Cutaneous Carcinoma With Mixed Histology: A Potential Etiology for Skin Cancer Recurrence and an Indication for Mohs Microscopically Controlled Surgical Excision

Philip R. Cohen, MD; Keith E. Schulze, MD; Bruce R. Nelson, MD

Disclosures

South Med J. 2005;98(7):740-747. 

In This Article

Case Reports

A 69-year-old white man developed a recurrent basal cell carcinoma on his nose at the border of the skin graft from his previous surgery 4 years earlier. He had recently noted a new pearly papule on his right nose adjacent to the prior surgical site. A lesional biopsy demonstrated basal cell carcinoma; the histologic subtype was not specified in the initial pathology report. He was referred for excision of the tumor using Mohs microscopically controlled surgery.

Cutaneous examination showed a 0.3 × 0.3 cm erythematous papule located at the distal border of a skin graft on the distal right nasal sidewall (Fig. 1). The first stage of Mohs surgery showed a basal cell carcinoma of mixed histologic subtypes (Fig. 2). There were buds of superficial basal cell carcinoma extending from the basal layer of the epidermis into the papillary dermis and aggregates of nodular basal cell carcinoma in the upper reticular dermis (Fig. 3). In the deeper reticular dermis, there were morpheaform strands of sclerosing basal cell carcinoma which reached the margin of the specimen (Fig. 4).

Clinical presentation of a basal cell carcinoma with mixed histology. A 3 mm red papule (within the solid circle) is located on the distal right nasal sidewall at the periphery of a previous skin graft (outlined by the dotted circle).

Microscopic examination of a basal cell carcinoma with mixed histology shows features of superficial and nodular basal cell carcinoma in the papillary and upper reticular dermis, respectively (and demonstrated in the upper portion of the figure). In the deeper reticular dermis, the tumor cells show features of sclerosing basal cell carcinoma (which are demonstrated in the lower portion of the figure) (hematoxylin and eosin, X 4).

Superficial portion of basal cell carcinoma with mixed histology. Superficial buds of basaloid tumor cells are shown extending from the overlying epidermis into the underlying papillary dermis. Nodular aggregates of tumor cells are present in the upper reticular dermis (hematoxylin and eosin, × 10).

Deeper portion of basal cell carcinoma with mixed histology. Strands of tumor cells are present between the collagen bundles in the deeper reticular dermis (hematoxylin and eosin, × 10).

The tumor was clear after the second stage of Mohs surgery. The postoperative defect extended to cartilage and measured 1.5 × 1.7 cm (Fig. 5). The wound was repaired with a full thickness skin graft (Fig. 6).

The postoperative defect measured 1.5 × 1.7 cm, extending to cartilage, after the second stage of Mohs surgery which cleared the basal cell carcinoma with mixed histology.

A full-thickness skin graft was used to repair the wound defect following removal of the basal cell carcinoma with mixed histology with Mohs microscopically controlled surgical excision.

A 79-year-old white woman developed a new skin lesion on the top of her left ear. The initial clinical differential diagnosis included a seborrheic keratosis, chondrodermatitis nodularis helicis, basal cell carcinoma, and squamous cell carcinoma. A lesional biopsy, consisting of three small pieces of tissue, showed a squamous cell carcinoma extending to the margins of the specimen; the histologic subtype was not specified in the initial pathology report. She was referred for excision of the tumor using Mohs microscopically controlled surgery.

Cutaneous examination showed a 1.1 × 0.6 cm erythematous ulcerated nodule with surrounding erythema on the left superior helix (Fig. 7). The first stage of Mohs surgery demonstrated a squamous cell carcinoma of mixed histologic subtypes in the dermis (Fig. 8). There were aggregates of well-differentiated keratinizing tumor epithelium that extended into the reticular dermis (Fig. 9). In addition, in the lateral portion of the specimen, there were thin strands of poorly differentiated tumor cells invading between the collagen bundles and reaching the margin of the specimen (Fig. 10).

Clinical presentation of a squamous cell carcinoma with mixed histology. An 11 × 6 mm ulcerated red nodule (within the solid circle) with surrounding erythema (outlined by dotted circle) on the left superior helix.

Microscopic examination of a squamous cell carcinoma with mixed histology shows adjacently located features of well differentiated squamous cell carcinoma (which are demonstrated in the middle and on the right side of the figure) and of poorly differentiated squamous cell carcinoma (which are demonstrated on the left side of the figure). In the dermis, there is also a dense lymphocytic inflammatory infiltrate that surrounds the tumor (hematoxylin and eosin, × 4).

Well differentiated squamous cell carcinoma is present in the deep reticular dermis. The aggregate of keratinizing tumor, consisting of epithelial cells with pale and glassy cytoplasm, is surrounded by lymphocytic inflammation (hematoxylin and eosin, × 20).

Low (A) and higher (B) magnifications of poorly differentiated squamous cell carcinoma. Among a dense infiltrate of lymphocytes, strands of epithelial tumor cells infiltrate deeply into the reticular dermis between the collagen bundles (hematoxylin and eosin, × 10 [A], × 40 [B]).

The tumor was clear after the second stage of Mohs surgery. The postoperative defect extended to cartilage and measured 1.5 × 1.0 cm (Fig. 11). The wound was repaired with a split thickness skin graft, which was harvested from the left forearm (Fig. 12).

The postoperative defect measured 1.5 × 1.0 cm, extending to cartilage, after the second stage of Mohs surgery which cleared the squamous cell carcinoma with mixed histology.

A split-thickness skin graft was used to repair the wound defect following removal of the squamous cell carcinoma with mixed histology with Mohs microscopically controlled surgical excision.

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