Abstract
Basal cell carcinoma (BCC), the most common malignancy of skin, is usually curable by simple excision. However, tumors invading deep structures may require extensive surgery to achieve complete resection. Here, we present a 63-year-old woman with a large basal cell carcinoma of the shoulder, necessitating forequarter amputation for definitive therapy. The patient presented to an outside hospital with fatigue and a large wound of the left shoulder with exposed bone, was diagnosed with osteomyelitis, then transferred for further management. By history, her wound began as a boil approximately fifteen years prior and became infected with MRSA requiring surgical debridement, but persisted with drainage. The patient was lost to follow up. Physical exam revealed a 27 x 14 cm wound on her left shoulder with extensive necrosis, loss of underlying subcutaneous tissues with raised, nodular edges, and exposure of proximal half of the humerus, acromion, and scapular spine. Biopsies from the wound edges revealed an infiltrative proliferation of basaloid epithelial cells with foci of stromal fibrosis and retraction artifact, typical for BCC. There were also broad zones with tumor cells displaying glassy eosinophilic cytoplasm with keratinization. While a BCC with zones of squamous differentiation was favored, the possibility of a collision tumor composed of both BCC and squamous cell carcinoma was considered. The patient underwent forequarter amputation, indicated for wound closure and complete tumor excision. Histopathologic examination of the amputation specimen revealed carcinoma throughout the ulcerated tissue with involvement of the humerus and tumor-free margins. Lymph nodes were negative for carcinoma. In addition to illustrating drastic surgical measures indicated for management of large, neglected skin cancers, the case also demonstrates challenges with the straightforward diagnosis of BCC in samples from large ulcerated lesions.
Financial Disclosure:
No current or relevant financial relationships exist.