Recurrent Deeply Invasive Basal Cell Carcinoma

Abstract

Introduction:

Basal cell carcinoma (BCC) is the most frequent skin malignancy worldwide. The majority of BCCs grow slowly and have a low metastatic potential. However, they can be destructive to surrounding tissues since they are locally invasive.

Methods:

This case report was conducted on a 78-year-old woman complaining of a solid lump on the left side of the neck and nonhealing lesion. Three years earlier, she had BCC on the same site. Clinical and radiographic examinations were made. The biopsy specimens revealed that it is a recurrent BCC. In operating room, during blunt tissue dissection, the arterial wall was damaged. Tumor was overgrown left internal carotid artery near the bifurcation. Infiltrated part of arteria wall was resected, and a synthetic arterial prosthesis was placed.

Results:

Follow-up after 4 months showed that the wound was healing well. No complications regarding cardiovascular and other organ systems were seen.

Basal cell carcinoma (BCC) is the most frequent skin malignancy worldwide, accounting for 70% to 80% of all skin malignancies, with 80% of cases occurring on the head and neck region.^1–3 The rate is constantly increasing, and the highest rise is observed in Europe, where the incidence has increased 5% in the past 10 years.¹ The majority of BCCs grow slowly and have a low metastatic potential. However, they may be destructive to surrounding tissues since they are locally invasive.⁴ And even with the appropriate treatment, there is a considerable risk of BCC recurrence.⁵

CASE REPORT

In March 2022, a 78-year-old woman was referred to the Hospital of Lithuanian University of Health Sciences, Kaunas Clinics, Department of Oral and Maxillofacial Surgery, with a complaint of a solid lump on the left side of the neck and nonhealing lesion. In 2016, the patient had a benign tumor, which was operated in the Plastic and Reconstructive Surgery Department. Three years later (in 2019), she had BCC on the same side of the neck, in parotid salivary gland region (Fig. 1A), which had complex treatment including excision and radiation therapy (Fig. 1B). During the operation in 2019, radical excision was done with ~1.5 cm intact tissues, damaged sternocleidomastoid muscle, digastric muscle posterior belly, and dorsal part of the parotid salivary gland were resected. The pathology results showed infiltrative BCC, which was excised nonradically, and infiltration reached the deep resection margin. The patient was sent to oncologists to plan radiation therapy.

FIGURE 1.

(A) Computed tomography (MDCT) with contrast (coronal MPR view): first malignant tumor with parotid salivary gland infiltration (2019). (B) Axial MR image (T1W HR m DIXON TSE with contrast): postoperative and post-RT control view (2020): no recurrent tumor mass in left parotid space. (C) Axial MR image (T1W HR m DIXON TSE with contrast): tumor infiltration reaches left lobe of thyroid gland and common carotid artery (2022). MPR indicates multi-planar reconstruction; RT, post-radiotherapy.

In January 2022, postoperative scar formed into a lump on the left side of the neck, a wound opened, and the voice started to sound hoarse. She had no other significant medical history. Extraoral clinical examination showed tense neck muscles on the left side open wound in the previous incision site. The biopsy specimens revealed that it is a BCC. The patient was sent to a radiology clinic for a detailed radiographic examination. Magnetic resonance imaging (MRI) of the patient and its description were obtained. Head and neck MRI revealed that inferomedially infiltration reached the superior lateral thyroid gland contour with its suspected infiltration, superomedially inferior part of the submandibular salivary gland may have been infiltrated, dorsally infiltration surrounded carotid space, common carotid artery and left internal carotid artery wall infiltration could not have been ruled out radiologically (Fig. 1C).

Surgical Procedure

The surgical procedure was made under general anesthesia. A rhombic-shaped incision was made on the affected side of the neck in healthy tissue boundaries. During blunt tissue dissection, arterial wall was damaged. The tumor was overgrown in the left internal carotid artery near bifurcation, so vascular surgeons were called for urgent consultation and treatment. The decision was made to resect infiltrated part of the arteria wall and place a synthetic arterial prosthesis. Arteria (5 cm) was resected, and a synthetic 6-mm diameter shunt was placed from the common carotid artery to the internal carotid artery; the external carotid artery was reimplanted into the side of shunt (Fig. 2A, B). Anastomoses were formed with 6-0 Prolene thread. Tumor was excised (Fig. 2C), and the wound was closed with a rotational pectoral flap. Active drainage was inserted to ease the hematoma. Hypoderm was sutured with 3-0 soluble thread, and the derma was closed with staples.

FIGURE 2.

(A) Operation view: affected arteria wall. (B) View after internal carotid artery resection and placement synthetic arterial prosthesis. (C) Excised tumor.

Histopathologic view of operative tissues showed atypical basal cells and abundant mitoses. Resection margins marked green. Tumor may be reaching the resection margin.

Postoperative instructions and care were given to the patients. Medications such as antibiotics, anti-inflammatories, and analgesics were prescribed. Vascular surgeons recommended to take aspirin for the rest of life. Rehabilitation physiotherapy was recommended to improve mobility and prevent postoperative complications, such as thromboembolism and muscle hypotrophy. After 12 days, active drain and staples were pulled out. Patient was feeling well so after 15 days was sent home.

Consultation and MRI after 4 months showed postoperative scar tissue. Patient felt less tension in operated area, increased neck movement, dysphonia passed. The wound was healing well. No complications regarding cardiovascular and other organ systems were seen. Consultation after 6 more months was recommended.

DISCUSSION

The BCC is a malignant nonaggressive tumor with slow growth, taking >6 months to achieve 1 cm, and local invasion that rarely metastasizes and invades deeply has a very low mortality rate.^2,6 The annual incidence of metastasis is estimated to occur between 0.00281% and 0.05%.^2,7 Basal cell carcinoma frequently develops in chronically sun-exposed skin on the head and the neck region (64.5%–95.9%).^2,3

Choosing a management strategy for an individual patient with a specific form of BCC among the many interventions available is difficult. Considerations include the availability and price of health care resources, patient parameters, like age, immunosuppression, and personal preferences, as well as tumor factors like histologic subtype, size, and location.⁸

Surgical excision is widely considered the gold standard for BCC treatment, particularly when diagnosed earlier, and is therefore the most common treatment.^2,5,8 The National Comprehensive Cancer Network currently recommends surgical excision for the following patients: those with low-risk BCC using 4-mm clinical margins and those with high-risk BCC using wider margins with linear or delayed repair with conventional re-excision.^3,4,9 Aggressive-growth subtypes, which have a greater recurrence rate and tend to cause severe local destruction, have tendency to extend beyond the clinical margins, penetrate deeper tissues, include infiltrative, morpheaform, micronodular, and basosquamous.^9,10 Surgical excision has a 5-year recurrence incidence of 11% to 17% for recurrent BCCs. Yet, radiation therapy has been shown to have low recurrence rates for both primary and recurrent BCC (7.4% and 9.5%, respectively).⁹ According to a 3-year follow-up study, the risk of recurrence was greatest within the first year after BCC excision.⁴

Recurrence may be caused by insufficient tumor removal, and the risk rises with tumor size, especially if the diameter is >2 cm. They have a worse prognosis than primary lesions because the relationship between tumor’s stroma and surrounding tissue may be altered during earlier treatment procedures, leading to easy spread.² Also, recurrent malignancies are more challenging to treat because of the infiltrating tumor being mixed with scarring from the initial treatment.⁶