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| CASE REPORT |
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| Year : 2015 | Volume
: 21
| Issue : 4 | Page : 290-293 |
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Basosquamous cell carcinoma of pinna
Vivek Sasindran1, Cyril Joseph2, Sathibhai Panicker3, Mithra Sara John1
1 Department of Otorhinolaryngology, Pushpagiri Institute of Medical Sciences and Research Centre, Tiruvalla, Kerala, India
2 Department of Plastic and Reconstructive Surgery, Pushpagiri Institute of Medical Sciences and Research Centre, Tiruvalla, Kerala, India
3 Department of Pathology, Pushpagiri Institute of Medical Sciences and Research Centre, Tiruvalla, Kerala, India
| Date of Web Publication | 16-Oct-2015 |
Correspondence Address:
Vivek Sasindran
Department of Otorhinolaryngology, Pushpagiri Institute of Medical Sciences and Research Centre, Tiruvalla - 689 101, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-7749.167417
Basosquamous cell carcinoma (BSC) is a rare cutaneous lesion with features of both basal cell carcinoma and squamous cell carcinoma. We report a case of a 75-year-old male presented in our outpatient department with an ulceroproliferative lesion left pinna extending into the external auditory canal at Stage II temporal bone malignancy. Wide excision pinna and lateral temporal bone resection with reconstruction with a pedicled fascial flap was carried out. Keywords: Basosquamous cell carcinoma, Lateral temporal bone resection, Pinna, Reconstruction
How to cite this article:
Sasindran V, Joseph C, Panicker S, John MS. Basosquamous cell carcinoma of pinna. Indian J Otol 2015;21:290-3 |
| Introduction | |  |
Basosquamous cell carcinoma is a term used to describe basal cell carcinomas (BCCs) that are associated with squamous differentiation. BSC has the potential for aggressive infiltration and distant metastasis and has an incidence rate of 1–2% of all carcinomas of the skin. Histologically basosquamous cell carcinoma is diagnosed when evaluating a tumor with contiguous areas of basal and squamous cell carcinoma (SCC) with a minimal intermediate area of blending between the two. This variant has a more aggressive behavior and has been associated with regional or widespread metastasis.
| Case Report | | |
A 75-year-old male presented with an ulceroproliferative lesion over left pinna of 1-year duration and maggot infestation of 1-week duration [Figure 1]. | Figure 1: A 4 cm ×4 cm sized irregular ulceroproliferative lesion involving antihelix, fossa triangularis, crus of helix, adjacent pre-auricular area and also medial aspect of the pinna with destruction of underlying cartilage, and extending into external auditory canal with no nodal involvement
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Incision biopsy done elsewhere revealed that the lesion to be an SCC.
High-resolution computed tomography temporal bone with magnetic resonance correlation revealed soft tissue density lesion involving left pinna and adjacent preauricular area with extension into external auditory canal (EAC), limited erosion of posterior canal wall, and without parotid involvement or any lymph node involvement [Figure 2]. | Figure 2: High-resolution computed tomography temporal bone of the patient showing soft-tissue density involving left pinna, pre-auricular area and extension into external auditory canal (red arrow) with limited canal wall erosion (yellow arrow)
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Hence, with the diagnosis of Stage II temporal bone malignancy, wide excision left pinna, and lateral temporal bone resection (LTBR) along with reconstruction using flap was carried out.
Surgical steps
A postauricular incision was placed followed by extended cortical mastoidectomy and posterior tympanotomy. The facial nerve was defined from the geniculate ganglion to stylomastoid foramen. Chorda tympani was sacrificed, and dissection extended into hypotympanum. Anterosuperiorly dissection extended forward along middle fossa plate widely excising the pinna, EAC tympanic membrane and finally into the glenoid fossa [Figure 3]. | Figure 3: Wide excision pinna with lateral temporal bone resection specimen
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Superficial temporal artery based temporoparietal fascial flap was used for reconstructing the defect [Figure 4] and [Figure 5] and covered with split thickness skin graft from the thigh. | Figure 4: Post resection cavity and not posterolateral temporal bone resection cavity
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Histopathological examination of the specimen revealed areas of cells in palisading pattern suggestive of BCC (red arrow) and areas with distinct keratinization and keratin pearls suggestive of SCC (black arrow) giving the diagnosis of basosquamous cell carcinoma [Figure 6]. | Figure 6: Areas of cells in palisading pattern (red arrow) and areas with distinct keratinization and keratin pearls (black arrow)
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Tumor margins were clear (1 cm away from growth) and adequate. Six months the postoperative patient is asymptomatic and has no evidence of recurrence. He is on regular follow-up [Figure 7].
| Discussion | | |
Basosquamous cell carcinoma (BSC) was describedfirst by MacCormac in 1910 as a tumor having histologic features of both BCC and SCC.[1] BSC is mostly considered as a variant of BCC, which differentiates into SCC with the assumption that BCC cells being pleuripotent cells differentiate into squamous cells which are more aggressive. Immunohistochemistry of BSC shows BCC with areas of squamoid differentiation and show positive staining for Ber EP4 (epithelial antigen: Clone Ber EP4) with negative staining for epithelial membrane antigen (EMA) (EMA: Clone E29.[2] BSC shows areas of definitive BCC (Ber EP4+) and SCC (cytokeratin AE1/AE3+) with a transition zone of diminished staining.[3]
BSC is more common in men. The usual age of presentation in the fifth to the eighth decade although few cases are reported even in the second decade. In the series reported by Borel, 97% of the tumors were located on the head and neck, face and ears being the commonest sites. The clinical morphology of BSCs has ranged from flat, rusty red colored tumors with clinically indistinct borders to ulcerative cutaneous neoplastic growths causing complete destruction of underlying soft tissue and bone, as in our case in which there was destruction of cartilage. BSC is more locally invasive and more likely to recur and metastasize than other forms of BCC [4] [Table 1].
Metastases of BSC are known to occur many years after the identification of the primary tumor.
These tumors are radioresistant. Hence, such patients should undergo regular follow-up as long as possible.
In a study conducted to explore the overall survival and progression-free survival for American Joint Committee on Cancer Stage 4 BSC at a single large Academic Referral Centre in a case series of 19 patients, most common sites of metastasis were bone (53%) followed by lymph nodes (37%) and skull base(10%).[5]
A male gender, large size (>20 mm), positive surgical resection margins and lymphatic or perineural invasion are indicators for the aggressiveness of basosquamous cell carcinoma.[2] The 5-year survival rate is estimated to be 17.5%.[6]
In general, temporal bone, malignancies are staged according to Pittsburgh staging system. Accordingly this case is T2N0M0 at Stage II malignancy.
Since the lesion is, limited lateral to the tympanic membrane with limited posterior bony canal wall erosion wide excision of pinna with LTBR was carried out. Radiation therapy has a limited success rate in temporal bone malignancy.
Reconstruction of soft-tissue defects after temporal bone resection can vary from the simple closure of the EAC to complex flap cover of extensive defects.
Larger defects created by lateral and subtotal temporal bone resections require closure with a combination of temporalis flaps and local rotation cutaneous flaps. Lower island trapezius flaps, free flaps, and pectoralis major flaps are also used. The occipital rotational flap is an alternative reconstructive technique following LTBR. The anterolateral thigh flap has gained acceptance in head and neck reconstruction because it has been proven to be a donor site with reliable vascularity, ease of harvest, and extreme versatility. The flap offers the advantages of being pliable with a large cutaneous territory; having a lengthy pedicle with good caliber vessels; possessing multiple components (adipofascial, muscle, fascia, and skin); being used as a sensate flap; and having the possibility of chimeric applications. The anterolateral thigh flap, first described in 1984 by Song et al., is a fasciocutaneous flap usually based on the musculocutaneous and septocutaneous perforators of the descending branch of the lateral circumflex femoral artery and its venae comitantes [7] Koshima et al. and Kimatafirst described the use of this flap for reconstruction of head and neck defects.[8],[9]
When a larger proportion of the ear is resected, the missing cartilage must be replaced to provide structural support. In elderly prosthetic ear is preferred. Whereas, in younger individuals, many are not willing to consider a prosthetic solution, autogenic ear reconstruction is considered. Autogenic ear reconstruction using costal cartilage is preferred over artificial materials like preformed silicone or Medpore shapes because of the significant risk of late extrusion even though they provide a realistic result.
Pinna reconstruction was not done for this patient as he was not opting for the same.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | MacCormac H. The relation rodent ulcer to squamous cell carcinoma of the skin. Arch Middx Hosp 1910;19:172-83.  |
| 2. | Beer TW, Shepherd P, Theaker JM. Ber EP4 and epithelial membrane antigen aid distinction of basal cell, squamous cell and basosquamous carcinomas of the skin. Histopathology 2000;37:218-23. |
| 3. | Jones MS, Helm KF, Maloney ME. The immunohistochemical characteristics of the basosquamous cell carcinoma. Dermatol Surg 1997;23:181-4. |
| 4. | Bowman PH, Ratz JL, Knoepp TG, Barnes CJ, Finley EM. Basosquamous carcinoma. Dermatol Surg 2003;29:830-2. |
| 5. | Zhu GA, Danial C, Liu A, Li S, Su Chang AL. Overall and progression-free survival in metastatic basosquamous cancer: A case series. J Am Acad Dermatol 2014;70:1145-6. |
| 6. | Akdeniz N, Calka O, Metin A, Yuca K, Ozen S. A destructive ulcer. Clin Exp Dermatol 2005;30:731-2. |
| 7. | Song YG, Chen GZ, Song YL. The free thigh flap: A new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37:149-59. |
| 8. | Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92:421-8. |
| 9. | Kimata Y, Uchiyama K, Ebihara S, Yoshizumi T, Asai M, Saikawa M, et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg 1997;123:1325-31. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1]
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