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Squamous Cell Carcinoma in-situ and Basal Cell Carcinoma Arising From Seborrheic Keratosis in the Same Patient Divya Gupta, Nidhi Singh, Ajay Goyal, Pampa Ch Toi1, Devinder Mohan Thappa From the Departments of Dermatology and 1Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. E‑mail:
[email protected]
Indian J Dermatol 2016:61(1):126
Sir, Seborrheic keratosis (SK) is a common benign tumor in which malignancies like melanoma and nonmelanoma skin cancers (NMSCs) can arise rarely. Herein, we report an unusual case of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in‑situ arising from SKs in the same patient. To our knowledge, this is the first report of such malignant transformation in type V‑VI skin. A 65‑year‑old man presented with a pigmented growth over chest and left thigh for 20 years. Six months ago, he had noticed pain with ulceration and serosanguinous discharge from the lesion over left thigh. Three months later, the chest lesion developed similar changes. On examination, a 6 cm × 4 cm hyperpigmented, verrucous plaque was seen over the anterior aspect of left thigh. The base was indurated, and the margins showed crusting and scaling [Figure 1]. Over the chest, a 2 cm × 2 cm similar plaque was seen. The right side of the lesion was ulcerated with bleeding, crusting and rolled out margin [Figure 2]. An incisional biopsy was done from both the lesions.
hyperchromatic nuclei, increased nuclear: Cytoplasmic ratio, abnormal mitoses and nuclear pleomorphism [Figure 3]. Histopathology of the chest plaque revealed irregular proliferation of basaloid cells with peripheral palisading and clefting between epithelium and surrounding stroma [Figure 4]. The cells showed predominantly adenoid pattern with few areas of melanin deposition [Figure 5]. In addition, both the sections showed presence of horn cysts in the vicinity of the tumor, suggestive of SK (arrows). Based on this, a diagnosis of SCC in‑situ and BCC (adenoid type) arising in SKs was made. The patient underwent wide local excision of the lesions and is currently asymptomatic. Seborrheic keratosis is one of the most common benign skin tumors in the elderly. Malignant transformation, though uncommon, is known to occur in skin types I‑III. The incidence of this varies from 0.14% to 7%, with higher frequencies being found in those studies where only the clinically suspicious lesions were biopsied.[1‑4] The most common type of malignancy arising in SK is variably reported as BCC,[1,4,5] SCC in‑situ[3] and invasive SCC.[2] Keratoacanthoma, malignant melanoma, and trichilemmal carcinoma have also been described.[5,6] The most common histological subtype of SK in which malignancies arise is acanthotic type and the most common type of BCC seen is superficial spreading type.[2]
Histopathology from the plaque over thigh revealed irregularly thickened epidermis with full thickness dysplasia, intact basement membrane, large
Malignant transformation is usually seen in males above 50 years of age. Head, neck and back are more often affected, where there is a greater degree of solar damage.[4] The contribution of SK towards the development of the tumor is debatable, with many authors calling it a matter of chance. Some have found tumor cells contiguous with the SK, whereas others have found them lying adjacent but separately from each other, calling it “collision tumor” or “compound tumor.”[3] Cascajo et al. opined that the different skin
Figure 1: Seborrheic keratosis over left thigh showing indurated base with crusting and scaling of margins
Figure 2: Seborrheic keratosis over chest with one area showing rolled out margins, ulceration, bleeding and crusting
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develops from basaloid cells, SCC from the spinous cells, and malignant melanoma from melanocytes.[5]
Figure 3: Horn cyst (arrow) with full thickness epidermal dysplasia, disorderly arrangement of cells, large hyperchromatic nuclei, pleomorphism, increased nuclear: Cytoplasmic ratio and abnormal mitoses – consistent with squamous cell carcinoma in-situ (H and E, original magnification × 100)
An earlier report of two separate lesions of Bowen’s disease arising from SK over two different locations (bilateral pretibial) in the same patient proposed that carcinomatous changes can affect several SK lesions in the same patient.[7] A retrospective study at a referral center found that almost 20% of the patients referred for Moh’s surgery had multiple synchronous NMSCs, and another 20% developed metachronous lesions over a period of next 2 years.[8] Increasing age and immunosuppression are common reasons for developing multiple primary skin cancers. However, to our knowledge, this is the first report of 2 different NMSCs developing simultaneously in SK at two different sites in the same patient having type V‑VI skin. Furthermore, our patient had adenoid type of BCC, which, to our knowledge, has previously not been described as arising out of SK. This report underscores the importance of low threshold for biopsy of suspicious lesions of SK in the presence of danger signs such as erythema, ulceration, bleeding and crusting as they may herald malignant transformation.
References
Figure 4: Horn cyst (arrow) with irregular proliferation of basaloid cells, peripheral palisading and clefting between epithelium and surrounding stroma – consistent with basal cell carcinoma, (H and E, original magnification × 40)
1. Mikhail GR, Mehregan AH. Basal cell carcinoma in seborrheic keratosis. J Am Acad Dermatol 1982;6:500‑6. 2. Maize JC, Snider RL. Nonmelanoma skin cancers in association with seborrheic keratoses. Clinicopathologic correlations. Dermatol Surg 1995;21:960‑2. 3. Vun Y, De’Ambrosis B, Spelman L, Muir JB, Yong‑Gee S, Wagner G, et al. Seborrhoeic keratosis and malignancy: Collision tumour or malignant transformation? Australas J Dermatol 2006;47:106‑8. 4. Lim C. Seborrhoeic keratoses with associated lesions: A retrospective analysis of 85 lesions. Australas J Dermatol 2006;47:109‑13. 5. Cascajo CD, Reichel M, Sánchez JL. Malignant neoplasms associated with seborrheic keratoses. An analysis of 54 cases. Am J Dermatopathol 1996;18:278‑82. 6. Oyama N, Kaneko F. Trichilemmal carcinoma arising in seborrheic keratosis: A case report and published work review. J Dermatol 2008;35:782‑5. 7. Monteagudo JC, Jorda E, Terencio C, Llombart‑Bosch A. Squamous cell carcinoma in situ (Bowen’s disease) arising in seborrheic keratosis: Three lesions in two patients. J Cutan Pathol 1989;16:348‑52. 8. Schinstine M, Goldman GD. Risk of synchronous and metachronous second nonmelanoma skin cancer when referred for Mohs micrographic surgery. J Am Acad Dermatol 2001;44:497‑9. Access this article online Quick Response Code: Website: www.e‑ijd.org
Figure 5: Adenoid pattern of basal cell carcinoma with occasional melanin pigment deposition, (H and E, original magnification × 100)
cancers associated with SKs developed from the three different types of cells that constituted SKs, that is, BCC
DOI: 10.4103/0019-5154.174178
