Indian Journal of Dermatology
ORIGINAL ARTICLE
Year
: 2014  |  Volume : 59  |  Issue : 1  |  Page : 56--59

Characteristics of mixed type basal cell carcinoma in comparison to other BCC subtypes


A Ghanadan1, A Abbasi2, M Rabet3, P Abdollahi1, MA Abbasi4,  
1 Department of Dermatopathology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Pathology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
3 Department of Dermatology, Shahid Beheshti University of Medical Science, Tehran, Iran
4 Department of Internal Medicine, Shahid Beheshti University of Medical Science, Tehran, Iran

Correspondence Address:
A Abbasi
Department of Pathology, Tehran University of Medical Sciences, Tehran
Iran

Abstract

Background: There are limited data exploring the characteristics of mixed type basal cell carcinoma (BCC). Objectives: To explore different characteristics of mixed type BCC. Design: Cross sectional study. Materials and Methods: 825 patients with BCC enrolled in this study. Results: Among 825 patients, 512 (62%) were male. Three hundred and fifty five (43%) presented with nodular subtype, 267 (32.4%) with mixed subtype, 25 with superficial and the 178 remaining presented with other subtypes. Four hundred and eighty three (58.6%) of the lesions were on the face, 243 (29.5%) on scalp, 52 (6.3%) on ears, 20 (2.4%) on neck, 15 (1.8%) on trunk and 12 (1.4%) on extremities. Anatomic distribution of mixed type was as follows: 137 on face, (51.4%), 100 (37.3%) on scalp, 19 (7%) on ear, 6 (2.1%) on neck, 4 (1.5%) extremity and 1 (0.7%) on trunk, which the difference from non mixed types was statistically significant (P = 0.002). The mean diameter of the mixed types and non mixed type BCCs were significantly different (2.7 ± 2.1 cm vs. 2.2 ± 1.6 cm; P = 0.01. The prevalence of necrosis in mixed type BCC was two times higher than non mixed type BCCs (OR = 2.3, CI 95% 1.3-3.9, P = 0.001). The most frequent combined subtypes were nodular-infiltrative (P < 0.001). Conclusion: Mixed type BCC has differences with other BCC subtypes in anatomical distribution and tumor diameter. Indeed, mixed type BCCs are frequently composed of aggressive subtypes than nonaggressive subtypes.



How to cite this article:
Ghanadan A, Abbasi A, Rabet M, Abdollahi P, Abbasi M A. Characteristics of mixed type basal cell carcinoma in comparison to other BCC subtypes.Indian J Dermatol 2014;59:56-59


How to cite this URL:
Ghanadan A, Abbasi A, Rabet M, Abdollahi P, Abbasi M A. Characteristics of mixed type basal cell carcinoma in comparison to other BCC subtypes. Indian J Dermatol [serial online] 2014 [cited 2022 Oct 2 ];59:56-59
Available from: https://www.e-ijd.org/text.asp?2014/59/1/56/123496


Full Text

 Introduction



Skin cancer is the most common cancer in countries with predominantly fair-skinned populations, and basal cell carcinoma (BCC) is the most common type of skin cancer in Caucasians, usually occurring on sun-exposed areas. [1],[2] Its annual incidence is estimated to be 2.75 million new cases worldwide [3],[4] with a projected annual increase of 10%, which can be due to sun exposure and increased outdoor activities. [5],[6] Despite the low mortality rate of the tumor, BCC can grow locally leading to extensive tissue damage. Considering the high prevalence of BCC on head and neck, the mentioned pattern of growth can cause high morbidity and impose high burden of disease. [3],[7],[8] There are various methods for BCC treatment including cryotherapy, curettage and electrodesiccation, intralesional immunomodulator (alpha interferon), photodynamic therapy, radiotherapy, surgical excision, topical chemotherapy (5-fluorouracil cream or solution) and topical immunomodulator (imiquimod 5% cream), and Mohs microscopically controlled surgery. [9],[10] The histologic tumor subtype is often a factor used by the clinician to choose the appropriate method for treating the tumor, in which more aggressive types need more aggressive treatment. [10] There are several subtypes of BCC with the nodular subtype being most common. However, the infiltrating, micronodular, multifocal, superficial, morphoeiform and mixed histopathological patterns are more aggressive and prone to recurrences. [3],[11],[12]

The term mixed BCC refers to BCCs with presence of two different subtypes of the tumor in one sample e.g., superficial BCC in dermis and sclerosing type in deep dermis. The reported incidence of mixed subtype varies between 11% and 39% according to published literature. [13],[14],[15]

Mixed BCC is important for many reasons. According to the literature, different BCC subtypes occur on different anatomic sites raising the idea that different subtypes might have different causes and pathogenesis. Studying the different subtypes of BCC can improve our knowledge of each subtype and also the main tumor. [16] Also, there is evidence supporting the idea in which mixed BCC subtype may be associated with tumoral recurrence and with accordance to the fact that different BCC subtypes need specific treatment methods exploring the characteristics of the mixed type may lead to find or choose a more effective treatment method. [17] According to lack of relevant data considering the characteristics of different BCC subtypes and the probable differences between them, the present study is designed to explore the characteristics of mixed type BCC and compare them with other BCC subtypes in Iranian population.

 Materials and Methods



This is a retrospective study of 825 patients with BCC in Razi Dermatology Center, Tehran, Iran. Patients with recurrent tumors were also included but recurrences were not counted as separate patients. All the skin colors were types III and IV of Fitzpatrick Classification Scale. The samples were included on the basis of the histopathological diagnosis of BCC, which was confirmed by two dermatopathologists.

The classifications of tumor subtypes were done using World Health Organization (WHO) classification system. Informed consent was obtained from all patients. Demographic data with tumor location were also obtained from all patients and their medical records.

Statistical analysis

The results are expressed as mean ± SD. Statistical analysis was performed using SPSS version 16.0.1 (SPSS Inc., Chicago, IL, U.S.A.). The statistical differences between proportions were determined by χ2 analysis. Numerical data were evaluated using analysis of variance, followed by Tukey's post hoc test. P < 0.05 was considered as significant.

 Results



Among 825 patients, 512 (62%) of them were male and 313 (38%) were female with mean age of 63 ± 12.1 vs. 60.9 ± 13. The mean age of the patients with mixed type was 62.23 ± 12.6 vs. 62.32 ± 12.4 in non mixed type group (P > 0.5). Among 825 patients, 355 (43%) presented with nodular subtype, 267 (32.4%) with mixed subtype, 25 with superficial and the 178 remaining presented with other subtypes, the details are summarized in [Table 1]. Indeed, 483 (58.6%) of the lesions were on the face, 243 (29.5%) on scalp, 52 (6.3%) on ears, 20 (2.4%) on neck, 15 (1.8%) on trunk and 12 (1.4%) on extremities, showing that 96.8% of the lesions were on head and neck of the patients. Anatomic distribution of mixed type was as follows: 137 on face, (51.4%), 100 (37.3%) on scalp, 19 (7%) on ear, 6 (2.1%) on neck, 4 (1.5%) extremity and 1 (0.7%) on trunk, which the difference from non mixed types was statistically significant (P = 0.002) [Table 2]. The anatomic distribution of mixed types was not different between male and female. The mean diameter of the mixed types and non mixed type BCCs were 2.7 ± 2.1 cm vs. 2.2 ± 1.6 cm, which the difference was significant (P = 0.01). According to results the prevalence of necrosis in mixed type BCC was two times higher than non mixed type BCCs (OR = 2.3, CI 95% 1.3-3.9, P = 0.001).{Table 1}{Table 2}

The frequency of different subtypes in mixed types is shown in [Table 3]. As seen in [Table 3], the most frequent combined subtypes were nodular-infiltrative, nodular-superficial, nodular-micronodular and nodular-adenoid, respectively (P < 0.001). There was no significant difference between different mixed type BCCs and anatomic or gender distribution. [Figure 1] and [Figure 2] are clinical and pathological images of mixed and non mixed type BCCs.{Figure 1}{Figure 2}{Table 3}

 Discussion



Basal cell carcinoma is the most frequent cancer in humans. [18],[19] It presents with different pathologic features and has specific anatomical site distribution. [20],[21],[22] One of the frequent histopathologic features of the tumor is mixed type BCC.

Despite the high frequency of the tumor there are little studies exploring the characteristics of different subtypes of BCC and the probable differences between them. There are different treatment methods for BCC tumors ranging from medical to surgical therapy in which tumor histopathologic pattern is one of the most determinant factors in choosing the suitable treatment method. [17],[23] According to our results most of the mixed type BCCs occurs on face and scalp as other BCC subtypes, but the results also show that mixed type BCC has more tendency to occur on scalp than face but other BCC subtypes more frequently occur on face than scalp. Our results reveal that most of the mixed type BCCs has larger diameter than other subtypes (comparing the tumors' largest diameters). Indeed, mixed type BCCs undergoes excisional biopsy more frequent than other BCC subtypes which is in accordance with the former result showing the greater mean of largest diameters of mixed type BCCs than other subtypes. Also the data show that necrosis has higher prevalence in mixed type than other BCC subtypes.

Exploring the pathologic features of the mixed type reveals that most of the mixed type BCCs has a nodular component. This can be logical because of the fact that nodular BCC is the most common subtype of BCC. [5],[14]

According to literature, mixed and infiltrative types of BCC are considered as aggressive forms of the tumor. [24] Considering the high prevalence of nodular-infiltrative pattern in our cases of mixed type BCC and also greater diameter of mixed type BCCs than other BCC subtypes the data can be in accordance with the previous data discussing the risk of BCC recurrence in mixed type BCC although we cannot directly conclude this with our results. [10],[13] Our study is a cross sectional study considering the different characteristics of mixed type BCC and compare the findings with other BCC subtypes. Here we reported some differences but the impact of them on the tumors behavior and treatment outcome cannot be assessed with our results. Further studies as suggested to determine the effects of different BCC subtypes on the patients' outcome and also behavior of each subtype.

In light of the fact that there are a little data available on characteristics of BCC and its different subtypes specially mixed type, the present study may provide some new and useful data about mixed type BCC, leading to better understanding and management of the tumor, although more studies are recommended.

References

1Rippey JJ. Why classify basal cell carcinomas? Histopathology 1998;32:393-8.
2Tiftikcioðlu YO, Karaaslan O, Aksoy HM, Aksoy B, Koçer U. Basal cell carcinoma in Turkey. J Dermatol 2006;2:91-5.
3Ghafouri-Fard S, Abbasi A, Moslehi H, Faramarzi N, Taba Taba Vakili S, Mobasheri MB, et al. Elevated expression levels of testis-specific genes tex101 and spata19 in basal cell carcinoma and their correlation with clinical and pathological features. Br J Dermatol 2010;162:772-9.
4Goh BK, Ang P, Wu YJ. Characteristics of basal cell carcinoma amongst Asians in Singapore and a comparison between completely and incompletely excised tumors. Int J Dermatol 2006;45:561-4.
5Patel Rv, Frankel A, Goldenberg G. An update on nonmelanoma skin cancer. J Clin Aesthet Dermatol 2011;4:20-7.
6Wong CS, Strange RC, Lear JT. Basal cell carcinoma. BMJ 2003;327:794-8.
7Raasch BA, Buettner PG, Garbe C. Basal cell carcinoma: Histological classification and body-site distribution. Br J Dermatol 2006;155:401-7.
8Scrivener Y, Grosshans E, Cribier B. Variations of basal cell carcinomas according to gender, age, location and histopathological subtype. Br J Dermatol 2002;147:41-7.
9Bath-Hextall F, Bong J, Perkins W, Williams H. Interventions for basal cell carcinoma of the skin: Systematic review. BMJ 2004;329:705.
10Cohen PR, Schulze KE, Nelson BR. Cutaneous carcinoma with mixed histology: A potential etiology for skin cancer recurrence and an indication for Mohs microscopically controlled surgical excision. South Med J 2005;98:740-7.
11Telfer NR, Colver GB, Morton CA. Guidelines for the management of basal cell carcinoma. Br J Dermatol 2008;159:35-48.
12Tilli CM, Van Steensel MA, Krekels GA, Neumann HA, Ramaekers FC. Molecular aetiology and pathogenesis of basal cell carcinoma. Br J Dermatol 2005;152:1108-24.
13Cohen PR, Schulze KE, Nelson BR. Basal cell carcinoma with mixed histology: A possible pathogenesis for recurrent skin cancer. Dermatol Surg 2006;32:542-51.
14Madan V, Lear JT, Szeimies R. Non-melanoma skin cancer. Lancet 2010;375:673-85.
15Russell EB, Carrington PR, Smoller BR. Basal cell carcinoma: A comparison of shave biopsy versus punch biopsy techniques in subtype diagnosis. J Am Acad Dermatol 1999;41:69-71.
16Bastiaens MT, Hoefnagel JJ, Bruijn JA, Westendorp RG, Vermeer BJ, Bouwes Bavinck JN. Differences in age, site distribution and sex between nodular and superficial basal cell carcinomas indicate different type of tumors. J Invest Dermatol 1998;110:880-4.
17Mosterd K, Arits AH, Thissen MR, Kelleners-Smeets NW. Histology-based treatment of basal cell carcinoma. Acta Derm Venereol 2009;89:454-8.
18Richmond-Sinclair NM, Pandeya N, Ware RS, Neale RE, Williams GM, van der Pols JC, et al. Incidence of basal cell carcinoma multiplicity and detailed anatomic distribution: Longitudinal study of an Australian population. J Invest Dermatol 2009;129:323-8.
19Zedan W, Robinson PA, Markham AF, High AS. Expression of the Sonic Hedgehog receptor ''PATCHED'' in basal cell carcinomas and odontogenic keratocysts. J Pathol 2001;194:473-7.
20Hakverdi S, Balci DD, Dogramaci CA, Toprak S, Yaldiz M. Retrospective analysis of basal cell carcinoma. Indian J Dermatol Venereol Leprol 2011;77:251.
21Jones MS, Maloney ME, Billingsley EM. The heterogenous nature of in vivo basal cell carcinoma. Dermatol Surg 1998;24:881-4.
22Raasch BA, Buettner PG, Garbe C. Basal cell carcinoma: Histological classification and body-site distribution. Br J Dermatol 2006;155:401-7.
23Thissen MR, Kuijpers DI, Krekels GA. Local immune modulator (imiquimod 5% cream) as adjuvant treatment after incomplete Mohs micrographic surgery for large, mixed type basal cell carcinoma: A report of 3 cases. J Drugs Dermatol 2006;5:461-4.
24Turhan-Haktanir N, Dilek FH, Demir Y, Sahin O. Presence of interferon regulatory factor-1 in aggressive and nonaggressive histological variants of basal cell carcinoma specimens. J Cutan Aesthet Surg 2010;3:34-7.