Recurrent BCC with Perineural Invasion

The patient is a 56 yo woman who had micrographic surgery for a BCC on the tip of the nose in August of 2008. The initial typing could not be done b/c the specimen was a superficial shave and deeper component could not be appreciated.

She presented in March 2012 with a subtle area of hypopigmentation at the site of the tumor. Because of the firmness of the nasal tip, induration could not be appreciated. The patient was worried that this might be a recurrence.

Clinical Photo:

A 3 mm punch biopsy showed "infiltrating BCC with perineural invasion (PNI)."

Photomicrographs courtesy of Dr. Jag Bhawan. Please click on Picasa for more images.
Teaching point: The initial shave bx was not adequate to type the lesion and this was also not commented on by Mohs surgeon. Complex BCCs of the nasal tip pose special problems. Dr. highlight some of these.

Questions to Mohs surgeons: How would you approach this woman who is concerned about cosmetic appearance of nose after second Mohs procedure? Is it likely that after almost four years of insidious growth this tumor may pose special problems for closure and necessitate plastic surgical reconstruction?

View Dr. Michael Albom's Comments on this patient.

References:
1. Leibovitch I, et. al, Basal cell carcinoma treated with Mohs surgery in Australia III. Perineural invasion. J Am Acad Dermatol 2005 Sep;53(3):458-63.
Abstract Conclusion: PNI is an uncommon feature of BCC. When present, PNI is associated with larger, more aggressive tumors, and the risk of 5-year recurrence is higher. This emphasizes the importance of tumor excision with margin control and long-term patient monitoring.

2. Geist DE et. al. Perineural invasion of cutaneous squamous cell carcinoma and basal cell carcinoma: raising awareness and optimizing management. Dermatol Surg: 2008 Dec;34(12):1642-51. Division of Dermatology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA. david.geist@umassmemorial.org

ABSTRACT: BACKGROUND: Perineural invasion (PNI) by cutaneous squamous cell carcinoma (CSCC) and basal cell carcinoma (BCC) is an infrequent but not rare complication of traditionally low-morbidity skin cancers that can lead to catastrophic sequelae; 2.5% to 14% of CSCC and approximately 3% of BCC exhibit PNI. Tumors with PNI tend to be larger, have greater subclinical extension, have a higher rate of recurrence, and have a greater risk of metastases. Tumors with PNI may result in major neurologic deficits.

OBJECTIVE: To review current recommendations for the management of PNI and to evaluate a treatment strategy involving excision using Mohs micrographic surgery (MMS) followed by adjunctive radiotherapy.

MATERIALS AND METHODS:Cases of PNI treated with MMS and radiotherapy were reviewed for recurrence, disease-free follow-up, and adverse events.

RESULTS:Twelve patients with incidental PNI treated with MMS and adjunctive radiotherapy are presented. After 3 to 32 months of follow-up, there had been no recurrences. Adverse events from radiotherapy were minor and self-limited.

CONCLUSIONS: The use of adjunctive radiotherapy in these patients remains controversial. When managing superficial skin tumors with PNI, a multidisciplinary team including a cutaneous surgeon and a radiation oncologist familiar with PNI is recommended.