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Basal Cell Carcinoma • Discus the Differential Diagnosis Jason Stratton MD Pathology Laboratory Associates/ Regional Medical Laboratory, Tulsa Oklahoma

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Basal Cell Carcinoma • Discus the Differential Diagnosis Jason Stratton MD Pathology Laboratory Associates/ Regional Medical Laboratory, Tulsa Oklahoma 11/14/2019 Objectives • Introduce BCC Histology • Discuss Histologic Types and Importance. Basal Cell Carcinoma • Discus the Differential Diagnosis Jason Stratton MD Pathology Laboratory Associates/ Regional Medical Laboratory, Tulsa Oklahoma. 12 Duplicate BASAL CELL CARCINOMA Basal Cell Carcinoma (BCC) • first described by Jacob in 1827 • most common human cancer (Lacour, 2002). • Pathologyor • by 1998 roughly one million new cases annually in the • Various growth patterns USA (Miller and Weinstock, 1994) • Often mixed • 4th decade of life and beyond • All proliferation of basaloid cells • Exception with specific genodermatoses or in patients with w/ peripheral palisade immune compromise • All surrounded by fibromucinous • UV light the major etiology : light skin phenotypes stroma • Amyloid deposits – from release particularly predisposed keratin into stroma • Other risk factors: arsenic, coal tar derivatives, • Mitotic figures & apoptotic cells irradiation, scars, draining sinuses, ulcers, burn sites [all • Clefting artifact (retraction) foci of chronic inflammation] between tumor and stroma • Lack of hemidesmosomes 34 BASAL CELL CARCINOMA BASAL CELL CARCINOMA histopathology Distributehistopathology of “undifferentiated” BCC • Indolent- or aggressive-growth types • Originally, BCC was classified into solid/undifferentiated vs • Indolent-growth variants (IGBCC) include those with specific differentiation • superficial – Eccrine • nodular basal cell carcinoma – Sebaceous • Nodulocystic – Keratotic/Pilar • Infundibulocystic – FollicularNot (pilomatricoma like) • Aggressive growth (AGBCC) variants • We now know that the only important histologic • infiltrative basal cell carcinoma prognosticator of biologic behavior is the architectural • micronodular growth pattern. • basosquamous (metatypical) carcinoma Do • morpheiform or sclerosing basal cell carcinoma 56 1 11/14/2019 BASAL CELL CARCINOMA histopathology of “undifferentiated” BCC BCC subtype and sun exposure • In a retrospective series of 1039 consecutive neoplasms: • BCC in sun-protected skin usually of superficial type • 21% were nodular; 6.4%+ve margin (63.2%) vs only 21% nodular and 15.8% infiltrative • 17.4% were superficial; 3.6% +ve margin subtypes • 14.5% were micronodular ; 18.6% +ve margin • BCC in sun-exposed skin infrequently of superficial • 7.4% were infiltrative; 26.5% +ve margin type (14.3%), while 42.9% were nodular type, 33.3% • 1.1% were morpheiform; 33.3% +ve margin were infiltrative, and 3% each were of morpheaform • One-third of all tumors showed mixed patterns and metatypical subtypes (p=0.028) (Crowson et al, Sexton et al, J Am Acad Dermatol,1990 1996) 78 Duplicate Superficial Basal Cell Carcinoma • Epidemiology or • Earlier age • Location • More frequent on trunk • Clinical features • More subtle • Often multiple • Erythematous patch BCC, superficial • Resemble dermatitis, but has pearly border / central superficial erosion w/ h/o of bleeding easily 910 Superficial Basal CellDistribute Carcinoma • Histopathology • Superficial lobules of basaloid cells • Usually confined to papillary dermis • Projecting from epidermis or adnexa • Multifocal Not• Usually connected by stroma & in 3D BCC, superficial Do 11 12 2 11/14/2019 Nodular Basal Cell Carcinoma • Epidemiology • Later age; most common pattern (60-80%) • Location • More frequent on head Superficial basal cell carcinoma : atypical basaloid cells form an axis parallel to the • Clinical features epidermal surface; mitoses and apoptotic cells rare • Elevated pearly nodules • Assoc. w/ telangiectasia 13 14 Duplicate Nodular Basal Cell Carcinoma • Histopathologyor • Large lobules of basaloid cells • Project into reticular dermis / deeper • May have adenoid (cribiform) or organoid pattern • Secondary features • Mucinous degeneration w/ cysts Nodular BCC : courtesy Dr. G. Monks, Tulsa OK 15 16 Distribute Not BCC, Nodular BCC, Nodular Do BCC, Nodular 17 18 3 11/14/2019 Micronodular Basal Cell Carcinoma • Location • Most common site is back • Clinical features • Not specific 19 20 Duplicate Micronodular Basal Cell Carcinoma • Histopathology or • Small lobules of basaloid cells • Project into reticular dermis / deeper • Fibrotic stroma • Prognosis & predictive factors • Worse • Possibly b/c surgical margins often underestimated Micronodular BCC : Plaque like;, poorly demarcated; nests smaller with individual fibrotic stroma; widely dispersed into deep dermis and/or subcutis 21 22 DistributeInfiltrating Basal Cell Carcinoma • Location • Usually on upper back & face • Clinical features • Pale, indurated poorly defined plaque • Paraesthesia / loss of sensation Not • Due perineural extension DoBCC, Micronodular 23 24 4 11/14/2019 Infiltrative basal cell carcinoma clinical correlates • poorly circumscribed • may invade subcutis and adjacent structures • perineural infiltration a distinct risk for recurrence • depressed yellowish or fibrotic plaque lacking rolled border or elevated nodule unless a co- existant nodular component Courtesy Dr. Michael Wilkerson, Galveston TX 25 26 Duplicate Infiltrating Basal Cell Carcinoma • Histopathology or • Infiltrative strands, cords, or columns of basaloid cells • Project into reticular dermis / deeper • Peripheral palisade & retraction usually absent • Frequent perineural invasion • No fibrosis / sclerosis • As seen in sclerosing / morpheiform variant • Prognosis & predictive factors • Worse • Again possibly b/c surgical margins often underestimated BCC, Infiltrative 27 28 Distribute Not Irregular tongues of tumor and stromal fibroplasia in mixed nodular and infiltrative growth BCC mitotic activity and individual Do cell necrosis 29 30 5 11/14/2019 Fibroepithelial Basal Cell Carcinoma (Fibroepithelioma of Pinkus, Pinkus tumor) • Location • Usually on back • Clinical features • Elevated flesh colored / erythematous nodule • DDx: SK, acrochordon Mixed nodular and infiltrative growth BCC 31 32 Duplicate Fibroepithelial Basal Cell Carcinoma • Histopathology or • Arborizing network of cords of basaloid cells • Prognosis & predictive factors • Indolent BCC, (Fibroepithelioma of Pinkus) 33 34 DistributeBasosquamous Carcinoma (Metatypical carcinoma, basosquamous cell carcinoma) • Clinical features • No distinguishing clinical features • Histopathology • More abundant cytoplasm Not • More marked keratinization • Prognosis & predictive factors • More aggressive behavior Fibroepithelioma of Pinkus: fleshy Do lesion above natal cleft 35 36 6 11/14/2019 Basosquamous/metatypical carcinoma : inter- cellular bridge formation, keratinization; admixed nodular or superficial component Basosquamous carcinoma: • Defined as an infiltrative growth BCC with areas of keratinization and/or intercellular bridge formation and a prototypic stromal response • Published recurrence rates 12-50% after surgical excision vs 4% after Mohs surgery Garcia, Poletti + Crowson. J Am Acad Dermatol 2009; 60:137 37 38 Duplicate “Differentiated” basal cell carcinomas Basosquamous (metatypical) carcinoma: differential diagnosis • Basal cell carcinomas show various lineage differentiation features that do not impact prognosis: • keratoticor BCC (de Faria, 1985), • Keratotic/pilar BCC, most often a nodular BCC • infundibulocystic BCC (Walsh and Ackerman, 1990) • follicular BCC (Aloi et al, 1988) [has collision features with with horn cyst formation (primitive attempt at pilomatricoma] hair differentiation) • pleomorphic BCC (Garcia et al, 1995) • mixed [basal cell and squamous cell] carcinoma, • BCC with eccrine differentiation (Kato and Ueno, 1993) • BCC with sebaceous differentiation a collision between two clonally distinctive, • fibroepithelioma of Pinkus (Pinkus, 1953) geographically separate neoplasms in the same • BCC with myoepithelial differentiation (Suster + Cajal, 1991) biopsy or excision • squamous cell carcinoma 39 40 Keratotic Basal CellDistribute Carcinoma • Clinical features • May be studded w/ small keratin cysts (milia) • Histopathology • Nodular architecture • ProminentNot keratin formation (horn cysts) center of tumor nodules follicular BCC : matrical Do differentiation 41 42 7 11/14/2019 Pleomorphic BCC Pleomorphic basal cell carcinoma infiltrative type (“BCC with monster cells” ) • giant nuclei scattered through tumor lobules or clustered suggesting a similar clone • All cases evaluated by static image analysis cytometry have proven to be aneuploid • mitoses present same frequency as in typical nodular BCC; rarely atypical (Elston et al, 1993; Garcia et al, 1995) • pleomorphic cells a form of senescent atypia; impart no prognostic significance 43 44 Duplicate Basal cell carcinoma with eccrine or apocrine differentiation Basal cell carcinoma • seen in roughly 1% of nodular BCC in our experience “rippled pattern” (Kato and Ueno, 1993) or • Characteristic interlobular • centrally disposed in basaloid tumor cell aggregates palisade of nuclei are tubules lined by cuboidal epithelium with an • Remainder of histologic internal eosinophilic cuticle characteristics are similar to nodular BCC • decorate with immunohistochemical stains for • Shares almost identical carcinoembryonic antigen (CEA) and epithelial histology to “rippled type membrane antigen (EMA) sebaceoma” 45 46 DistributeClear Cell BCC (BCC with Trichilemmal Differentiation) • Clear cell change in otherwise typical BCC of any pattern due to glycogen accumulation in cytosol • Differential diagnosis : • sebaceous carcinoma • clear cell squamous cell carcinoma Not • other clear cell carcinomas metastatic to skin (ie renal cell ca or thyroid carcinoma)
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