Unusual Infiltrative Basal Cell Carcinoma Mimicking Pyoderma Gangrenosum: A Case Presentation and Discussion Sara G. Afzal-Asr, MS, OMS III,* Keith D. Wright, MD,** Jonathan S. Weiss, MD**
*Medical Student, 3rd year, Philadelphia College of Osteopathic Medicine, Suwanee, GA **Dermatologist, Gwinnett Dermatology, Snellville, GA
Disclosures: None Correspondence: Sara G. Afzal-Asr; [email protected]
Abstract Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis of unknown etiology frequently associated with systemic diseases, while basal cell carcinoma (BCC) is the most common malignancy of sun-exposed areas. We report a case of infiltrative basal cell carcinoma in a 77-year-old male that mimicked a classic case of PG. Physical examination revealed a 10 cm x 7 cm, cutaneous ulcer with hemorrhagic exudate and a violaceous border. The ulcer, which was located on the left pretibial region, was clinically diagnosed as PG. An excisional biopsy was performed, and the histopathological examination strongly supported the diagnosis of infiltrative BCC. This report details an unusual presentation of infiltrative basal cell carcinoma and discusses key aspects that led to the accurate diagnosis of BCC.
Introduction diagnosis. Additionally, histopathological studies wound care with adjuvant therapy. As of the time Pyoderma gangrenosum (PG) is a rare, neutrophilic revealed sheets of small, round tumor cells with of this writing, there has been no recurrence of dermatosis frequently associated with systemic enlarged hyperchromatic nuclei, small nucleoli, the carcinoma. morbidities such as inflammatory bowel diseases, and minimal cytoplasm, all of which were atypical rheumatoid arthritis, and myeloproliferative in cytology (Figure 2). Infiltrative BCC generally Discussion 1 Basal cell carcinoma accounts for approximately disorders. Basal cell carcinoma (BCC) is the most demonstrates many similarities to nodular BCC, and there were both nodular and infiltrative 70% of all malignancies of the skin and presents in a common cutaneous malignancy and typically 6 variety of subtypes. In early stages, it can manifest occurs in sun-exposed regions such as the head and patterns of growth present. Elongated strands as a small plaque or nodule with telangiectasias, neck. This localized cancer typically presents as a of basaloid cells were observed, with thick cells infiltrating between collagen bundles. The findings and later can progress and present as a non- raised, pearly, translucent papule or nodule with 3 2 healing ulcer. Although the majority of basal cell telangiectasias. Unlike most cancers, BCC rarely indicated nodular and infiltrative forms of basal carcinomas can be easily diagnosed clinically, more metastasizes, but significant disfigurement and cell carcinoma. 2 complex, atypical presentations can make accurate destruction can be caused by local expansion. Basal Outcome and Follow-up clinical diagnosis challenging. Histopathological cells arise from the innermost layer of the epidermis. Surgery was indicated for the removal of the examination was critical to accurately diagnosing Several clinical and histological subtypes of BCC lesion, and complete excision of the carcinoma our case as infiltrative BCC. have been described, including nodular, superficial, 3,4 extended to the tibial periosteum. Biopsy of micronodular, infiltrative, and morpheaform. BCC the excised lesion demonstrated two foci in the There have been a number of clinical cases reported can present with features that can be inaccurately 7 5 superior half of the specimen, consistent with in which PG has mimicked BCC. This case diagnosed for other conditions. Here, we report a BCC. The peripheral margins were devoid of was remarkable because BCC resembled PG. rare presentation of infiltrative basal cell carcinoma cellular atypia. Following surgery, the patient had PG typically presents as a painful ulcer with an that mimicked pyoderma gangrenosum (PG). an open defect of 14 cm x 12 cm with a focally undermined violaceous border. The lower extremities, positive deep margin. The patient was placed specifically the pretibial regions, are the most Case Presentation on vacuum-assisted wound closure three times commonly affected sites, but other parts of the body A 77-year-old man presented with a progressive 8 can also be involved. PG is frequently associated onset of a tender, erythematous and hemorrhagic a week for three months, followed by further with systemic hematological and autoimmune ulcer measuring 10 cm x 7 cm on the left pretibial diseases, including Crohn’s disease, ulcerative region (Figure 1). The patient reported that 7 colitis, and rheumatoid arthritis. T-lymphocyte approximately seven months prior, a smaller, 4 cm helper/suppressor imbalance, impaired neutrophilic x 4 cm plaque was abraded by a canine. Following chemotaxis, and deranged monocyte function have this incident, the plaque gradually increased in 9 been postulated in the pathogenesis of PG. size and presented as a chronic, non-healing lesion with central deep ulceration and a violaceous border. For the following seven months, the patient sought supportive care at a wound clinic, but the ulcer continued to worsen and enlarge despite this treatment.
Diagnosis Biopsies from the left anterior pretibial region were taken with wide local excisions (9 cm) in 26 resections. The deep margin of resection of the superior portion of the specimen was positive for basal cell carcinoma with infiltrative pattern. The histopathology of the broad surface ulceration also demonstrated fibropurulent debris, prominent vascularity and dermal fibroplasia. Within the lobules, an atypical, basaloid, epithelial neoplasm was present that demonstrated a nodular and infiltrative pattern of growth. Laboratory findings were normal; smears and cultures for bacteria and fungi were negative. Histologic examinations were devoid of neutrophils, giant cells, and eosinophils. Figure 1. Erythematous, hemorrhagic, 10 cm Figure 2. Low-power view showing atypical, Although the physical findings were suggestive of x 7 cm ulcer on left pretibial region, sharply basaloid, epithelial neoplasm with nodular and PG, the laboratory findings did not support that outlined by violaceous wound edge. infiltrative growth pattern (H&E, 40x).
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UNUSUAL INFILTRATIVE BASAL CELL CARCINOMA MIMICKING PYODERMA GANGRENOSUM: A CASE PRESENTATION AND DISCUSSION