Basal cell carcinoma (BCC) causing spinal cord compression
1. Dermatology and Laser Center, Long Branch, NJ 2. Sackler School of Medicine, NY/American Program, Tel Aviv, ISRAEL 3. Department of Pathology, Monmouth Medical Center, Long Branch, NJ
Basal cell carcinoma (BCC) is the most common cutaneous malignancy affecting populations with light skin, though these tumors rarely cause severe morbidity or mortality. We report an adult male with back pain and leg weakness associated with a neglected, ulcerated lower back tumor of fifteen years duration. The clinical impression of BCC causing spinal cord compression was confirmed by microscopy and magnetic resonance imaging (MRI).
Basal cell carcinoma (BCC) is one of the most common cancers in humans in many countries. In the literature, areas of primary BCC have mostly been the face, scalp, and upper torso.
Rarely do BCC's cause devastating disfigurement or disability. "High risk" BCC's can be characterized as those of long duration, larger than 2 cm, located in mid face or ear, with aggressive histologic subtype, previously treated, neglected, or previously irradiated.[2,3]
A 53 yr old white male walked into the office complaining of a growth on his back which had been present for 15 years. Increasing back pain had necessitated the frequent use of ibuprofen. A physical exam revealed an 18cm x 30cm necrotic ulcer with rolled borders and telangiectasia on his back extending from scapula to scapula and from the 1st thoracic vertebra to the 2nd lumbar vertebra (figure 1). The patient refused a dressing and refused to be examined by an internist. A punch biopsy taken from the left lateral border and a bacterial culture were performed. He was started on Ciprofloxacin 750 mg bid.
Histologically, the solid/nodular type of basal cell carcinoma was demonstrated (figure 2) which showed an origin from the overlying epidermis (figure 3). The cytoplasm of the individual cells were poorly defined and mitotic activity and apoptosis were observed, though these features have no prognostic significance. (figure 4) [4.5]. The solid pattern of BCC may combine with an almost pure mucinous stroma to form the adenoid variant of BCC, which was observed in some areas of the tumor. (figure 5).
Seven days later, the patient still had not seen an internist, and complained of his legs "being wobbly". He was referred to the nearest ER to evaluate him for spinal cord compression, but insisted his complaint was a result of taking the antibiotics. Ciprofloxin was discontinued, and he was started on trimethoprim/sulfamethoxazole tablets as the culture was positive for Staph aureas, Group A streptococcus and Enterobacter cloacae.
The following day the patient came to the office parking lot and could not exit his vehicle because of leg weakness. He was immediately escorted to the ER. The clinical and microscopy findings of our patient suggested the diagnosis of a BCC causing T4 spinal cord compression. Subsequently, an MRI showed tumor extending through the soft tissue into the vertebral bodies and thus pressing on the cord at the T4 level.
Specific therapeutic measures advised were continuance on antibiotics and initiation of radiation therapy. Local care and wet dressings of saline and gauze were applied. The patient agreed to antibiotic treatment and a metastatic workup.
After radiotherapy, the patient was transferred to Mt. Sinai Hospital (New York, NY) and underwent surgical excision and grafting with placement of a steel rod in his spine. He subsequently developed sepsis and died.
Although basal cell carcinoma is one of the most common cancers in humans, BCC's rarely cause gross disfugurement, disability or death. In deaths from BCC, the mean age reported was 85 and refusal of surgical intervention was documented in 40%. Death can follow either metastasis or tumor extension into vital structures. Rates of metastasis for BCC have been estimated at 0.1% . Metastatic sites were more common in lung, bone and lymph nodes and less common in pleura, spleen and brain. Metastases rarely have been found in adrenals, kidney, pancreas, diaphragm, pericardium, dura, and skin. No consistant clinical or histological subtype characteristics differentiate a non-metastatic BCC from a metastatic BCC.[1,8]
In our patient, however, the severe morbidity and eventual death resulted from direct extension of his BCC into the vertebral bodies leading to cord compression. Only one other case of BCC causing cord compression has been reported. Our patient fit the high risk category for BCC outcome in terms of the size of his tumor, the duration the tumor was present and his delay in seeking treatment. The patient's neglect of his tumor and poor compliance with the indicated treatment further hindered his chances of recovery.
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