Long-term survival in basal cell carcinoma metastatic to bone: a case report

A systematic review of clinical outcomes for patients diagnosed with skin cancer spinal metastases

OBJECT Surgical procedures and/or adjuvant therapies are effective modalities for the treatment of symptomatic spinal metastases. However, clinical results specific to the skin cancer spinal metastasis cohort are generally lacking. The purpose of this study was to systematically review the literature for treatments, clinical outcomes, and survival following the diagnosis of a skin cancer spinal metastasis and evaluate prognostic factors in the context of spinal skin cancer metastases stratified by tumor subtype. METHODS The authors performed a literature review using PubMed, Embase, CINAHL, and Web of Science to identify articles since 1950 that reported survival, clinical outcomes, and/or prognostic factors for the skin cancer patient population with spinal metastases. The methodological quality of reviews was assessed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) tool. RESULTS Sixty-five studies met the preset criteria and were included in the analysis. Of these studies, a total of 25, 40, 25, and 12 studies included patients who underwent some form of surgery, radiotherapy, chemotherapy, or observation alone, respectively. Sixty-three of the 65 included studies were retrospective in nature (Class of Evidence [CoE] IV), and the 2 prospective studies were CoE II. Based on the studies analyzed, the median overall survival for a patient with a spinal metastasis from a primary skin malignancy is 4.0 months; survival by tumor subtype is 12.5 months for patients with basal cell carcinoma (BCC), 4.0 months for those with melanoma, 4.0 months for those with squamous cell carcinoma, 3.0 months for those with pilomatrix carcinoma, and 1.5 months for those with Merkel cell carcinoma (p < 0.0001). The overall percentage of known continued disease progression after spine metastasis diagnosis was 40.1% (n = 244/608, range 25.0%-88.9%), the rate of known recurrence of the primary skin cancer lesion was 3.5% (n = 21/608, range 0.2%-100.0%), and the rate of known spine metastasis recurrence despite treatment for all skin malignancies was 2.8% (n = 17/608, range 0.0%-33.3%). Age greater than 65 years, sacral spinal involvement, presence of a neurological deficit, and nonambulatory status were associated with decreased survival in patients diagnosed with a primary skin cancer spinal metastasis. All other clinical or prognostic parameters were of low or insufficient strength. CONCLUSIONS Patients diagnosed with a primary skin cancer metastasis to the spine have poor overall survival with the exception of those with BCC. The median duration of survival for patients who received surgical intervention alone, medical management (chemotherapy and/or radiation) alone, or the combination of therapies was similar across interventions. Age, spinal region, and neurological status may be associated with poor survival following surgery.

Metastatic basal cell carcinoma. Report of five cases

BACKGROUND

Metastatic basal cell carcinoma (MBCC) is rare. Risk factors for the development of MBCC include a history of persistent basal cell carcinoma (BCC) for many years, refractory to conventional methods of treatment and previous radiation treatment either in early adulthood or for localized cancer. Most MBCC originate from large tumors.

METHODS

The authors report five patients with basal cell carcinomas (BCC) of the ear (two patients), scalp, inner canthus, and nasolabial fold that metastasized to the regional lymph nodes, skin, and submandibular gland. In addition, the authors reviewed more than 40 reports of MBCC (n = 65) from 1981 to 1991 and tabulated the primary tumors by size and depth of invasion according to TNM classification, a classification that previously has not been used for BCC.

RESULTS

The authors tabulated the size distribution of tumors of 45 patients with MBCC. The overall mean and median diameters of the primary BCC were 8.7 and 7.0 cm, respectively. The mean area of the primary MBCC lesion that originated on the face and trunk was 62 and 217 cm2, respectively. Using the TNM classification, approximately 9% of MBCC originate from tumors smaller than 10 cm2. In addition, the authors found that large (T2 and T3) and deep (T4) BCC account for approximately 75% of the metastatic tumors. Metastatic BCC from primary tumors smaller than 1 cm in diameter are exceptionally rare.

CONCLUSIONS

Approximately 67% of MBCC (n = 238) originate from facial sites. Using the data base of the Mohs Surgery Clinic, the authors found that BCC greater than 3 cm in diameter have approximately a 1.9% incidence of metastasis, and the overall rate of metastases for morpheaform BCC is less than 1%. Patients with tumors classified as T3 and T4 lesions ideally should be followed up for 10 or more years for the remote possibility of the development of MBCC.

Metastatic basal cell carcinoma presenting in the oral cavity and auditory meatus. A case report and review of literature

Basal cell carcinoma is a common neoplasm of the skin which rarely metastasizes. A rare case of metastatic basal cell carcinoma to the mandibular alveolar ridge and to the auditory meatus is described. The pertinent literature since 1977 is reviewed and the possible pathways of metastatic spread are discussed.

Systemic cytotoxic therapy of basal cell carcinoma. A review of the literature

Fifty-five cases of systemic, cytotoxic therapy of patients with basal cell carcinoma have been reported in 53 patients in the English literature since the first report in 1960. Cytotoxic therapy without cis-platinum was used in 28 cases, resulting in only one partial response. On the contrary, 17 out of 22 evaluable patients (77%) responded to systemic treatment with cis-platinum-containing regimens. In 10 patients (45%) complete disappearance of the tumor was noted. These patients survived for a median time of more than 22 months (range 4+ to 51+ months). Although the experience is limited, the use of cis-platinum-containing regimens seems justified in the rare instances of metastatic disease, or when local treatment fails. When the primary tumor is very large, pretreatment with cis-platinum alone or in combination might be of value.

Metastatic basal cell carcinoma of the head and neck

Five new cases of metastatic basal cell carcinoma are presented to highlight the potential of this tumor to develop malignant metastases. Histologic criteria of the primary and metastatic site are presented along with a review of the pertinent world literature.

Metastatic basal cell carcinoma. Report of five cases and review of 170 cases in the literature

We report five cases of metastasizing basal cell carcinoma. The incidence of metastases in all patients with basal cell carcinomas who had surgery in the same period was 0.1%. There was no squamous differentiation in the histology of any of the primary lesions, but we found some squamous differentiation in a late recurrence in one patient and in the metastases in two patients. All other histologic features were identical in both the primary tumor and in the metastases. Perineural spread and blood vessel invasion were evident in the primary tumor and/or recurrence of three of the five patients and may be important pointers to possible recurrence and metastasis. Of 205 cases of metastasizing basal cell carcinomas mentioned in the literature, we accepted and evaluated 170 cases of tumors of the skin with histologic proof of metastasis. The male-to-female ratio was 2:1, median age at onset of primary tumor, 45 years, median interval between onset of tumor and first sign of metastasis, 9 years, median age at first sign of metastasis, 59 years, and median survival after first sign of metastasis, only 8 months. The site of the primary tumors is similar to that in nonmetastasizing basal cell carcinoma. Metastatic spread is most often to lymph nodes, lungs, and bones with lymphogenic and hematogenic spread equally frequent. Age or sex of the patient seemed to have no influence on survival or way of metastatic spread. As metastasis of basal cell carcinoma is extremely rare (1 in 1,000 to 35,000), many authors sought or postulated histologic "degeneration" into a squamous cell carcinoma, but no such unequivocal evidence has ever been found. Areas of squamous differentiation were reported in less than 15% of both primary and metastatic lesions of metastasizing basal cell carcinoma. The mode of metastatic spread and the characteristics of the histology make it rather unlikely that metastasis of a basal cell carcinoma is due to a change toward squamous cell carcinoma.

Metastatic basal cell carcinoma of the skin. Metastasis to the skeletal system producing myelophthisic anemia

In the typical patient with a metastasizing basal cell carcinoma, the tumor is large, ulcerated, and has been neglected. Recurrences are common, and the tumor is usually refractory to all modalities of treatment. Our patient neglected to seek medical help for 10 years, at which time metastases were already present. Our case is unique because the metastases to the skeletal system produced a myelophthisic anemia.