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Basal cell carcinoma is a common non-melanotic skin cancer with a prevalence of 74.5%-82.6% in the Iranian population. BCC rarely metastasizes. However, metastasis can cause significant morbidity. The prevalence of metastatic basal cell carcinoma varies between 0.0028% and 0.55% of all cases. We describe a case of lung metastasis of basal cell carcinoma of the scalp.
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Case Report
2018 NRITLD, National Research Institute of Tuberculosis and Lung Disease, Iran
ISSN: 1735-0344 Tanaffos 2018; 17(1): 62-65
A Rare Report of Lung Metastasis of the Common Non-
Melanotic Skin Cancer
Mohsen Shafiepour 1, Arda Kiani 2, Kimia
Taghavi 1, Sharareh Seifi 1, Mitra Sadat
Rezaie 3, Seyed Mohammad Reza
Hashemian 4, Atefeh Abedini 1
Basal cell carcinoma is a common non-melanotic skin cancer with a prevalence
of 74.5%82.6% in the Iranian population. BCC rarely metastasizes. However,
metastasis can cause significant morbidity. The prevalence of metastatic basal
cell carcinoma varies between 0.0028% and 0.55% of all cases. We describe a
case of lung metastasis of basal cell carcinoma of the scalp.
Key words: Basal cell carcinoma, Pulmonary, Lung metastasis,
Metastatic basal cell carcinoma
1 Chronic Respiratory Diseases Research Center,
National Research Institute of Tuberculosis and Lung
Disease (NRITLD), Shahid Beheshti University of
Medical Sciences, Tehran, Iran, 2 Tracheal Diseases
Research Center, NRITLD, Shahid Beheshti University of
Medical Sciences, Tehran, Iran, 3 Virology Research
Center, NRITLD, Shahid Beheshti University of Medical
Sciences, Tehran, Iran, 4 Clinical Tuberculosis center,
NRITLD, Shahid Beheshti University of Medical
Sciences, Tehran, Iran
Received: 30 July 2017
Accepted: 15 December 2017
Correspondence to: Abedini A
Address: Chronic Respiratory Diseases Research
Center, NRITLD, Shahid Beheshti University of
Medical Sciences, Tehran, Iran.
Email address: dr.abedini110@gmail.com
INTRODUCTION
Basal cells are small, round cells found in the lower
layer of the epidermis (1,2). Basal cell carcinoma (BCC) is
the most common non-melanotic skin malignancy and also
the most common type of skin cancer (3,4). BCC is usually
characterized by invasive local growth and tissue
destruction, with a worldwide prevalence of up to 80% and
74.5%82.6% in Iran (1,2,5,6). BCC is more common among
fair-skinned males and occurs nearly 85% of the time in the
head and neck region (7,8). Similar to squamous cell
carcinoma (SCC) and Merkel cell carcinoma (MCC), BCC is
distinguished by large, facial, invasive, destructive,
ulcerated, long-term, and treatment-resistant scars or
lesions (1,9). The metastatic potential of BCC is 0.0028% (28
cases per 1,000,000 BCC cases)0.55% (1,7). Therefore, only
a few cases of metastatic BCC (MBCC) have been reported
in Iran, none of which demonstrated metastasis to the
lung (1,2).
The current report is from Masih Daneshvari hospital, a
referral center for pulmonary and lung diseases in Iran,
which describes a rare case of metastasis of BCC to the
lung.
TANAFFOS
Shafiepour M, et al. 63
Tanaffos 2018; 17(1): 62-65
CASE SUMMARIES
On October 2011, a 65-year-old fair-skinned female
suffering from a waxy flat scalp lesion presented to
Loghman Hakim hospital. There was no history of
previous skin cancers. A punch lesion biopsy of 4-mm
height and 5-mm depth was performed. Histopathology
reported the biopsy specimen as a focal epidermal fibrin
leukocyte ulcer. The microscopic examination showed BCC
characterized by strands of neoplasm containing round
vesiculated hyperchromatic nuclei, clear cytoplasm
producing shrunken nests, and sclerotic collagen bundles
surrounding the neoplasm strands (10). The patient
presented for excision surgery 9 weeks after the initial
biopsy. The lesion, with clinically 7-mm marked margins,
and full-thickness skin was excised. On pathological
examination of the 22- × 12-mm specimen, the tumor was
diagnosed as multifocal infiltrative BCC. The patient was
administered 500 mg cephalexin and 325 mg
acetaminophen to prevent local infection. The liver
function tests and other routine blood investigations were
within normal limits. Local recurrence appeared at the
same site 5, 12, and 18 months after the excision surgery.
Several punch lesion biopsies were conducted.
Histopathology descriptions reported ulcerated surface
tumors; focally invading hypodermis; infiltrative mixed
nodular, solid morphemic, and pigmented type of BCC.
Moreover, the reports noted that the tumors had focally
invaded the hypodermis as M80106: metastatic carcinoma;
C44.4: malignant neoplasm of skin of scalp and neck; and
M8090/3: basal cell carcinoma (11). The lymphatic vascular
invasion was also diagnosed in the last skin biopsy. A
second excision surgery was done in 2014, and no evidence
of tumor recurrence was detected until 2015. However, on
computed tomography, no pulmonary invasion was
observed at the time of the last excision.
In September 2015, one year after the second excision
surgery, the patient presented to Masih Daneshvari
hospital suffering from productive cough and chest pain.
No abnormal activity was detected outside the lungs on
analyzing the complete blood count and liver function
tests. The probability of metastasis was evaluated
considering the history of multiple lesions. Accordingly,
the patient underwent chest radiography and computed
tomography. The chest radiograph demonstrated large
lobulated lesions in both lung lobes (Figure 1). Bilateral
multiple nodular lung lesions in both the lungs were
detected in the computed tomogram (CT scan) (Figure 2).
All features suggested a metastatic lesion in the lungs. A
CT-guided fine needle aspiration cytology (FNAC) from
both lung lesions was performed.
Figure 1. Large lobulated lesions in both the lung lobes in the chest
radiography
Figure 2. Computed tomogram showing a large solid lobulated margin
mass lesion involving the left lung lobe and also the right lung lobe
The specimen showed multiple filiform tan-whitish
tissues, 4cm in length and 0.1cm in greatest dimension,
retained in formalin. The pathological examination of the
CT-guided biopsy confirmed that the lung tissue was
infiltrated by a neoplasm creating nests composed of
uniform cells with peripheral palisades. The CT-guided
biopsy and cytology defined positive malignant cells
identical with MBCC of the lung (Figure 3).
64 Lung Metastasis of the Non-Melanotic Skin Cancer
Tanaffos 2018; 17(1): 62-65
Figure 3. Pathological examination of the CT guided biopsy showed
tissue infiltrated by a neoplasm creating nests composed of uniform
cells with peripheral palisades which was defined as metastatic basal
cell carcinoma (MBCC)
The specimen was re-examined, and immune
histochemical staining was done. The tumor cells were
positive for P63 and negative for chromogranin. TTF1,
EMA, and TG were negative, which ruled out cutaneous
neuroendocrine carcinoma (Merkel cell carcinoma). The
findings were similar to the patient's BCC histological
features, which developed five years ago. The similarity of
the tumors and histological features indicated that the
pulmonary nodules were rare metastatic BCC.
Postoperative chemotherapy with 5-fluorouracil (FU) and
cisplatin was administered to the patient. In August 2016,
after 8 weeks of chemotherapy, on clinical examination, her
carcinoma had visibly resolved. The patient's white blood
cell count decreased from 9100 U/L before chemotherapy
to 4400 U/L. Also, a follow-up chest CT and radiograph
showed an improvement in health. The liver function and
routine blood tests showed hyperglycemia and
hypertriglyceridemia as side-effects of the chemotherapy.
An irregular shaped hyperpigmented macule on the skin
of the back of the patient’s hand was diagnosed as a senile
lentigo. The results were likely to be age-related.
DISCUSSION
BCC is most frequently observed in fair-skinned
individuals, and 90% occur in sun-exposed areas such as
the head and neck region. Three main types of BCC appear
to be predominant. The first type manifests as a deep ulcer
with raised margins. The second type is a superficial, flat
lesion with a waxy surface that is macular and slightly
erythematous. The third type appears as a polyploidy
tumor with an intact surface. Recurrence and metastasis is
generally observed in superficial, infiltrative,
micronodular, and morpheaform BCC (1,2).
MBCC is metastatic, which occurs at distant, non-
contiguous sites from the primary cutaneous BCC lesions,
with similar histological characteristics to those of the
primary BCC (2). MBCC is extremely rare, but it carries
high morbidity and mortality rates. Persistence of BCC for
many years and recurrence despite optimal treatment are
some risk factors predisposing patients to MBCC. Forty-
two percent of the MBCC disseminate to the lungs, with
symptoms such as productive cough and chest pain (2). In
contrast, the current case was reported as a rare pulmonary
metastasis due to the relapse of scalp lesion, after five years
of repeated diagnosis and rejection.
To our knowledge, no previous case of lung MBCC has
been described in Iran.
The therapy of MBCC is surgical excision combined
with chemotherapy and radiation therapy. Chemotherapy
with cisplatin, either alone or in combination with 5-
fluorouracil (FU), cyclophosphamide, cis-
diaminedichloroplatinum, vincristine, and bleomycin to
overcome resistance has shown significant positive
responses (12). Recently, sonidegib, an oral inhibitor, has
been approved by the FDA (13). The available data on
sonidegib is too limited to determine the overall survival
rate. Besides the diagnosis and treatment of MBCC, the
prognosis is recommended within five years of cure time.
CONCLUSION
Although MBCC is a rare entity, its occurrence should
be borne in mind, especially when dealing with a giant,
Shafiepour M, et al. 65
Tanaffos 2018; 17(1): 62-65
recurrent, or long-standing tumor in the head and neck
region.
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