and show focal clefting from the stroma. The margins are negative for basal cell carcinoma.

Infiltrative BCC

The sections show ulcerated skin. In the dermis, there are single atypical cells, small clusters of atypical cells and rows of atypical cells. The atypical cells have moderate grey cytoplasm, irregular nucleoli, and pale nuclei. Mitotic activity is present. The stroma is partially sclerotic.

The epidermis (where present) has basal atypia and focal parakeratosis.

The atypical lesion is present at the deep and lateral margins.

Small basal cell - curettage afterward

The sections show hair-bearing skin with small groups of basaloid cells attached to the epidermis. The groups of basaloid cells have peripheral palisading of the nuclei and are surrounded by a myxoid stroma. The groups of basaloid cells are well demarcated from the stroma and show focal clefting from the stroma. The edge of the tissue focally has basal cell carcinoma, the deep aspect is clear.

See also

References

  1. Busam, Klaus J. (2009). Dermatopathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Saunders. pp. 389. ISBN 978-0443066542.
  2. Ting, PT.; Kasper, R.; Arlette, JP. (Jan 2005). "Metastatic basal cell carcinoma: report of two cases and literature review.". J Cutan Med Surg 9 (1): 10-5. doi:10.1007/s10227-005-0027-1. PMID 16208438.
  3. Cox, NH. (Jul 1992). "Basal cell carcinoma in young adults.". Br J Dermatol 127 (1): 26-9. PMID 1637690.
  4. URL: http://emedicine.medscape.com/article/1101146-diagnosis. Accessed on: 6 May 2010.
  5. 5.0 5.1 Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1180-1. ISBN 978-1416031215.
  6. 6.0 6.1 Busam, Klaus J. (2009). Dermatopathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Saunders. pp. 390. ISBN 978-0443066542.
  7. Slodkowska, EA.; Cribier, B.; Peltre, B.; Jones, DM.; Carlson, JA. (Aug 2010). "Calcifications associated with basal cell carcinoma: prevalence, characteristics, and correlations.". Am J Dermatopathol 32 (6): 557-64. doi:10.1097/DAD.0b013e3181ca65e2. PMID 20489568.
  8. Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 284. ISBN 978-0470519035.
  9. URL: http://missinglink.ucsf.edu/lm/DermatologyGlossary/basal_cell_carcinoma.html. Accessed on: 4 September 2011.
  10. Rustemeyer, J.; Günther, L.; Deichert, L. (Sep 2011). "A rare association: basal cell carcinoma in a vitiliginous macula.". Oral Maxillofac Surg 15 (3): 175-7. doi:10.1007/s10006-010-0240-y. PMID 20623309.
  11. Basal cell carcinoma. eMedicine. Prognosis section. URL: http://emedicine.medscape.com/article/276624-overview. Accessed on: 17 September 2011.
  12. Ghazarian, Danny; 14 September 2011.
  13. 13.0 13.1 Busam, Klaus J. (2009). Dermatopathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Saunders. pp. 392-5. ISBN 978-0443066542.
  14. Kirzhner, M.; Jakobiec, FA.; Borodic, G.. "Desmoplastic trichoepithelioma: report of a unique periocular case.". Ophthal Plast Reconstr Surg 28 (5): e121-3. doi:10.1097/IOP.0b013e318245535a. PMID 22366669.
  15. Sellheyer, K.; Nelson, P.; Kutzner, H.; Patel, RM. (Apr 2013). "The immunohistochemical differential diagnosis of microcystic adnexal carcinoma, desmoplastic trichoepithelioma and morpheaform basal cell carcinoma using BerEP4 and stem cell markers.". J Cutan Pathol 40 (4): 363-70. doi:10.1111/cup.12085. PMID 23398472.
  16. Yu, L.; Galan, A.; McNiff, JM. (Oct 2009). "Caveats in BerEP4 staining to differentiate basal and squamous cell carcinoma.". J Cutan Pathol 36 (10): 1074-176. doi:10.1111/j.1600-0560.2008.01223.x. PMID 19187107.
  17. Beer, TW.; Shepherd, P.; Theaker, JM. (Sep 2000). "Ber EP4 and epithelial membrane antigen aid distinction of basal cell, squamous cell and basosquamous carcinomas of the skin.". Histopathology 37 (3): 218-23. PMID 10971697.
  18. URL: http://www.ihcworld.com/_newsletter/2004/2004-12_basal_cell_vs_squamous_v1.pdf. Accessed on: 19 December 2012.
  19. Bircan, S.; Candir, O.; Kapucoglu, N.; Baspinar, S. (Apr 2006). "The expression of p63 in basal cell carcinomas and association with histological differentiation.". J Cutan Pathol 33 (4): 293-8. doi:10.1111/j.0303-6987.2006.00436.x. PMID 16630179.

External links