Dermatology Online Journal

Letter: Basal cell carcinoma with vascular invasion
Mac Machan MD, Jan-Marie Kroh MD, Edgar Hunt MD, Garth Fraga MD
Dermatology Online Journal 18 (4): 13

University of Kansas Medical Center, Kansas City, Kansas

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Abstract

Non-melanoma skin cancer (NMSC) is the most common cancer in humans. Basal cell carcinoma accounts for 75 percent to 80 percent of NMSC. We report a primary cutaneous BCC on the upper chest in which vascular invasion was demonstrated by histopathology and the unique application of dual immunohistochemistry.

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Non-melanoma skin cancer (NMSC) is the most common cancer in humans. Basal cell carcinomas (BCCs) account for 75 percent to 80 percent of all NMSC; there are approximately 1 million new cases reported annually by the Skin Cancer Foundation [1]. Metastasis of basal cell carcinoma (BCC) is rare, with reported rates between 0.003 percent and 0.06 percent [2]. Both lymphatic and hematogenous spread has been inferred from the sites of metastatic disease, but to the best of our knowledge, angiolymphatic invasion has never been documented in primary cutaneous BCC. We report a primary cutaneous BCC in which vascular invasion was demonstrated by histopathology and dual immunohistochemistry.

Figure 1
Figure 1A. Dermal proliferation of basaloid cells. (x200) Figure 1B. Tumor aggregate within small muscular venule at the periphery of the excision. (x400) Figure 1C. Smooth muscle actin (brown) and cytokeratin 5/6 (red) dual immunohistochemistry highlights tumor cells in the muscular venule. (x400) Figure 1D. A papillary post-capillary venule. (x400)

A 51-year-old immunocompetent male presented in February 2011 with a 9 mm x 4 mm pearly papule near the mid line of his upper chest. He had a history of chronic sun exposure, basal cell carcinoma, and atypical nevi. Excision revealed a neoplasm comprised of basaloid cells arranged in micronodular and infiltrating aggregations forming epithelial-stromal clefts and exhibiting peripheral palisading. The tumor widely invaded the reticular dermis and was interpreted as an infiltrating and micronodular BCC. A tumor aggregate was identified within a muscular venule in the deep reticular dermis. Intravascular tumor was confirmed with dual immunohistochemistry, which also highlighted rare tumor cells within papillary post capillary venules (Figure 1). Re-excision of the site demonstrated surgical scar. The patient elected clinical follow-up with physical examination every three months. No lymphadenopathy, organomegaly, or systemic symptoms have been identified to date.

Metastatic BCC is generally unresponsive to chemotherapy. It carries a dismal prognosis with a 5-year survival of 10 percent [3]. Risk factors for metastasis include large tumor size (> 2 cm), primary tumor of the face or ear, increased depth of invasion, defective cellular immunity, exposure to radiation, and recurrence [1, 4]. Dual immunohistochemistry consists of sequentially applying two antibodies with different chromogens to a single tissue section. It allows co-localization of different epitopes in tissue sections. It has been used to highlight lymphatic invasion in malignant melanoma [5]. We used an antibody against smooth muscle actin to highlight the muscle cells in veins and cytokeratin 5/6 to highlight basal cell carcinoma. It confirmed the area of interest identified on routine hematoxylin-eosin sections and also revealed a smaller focus involving a postcapillary venule. We recognize the possibility of inadvertent transfer from the scalpel to the vessel during gross sectioning. However, the vascular BCC in our case tracked the course of the vascular lumen across multiple level sections and we do not think the vascular invasion was an artifact of gross dissection. To the best of our knowledge, this is the first case of primary cutaneous BCC with histopathologically documented venous invasion. Dual immunohistochemistry may be of value in evaluating angiolymphatic invasion in aggressive phenotypes of primary cutaneous BCC.

References

1. Rubin AI, Chen EH, Ratner D. Basal-cell carcinoma. N Engl J Med 2005;353:2262-9. [PubMed]

2. von Domarus H, Stevens PJ. Metastatic basal cell carcinoma. Report of five cases and review of 170 cases in the literature. J Am Acad Dermatol 1984;10:1043-60. [PubMed]

3. Spates ST, Mellette JR, Jr., Fitzpatrick J. Metastatic basal cell carcinoma. Dermatol Surg 2003;29:650- 2. [PubMed]

4. Alimoglu Y, Kilic E, Mercan H , Inci E. Metastatic Basal cell carcinoma. J Craniofac Surg;22:1134-6. [PubMed]

5. Petitt M, Allison A, Shimoni T, Uchida T, Raimer S, Kelly B. Lymphatic invasion detected by D2- 40/S-100 dual immunohistochemistry does not predict sentinel lymph node status in melanoma. J Am Acad Dermatol 2009;61:819-28. [PubMed]

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