Cranial invasion by basal cell carcinoma

Skull invaders: when surgical pathology and neuropathology worlds collide

Skull and dura serve as effective barriers to penetration by most tumors, often preventing masses originating intracranially from extending into the contiguous bone and soft tissues, or those arising in head and neck regions from extending into the dura and brain tissue. We review our 15-year experience with extracranial tumors that had sufficiently invaded adjacent skull, dura, or brain from the "outside-in" to require a neurosurgeon to participate in the surgical resection and discuss our 40 cases in context with the literature. Sinonasal-origin tumors (n = 17) and cutaneous tumors (n = 10) were the most frequent skull-invaders. Most of the cutaneous tumor types were squamous cellcarcinomas (n = 9); diverse sinonasal-origin types included 4 squamous cell carcinomas, 4 adenoid cystic carcinomas, 2 sinonasal undifferentiated carcinomas, 2 sinonasal adenocarcinomas, and single examples each of sinonasal-origin hemangiopericytoma, solitary fibrous tumor, melanoma, mucocele, and teratocarcinoma. There were 9olfactory neuroblastomas, and middle ear-origin basal cell carcinoma,recurrent glomus jugulare, and orbital malignant hidradenoma were also seen. Unique tumors included a cutaneous cylindroma invasive of skull convexity occurring in familial cylindromatosis and a ganglioneuroma of the middle ear with massive bilateral skull base extension. Convexity dural spread, a seldom-reported pattern of dissemination, was seen in 1 olfactory neuroblastoma and 1 adenoid cystic carcinoma. The ability to show skull/dural invasion did not correlate with specific histopathologic features; even benign tumor types can show skull/dural penetration.

Rodent under the hat

This report describes a case of neglected scalp basal cell carcinoma (BCC) resulting in total destruction of soft tissue and underlying cranium, with remarkably preserved dura and no parenchymal involvement. A 57-year-old woman presented with a 2-week history of lethargy. On removal of her hat, a large round ulcer was revealed. It transpired that the patient noticed a pruritic scalp lesion 9 months ago. As the lesion and wound enlarged, she was too embarrassed to inform her family and hid it under a hat at all time. She never experienced meningitic symptoms. Biopsy confirmed BCC. Subsequently, she underwent two free latissimus dorsi flap reconstructions to cover the wound and palliative radiotherapy. She responded well to treatment. This case provides a rare opportunity to observe the natural history of scalp BCC. The reasons for the rarity of this mode of presentation and the low incidence of intracranial infection are discussed.

Basal cell carcinoma with intracranial invasion

The risk of invasion and destruction of cranium, underlying dura, and cranial nerves by basal cell carcinoma (BCC) is extremely low, with an estimated incidence of 0.03%. Intracranial BCC invasion by direct extension is rare, and orbital spread from a nasal lesion has not been reported in the literature. We describe a case of intracranial invasion of a multiply recurrent nasal BCC, which caused progressive bilateral blindness from optic nerve compression, with spinal canal involvement causing subsequent lower extremity weakness and paralysis. This case underscores the importance of early and appropriate treatment of high risk BCC, and aggressive treatment of recurrent lesions as early as possible.

Lethal basal cell carcinoma secondary to cerebral invasion

Intracranial invasion by a basal cell carcinoma on the scalp is extremely rare. We present an autopsy case of a 57-year-old woman who developed a large destructive basal cell carcinoma with extension through the calvarium and compression of the dura. We compare 7 similar cases reported in the literature and review the risks for development of these aggressive fatal basal cell carcinomas on the scalp.

Craniofacial Resection for Nonmelanoma Skin Cancer of the Head and Neck

OBJECTIVES/HYPOTHESIS

We reviewed our experience with craniofacial resection for advanced, nonmelanoma skin cancer of the head and neck to determine prognostic factors, local control rate, disease free survival, morbidity, and mortality.

STUDY DESIGN

Retrospective review of consecutive patients treated at a tertiary referral center from 1982 to 1993.

METHODS

Charts of patients having craniofacial resection for aggressive nonmelanoma cutaneous malignancies were reviewed and living patients followed for 10 additional years. Demographics, histology, previous interventions, treatment, surgical pathology, reconstructions, and complications were examined. The product-limit method was used to calculate survival functions, and the log-rank test was used to compare survival distributions.

RESULTS

Thirty-five patients, mean age 66.7 years, received treatment at our facility. Follow-up ranged from 2 to 191 (mean 47.4) months. Histology included 20 squamous cell carcinomas (SCC) and 15 basal cell carcinomas (BCC). Sixty percent had craniofacial resection alone, and 28.6% also had postoperative radiotherapy. There were two perioperative deaths, and 37.1% suffered early and 14.3% late surgical complications. Two- and five- year survival was significantly better (P=.02) with BCC (92% and 76%) than with SCC (54% and 24%). Long-term disease-specific survival was 20%, and 11.4% of our subjects were living with disease. Intracranial extension (P=.02), perineural invasion (P=.049), and prior radiotherapy significantly decreased 5-year survival.

CONCLUSIONS

Acceptable mortality and morbidity is possible using craniofacial resection to treat advanced nonmelanoma skin cancer. Although disease-specific survival remains poor, positive trends were noted in local control beginning at 2 years of follow-up. Because patients often have few remaining options for cure, craniofacial resection is justified when technically feasible.

Extensive cerebral invasion of a basal cell carcinoma of the scalp

Basal cell carcinomas (BCC) are the most common cutaneous malignant neoplasms affecting fair-skinned human beings. They may progressively enlarge and spread by peripheral extension. Intracranial invasion is very rare. A case of a giant BCC of the scalp invading directly into the left hemisphere through the frontal and parietal lobe and meninges is presented. Brain invasion along Virchow-Robin's spaces is demonstrated histopathologically. A review of literature failed to disclose a previous report of similar extensive and fatal cerebral invasion from a basal cell carcinoma of the scalp.

Deep cerebral invasion by basal cell carcinoma of the scalp

We report recurrent basal cell carcinoma of the scalp with deep cerebral invasion in an 82-year-old man. Plain films and CT showed extensive, full thickness, skull destruction at the vertex. Gadolinium-enhanced MRI revealed neoplastic invasion of the meninges and left cerebral hemisphere, down to the lateral ventricle. We postulate that tumour extended into the brain along perivascular spaces of transcerebral vessels. This hypothesis is supported by the cleft-like contrast enhancement on MRI.