Research Article (Open access) |
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SSR Inst. Int. J. Life Sci., 6(2): 2487-2493, March 2020
Histopathological
Spectrum of Basal Cell Carcinoma-7 Years Retrospective Study
Somil
Singhal*
Consultant
Pathologist, Kriti Pathology (A Complete Diagnostic Solution), A Unit of Kriti
Scanning Centre (P) Ltd., Allahabad, India
*Address for Correspondence: Dr. Somil Singhal, Consultant Pathologist, Kriti Pathology (A Complete
Diagnostic Solution), A Unit of Kriti Scanning Centre (P) Ltd. Allahabad, Uttar
Pradesh, India
E-mail: somil15feb@gmail.com
ABSTRACT- Background: Basal cell carcinoma is the most
common malignant tumour of the skin worldwide. The objective was to find out
the age and sex incidence of basal cell carcinoma in patients attending the outpatient
department of dermatology and to find out the various clinical and
histopathological features of basal cell carcinoma.
Methods: It was a retrospective study carried
out in a NABH, NABL and JCI accredited hospital, New Delhi, India. Patients
with a clinical diagnosis of basal cell carcinoma were included in the study
after thorough history, clinical examination, routine and special
investigations like skin biopsy.
Results: Out of 20 patients with basal cell
carcinoma 6 were males and 14 were females with a male to female ratio of
1:2.33. Most commonly affected age group was 51–70 years (70%). Distribution of
BCC in our study was confined to head and neck area. Most common morphological
subtype encountered in this study was nodular/nodulo-ulcerative BCC (70%),
followed by the pigmented type (25%) and superficial BCC (5%). The most common
histological variant observed in the present study i.e. nodular type (55%),
followed by the pigmented variant (25%), adenoid (5%), basosquamous (5%),
superficial BCC (5%) and BCC with sebaceous differentiation (5%).
Conclusion: This study
highlights a paradoxically increasing trend of BCC with female predilection.
Early detection and treatment of lesions are crucial to decrease the functional
and cosmetic disfigurement and also this study highlights the importance of
improving awareness among general practitioners, public health workers and the
general population.
Keywords:
Basal cell carcinoma, Clinical
variants, Excision biopsy, Histopathology
INTRODUCTION- Basal cell carcinoma is the most common malignant skin
tumor and the most prevalent cancer type among white- skinned populations
worldwide and particularly in industrialized Western societies [1].
In addition, the incidence of skin cancer is rising all over the world.
Geographical location plays an extremely important role in the distribution and
frequency of incidence rates. In people with outdoor occupations like miners,
quarry men, railway engine drivers and firemen, the frequency of BCC is high [2].
It is a slow-growing malignant tumour of the skin that invades the adjacent
tissues with a metastatic incidence of 0.01%–0.028%. [3] Ultraviolet
radiation plays a major role in the development of BCCs. Radiation exposure,
exposure to arsenic salts, chemical carcinogens, chronic irradiation, chronic
inflammation, pre-existing skin lesions such as discoid lupus erythematosus, burn scar and
vaccination scar are the various other causal factors [4]. Ethnical
differences in types of skin, immunological and genetic factors also play a
role in the development of BCC. Males are more
commonly affected than females. BCC generally occurs in adults over 40
years of age, but it may occur in children and young adults [5]. In children,
it is usually associated with genetic defects such as xeroderma pigmentosum,
nevus sebaceous, nevoid basal cell syndrome, Rombo syndrome or Bazex syndrome, Brooke-Spiegler syndrome.
MATERIALS AND METHODS- It was a retrospective study conducted for a period of seven
years from September 2004 to September 2011 in patients attending outpatient
Department of Dermatology, Maharaja Agrasen Hospital, New Delhi, India.
The patients, who attend
the dermatology outpatient department, with a clinical diagnosis of basal cell
carcinoma were selected for the study. Thorough history related to age, sex,
occupation and the duration of the lesions was noted. Specific and relevant
history about the lesion was taken, including family history. History of any
medical or surgical interventions also noted. Thorough clinical examination of
the lesions with reference to site, number, size, shape, colour, surface border
and consistency of the lesion were also noted. Routine investigations like
complete blood count, random blood sugar, bleeding time, clotting time, HIV 1
and 2 antibody, VDRL and X- ray chest was taken from all the patients. Using
pretested proforma, patient details, clinical findings and investigations were
recorded. Excision biopsy was done in the dermatology operating room. Excised
specimen was received for histopathological examination. Sections were stained
with H and E and studied in both low and high-power magnifications. Pathologist
opinion was obtained. The clinical and histopathological correlation were done.
Inclusion criteria- Patient, who was ready
to give consent for pictures and biopsy procedure for study.
Exclusion Criteria- Patients with known
congenital abnormalities, HIV patients/ known malignancy or chemotherapy/
pregnant patients and those, who were not willing to give consent for biopsy
procedure.
Ethics approval and consent to participate- The above study was approved by the Human Ethical Committee
(Ethics Committee approval number: SNMC/IECHSR/ 20141/A-14c1.1 dated 19
November 2014) of the “S Nijalingappa Medical College, HSK (Hanagal Shree Kumareshwar)
Hospital and Research Centre, Nava
Nagar, Bagalkot, Karnataka and informed consent was obtained from the patients
before the study.
Age groups |
Males |
Females |
Total |
Percentage
(%) |
11-20 |
1 |
0 |
1 |
5 |
21-30 |
0 |
0 |
0 |
0 |
31-40 |
2 |
0 |
2 |
10 |
41-50 |
1 |
0 |
1 |
5 |
51-60 |
2 |
6 |
8 |
40 |
61-70 |
0 |
6 |
6 |
30 |
71-80 |
0 |
2 |
2 |
10 |
Site |
Numbers of
cases (%) |
Nose |
6 (30%) |
Periocular
area |
5 (25%) |
Cheek |
3 (15%) |
Forehead |
2 (10%) |
Post auricular area |
2 (10%) |
Upper
lip |
1 (5%) |
Chin |
1 (5%) |
Morphological types of Basal cell carcinoma- Most common morphological subtype of
basal cell carcinoma was nodular /nodulo-ulcerative growth (70%). It was
followed by pigmented variant (25%) and superficial basal cell carcinoma (5%)
is given in Table 3.
Morphology |
Number
of Cases (n=20) |
Percentage
(%) |
Nodular / Nodulo-ulcerative |
14 |
70 |
Pigmented |
5 |
25 |
Superficial |
1 |
5 |
Fig. 3:
Gross
Variant of Nodular Basal Cell Carcinoma (Diffuse freckling on face suggestive
of Xeroderma pigmentosum and Nodulo-ulcerative growth on right side of nose)
Fig. 7: Baso squamous carcinoma showing focal keratinization
Table
4: IHC study to rule out the mimics of
superficial variant of basal cell carcinoma
Differential
Diagnosis |
IHC Marker |
Positive |
Negative |
Trichoepithelioma |
CD 10 |
+ Peritumoral,
Stromal reaction |
- |
Sebaceoma |
BerEp4 EMA |
Rarely + Typically + |
- |
Microcystic adnexal carcinoma |
CK 20 |
- |
- |
Basal Cell Carcinoma |
BCL-2, Ber-Ep4 CD34 |
- |
- |
Table 5: Immunohistochemistry
study to rule out the mimics of Morphoeic variant of basal cell carcinoma
IHC Markers |
Basal Cell
Carcinoma |
Trichoblastoma |
CD 10 |
Present in
Epithelium |
Present in
Peritumoral |
BCL2 |
Absent |
Absent |
Table 6: Immunohistochemistry studies to rule
out the mimics of Baso squamous variant of basal cell carcinoma
IHC Markers |
Basal Cell
Carcinoma |
Basosquamous Variant |
34 BETA E 12 |
- |
+ |
AE1/AE3 |
- |
+ |
MNF116 |
- |
+ |
CK 5/6 |
+ |
+ |
CAM 5.2 |
- |
- |
BerEP4 |
- |
- |
S100P |
- |
- |
Table 7: Immunohistochemistry studies to confirm the
diagnosis of basal cell carcinoma
IHC Markers |
Positive |
Negative |
CK 5 |
+ |
- |
CK 6 |
+ |
- |
CK 14 |
+ |
- |
CK 7 |
+ |
- |
Ber EP4 |
+ |
- |
P63 |
+ Nuclear Expression |
- |
CK 20 |
- |
- |
EMA |
- |
- |
CEA |
- |
- |
DISCUSSION-
This study included a total of 20 patients
with basal cell carcinoma. Among these 6 patients were males and 14 patients
were females. In this study, females were more commonly affected (70%) than
males (30%) with a male to female ratio of 1: 2.33. It was consistent with
Laishram et al. [6] study
‘pattern of skin malignancies in Manipur, India, which shown male to female
ratio of 1:2 and contrast to western studies that conducted by Hakverdi et al. [7], retrospective
analysis of basal cell carcinoma showed male preponderance.
BCCs are more common in
males as reported in most studies worldwide, presumably due to greater
occupational exposure to ultraviolet radiation (UVR). However, an unusual
female preponderance was noticed in our study [8]. Since Indian
housewives, especially rural women work in open kitchen during their household
chores and work in the fields during sowing and harvesting seasons exposing
them to intermittent, high intensity UVR. It might explain the higher frequency
of BCC in females in our study as intermittent rather than constant, cumulative
UVR exposure was implicated in the pathogenesis of BCC. This female
predilection may also be attributed to structurally thinner skin with lower
collagen density in the dermis when compared to men [9].
The most commonly
affected age group in this study was 51–60 years (40%), followed by 61-70 years
(30%) with a mean age of 56.7 years. It was similar to a study conducted by
Obaidullah and Aslam, which showed a mean age of 56.3 years [8].
Maximum age of the patient affected by BCC in our study was 72 years and the
youngest age was 14 years. Although basal cell carcinoma is rare in younger
individuals, an increased incidence has also been noticed in children and young
adults [5]. Here, we reported a
14 year old male patient with diffuse freckling on the face suggestive of
xeroderma pigmentosum and nodulo- ulcerative type of basal cell carcinoma on
right side of nose. Xeroderma pigmentosum is a rare autosomal recessive disease
characterized by photosensitivity, pigmentary changes and early neoplasia
resulting from abnormal DNA repair.
Higher rates of occurrence of BCC among the elderly may be due to cumulative
UVR induced DNA damage as well as reduced efficiency of immune-surveillance and
DNA repair mechanisms with aging [9].
The distribution of BCC
in the present study was confined head and neck area. The most common site of
involvement was nose (30%), followed by periocular area (25%) and cheek (15%).
It was similar to a study conducted by Malhotra et al. [10] ‘Basal cell carcinoma in the north Indian
population’ which showed head and neck being the commonest site (91.2%). Another study conducted by Asif et al. [11] showed nose being
the common site (28.9%) followed by eye (24.7%) and cheek (20.4%) which was
closely resembles to this study. The most common morphological sub type of BCC
encountered in our study was nodular/nodulo-ulcerative type (70%), followed by
pigmented BCC (25%) and superficial BCC (5%).
These findings are
consistent with a study conducted by Sumirkumar et al. [12], ‘A study of basal cell carcinoma in south
Asians’ which showed common morphological subtype is being
nodular/nodulo-ulcerative BCC (77.8%) and pigmented BCC (22.2%). The patients
with nodular type of BCC, having cutaneous features of skin coloured or
hyperpigmented papules, nodules and plaques were present on head and neck area
most commonly on nose, periocular and cheek. Some patients with
nodulo-ulcerative lesions showed surface changes like ulceration and crusting [13].
The patients with pigmented BCC were present as nodular lesions with grey-black
pigmentation [14]. In our study, 5 patients were appearing
clinically pigmented. Superficial BCC usually appears as erythematous, scaly
patches that slowly increase in size by peripheral extension with fine thread
like border. The patches usually show superficial ulceration, crusting and
sometimes with central atrophic scarring. Superficial BCC usually occurs on the
trunk. But in our study, one female patient was present with superficial BCC on
forehead. The most common histopathological variant in our study was nodular
type (55%) with a significant proportion of tumours being pigmented (25%).
Other subtypes included adenoid (5%), basosquamous (5%), superficial (5%) and
BCC with sebaceous differentiation (5%).
These findings closely
resembled Malhotra et al, study which shows the nodular type being the most
common histologic variant (64.7%) [10]. Common histological features of basal
cell carcinomas are Basaloid tumor cells, Peripheral palisading of lesional
cell nuclei and clefting artefact
between the epithelium and stroma.
It was the most common histological subtype observed in our study. H and E
stained smears showed nodules of basaloid cells with peripheral palisade
arrangement and peritumoral lacunae were noted in all cases. Some cases showed
cystic spaces within tumour masses. It was the second most common histological
subtype in our study. Histological features resembled with nodular BCC, in
addition in the presence of melanin within tumour cells and macrophages were
noted in pigmented variant.
One case presented with
superficial BCC with typical features of buds and irregular proliferation of
tumour tissue attached to the under surface of the epidermis. This was the rare
histopathological variant of BCC. Here we observed one case with Adenoid basal
cell carcinoma. In this type tumour cells were arranged within clusters and
focal lace like pattern of cells were made out.
It was a rare histological variant of BCC, which shows cystic spaces within the
tumour lobules. Here one case presented clinically as nodular type of BCC and histology
showed BCC with sebaceous differentiation [15].
In this study, we
observed one rare case with histological findings suggestive of baso squamous
carcinoma, which was clinically; appear as nodulo-ulcerative form of BCC.
Basosquamous carcinoma (BSC) is a rare epithelial neoplasm with histological
features of both basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)
and it is linked by a transition zone. It is also known as metatypical
epitheliomas. The most common location of BCC is on the head and neck and
mainly involving the central face and has a significant male predominance [16].
In contrast to pure BCC, basaloid cells in basosquamous carcinoma have
eosinophilic cytoplasm, often with lack of peripheral palisading and retraction
artifact and may exhibit cytoplasmic keratinisation [17]. Like
squamous cell carcinoma, basosquamous carcinoma also more aggressive and
locally invasive [18,19]. The risk of metastasis is more in
basosquamous carcinoma than forms of BCC. Metastatic basosquamous carcinoma is
difficult to treat and its prognosis is poor
[20-22].
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