Pleomorphic basal cell carcinoma.

Basal cell carcinoma (BCC) is arguably the most common cancer in the United States. In 2006, there will be approximately one million new BCCs diagnosed meaning that almost 50% of new cancers will be a BCC. Because of its ubiquitous nature, a general knowledge of this tumor is important for most clinicians.

While most are likely to be aware of the more common histopathologic subtypes of BCC (superficial, nodular, micronodular, infiltrating, and sclerosing), many may be unaware of other less common ones. Tschen et al (1) do a thorough job discussing the relatively rare pleomorphic histopathologic variant (less than 60 have been reported), reporting 3 cases they have encountered, and presenting a concise review of the existing related literature. From the compilation and summary of available information about pleomorphic BCC, Tschen et al give us an approximate idea of its typical demographics, clinical features, histopathologic findings, and even electron microscopic, immunohistochemical, and flow cytometric characteristics.

Probably the least amount of available information regarding pleomorphic BCC concerns its clinical aggressiveness and the most appropriate form of treatment. While the 3 pleomorphic BCCs that the authors treated with Mohs micrographic surgery (MMS) cleared after 1 or 2 tissue layers (indicating that they did not demonstrate significant subclinical extension), one could argue that given the insufficient data that currently exists, conservative treatment that will ensure the highest cure rate is currently recommended. Since MMS has been shown to deliver superior 5-year cure rates (2-6) and to be very competitive cost-wise (7,8) when compared with other margin controlled surgeries (eg, excision with frozen section guidance), prudent conservative treatment would dictate that MMS be utilized to treat pleomorphic BCC when possible.

Lastly, despite the concise and well-written summary of pleomorphic BCC given to us by Tschen et al, due to the rarity of this tumor, further data and description of it are needed to increase the quality of the information and evidence concerning it. Investigations into the inconsistent immunohistochemical profiles and the aneuploid nature of these BCCs may reveal insights into this tumor or BCC in general and may shed light on possible new methods of detection or treatment. Practitioners are encouraged to report their encounters with pleomorphic BCC for these purposes.

References

1. Tschen JP, Cohen PR, Schulze KE, et al. Pleomorphic basal cell carcinoma: case reports and review. South Med J 2006;99:296-302.

2. Shriner DL, McCoy DK, Goldberg DJ, Wagner, RF Jr. Mohs micrographic surgery. J Am Acad Dermatol 1998;39:79-97.

3. Smeets NW, Kuijpers DI, Nelemans P, et al. Mohs' micrographic surgery for treatment of basal cell carcinoma of the face: results of a retrospective study and review of the literature. Br J Dermatol 2004;151:141-147.

4. Snow SN, Madjar DD Jr. Mohs surgery in the management of cutaneous malignancies. Clin Dermatol 2001;19:339-347.

5. Rowe DE. Comparison of treatment modalities for basal cell carcinoma. Clin Dermatol 1995;13:617-620.

6. Rowe DE, Caroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 1989;15:315-328.

7. Bialy TL, Whalen J, Veledar E, et al. Mohs micrographic surgery vs traditional surgical excision: a cost comparison analysis. Arch Dermatol 2004;140:736-742.

8. Cook J, Zitelli JA. Mohs micrographic surgery: a cost analysis. J Am Acad Dermatol 1998;39:698-703.

Conway C. Huang, MD

From the Department of Dermatologic Surgery and Cutaneous Laser Surgery, University of Alabama School of Medicine, Birmingham, AL.

Reprint requests to Conway C, Huang, MD, University of Alabama School of Medicine, 1530 3rd Avenue South, EFH 414, Birmingham, AL 35294. Email: [e-mail]

Accepted December 21, 2005.