Rare case of a basal cell carcinoma with intravascular invasion

Dear Editor,

Basal cell carcinoma (BCC) is the most common cutaneous malignancy (Mazloom et al., 2018). Metastasis, although rare, carries a poor prognosis (Machan et al., 2012). Invasion of BCC into the vasculature has only been reported a few times in the literature, and its impact on prognosis is not well understood (Machan et al., 2012, Mazloom et al., 2018). Herein, we report an extremely rare case of intravascular BCC and considerations for management.

A 63-year-old previously healthy woman presented for Mohs surgery of a BCC located on the nasal dorsum. In the first stage of Mohs surgery, en face frozen section demonstrated a BCC with infiltrative and nodular patterns in the deep dermis and intravascular invasion (Fig. 1). The tumor was cleared with an additional stage of Mohs surgery without evidence of tumor in the vasculature examined. Because of the presence of intravascular invasion, the patient was referred to radiation oncology to discuss further treatment options. After considering the risks and benefits, she decided not to pursue radiation therapy and opted for close clinical monitoring instead. Five months after Mohs surgery, the patient demonstrated no clinical evidence of recurrence.

Fig. 1.

Nodular basal cell carcinoma with intravascular invasion and overlying infiltrative components in the deep dermis.

There have only been 10 other cases of BCC with intravascular invasion reported in the literature (Mazloom et al., 2018). Two had no reported follow-up, and four reported no recurrence with variable follow-up times ranging from 4 months to 5 years. One case demonstrated local recurrence after 4 years without metastatic disease. This case had a number of high-risk features, including location on the scalp and infiltrative histologic features with perineural invasion (PNI; Mazloom et al., 2018). Three cases had recurrence with metastatic disease, with follow-up times ranging from 4 to 13 years. Of these, one case was within a large scar (3.2 × 3.8 cm) on the posterior shoulder and demonstrated infiltrative features on histology (Mazloom et al., 2018). Another was located on the chin, treated with radiation therapy prior to surgical excision, and demonstrated undifferentiated features on histology with PNI (Mazloom et al., 2018). The third was located on the cheek and demonstrated PNI on histology results (Mazloom et al., 2018).

Based on these case reports, metastasis occurs at a higher rate in BCC with vascular invasion than BCC without vascular invasion. However, additional tumor features and risk factors predispose BCC to poor clinical outcomes. Therefore, the clinical significance of intravascular invasion and its contribution to poor clinical outcomes is unclear. Given the median time to recurrence for BCC of 9 years (Mazloom et al., 2018) and the variable follow-up times reported here, it is possible that the rate of metastatic disease associated with BCC with vascular invasion is underestimated in the literature.

The patient in the case reported herein had an infiltrative BCC on the nasal dorsum that had invaded the underlying vasculature. Given the tumor’s histologic subtype and location, it was classified as high risk (National Comprehensive Cancer Network [NCCN], 2019). The NCCN recommends adjuvant radiation therapy for high-risk tumors with negative margins and PNI (NCCN, 2019). However, the role of adjuvant radiation therapy for tumors with intravascular invasion is unclear. There is little evidence to support the use of sentinel lymph node biopsy and positron emission tomography scans for BCC (Fosko et al., 2003). Further studies are required to understand how intravascular invasion affects the prognosis and management of BCC.

Conflict of Interest

None.

Funding

None.

Study Approval

NA.

Financial Disclosures

Dr. Hao Feng is a consultant and medical monitor for Cytrellis Biosystems Inc.