Basal Cell Carcinoma of the Lip and Mentum

A 52-year-old non-diabetic female presented with a 20-year history of hyperpigmented lower lip ulcer which gradually involved the mentum, and on punch biopsy revealed basal cell carcinoma. As a housewife, she had no excessive exposure to sunlight or radiation, and no family history of cancer. On examination, a non-healing ulcer with hyperpigmented rolled-up borders had eroded the lower lip and mentum, extending into the alveolus and mandible. Wide excision with segmental mandibulectomy, bilateral supraomohyoid neck dissection and pectoralis major myocutaneous flap reconstruction were performed and radiotherapy scheduled 6 weeks after surgery. Basal cell carcinoma (BCC) is the most common skin malignancy with estimated annual incidences of 1 million, over 500,000 and 190,000 in the USA, Europe and Australia, respectively1. More than 60% of all skin cancers in the Philippines are basal cell carcinoma2. A slow-growing, locally invasive malignant epidermal tumor, it infiltrates tissues in a three-dimensional contiguous fashion through the irregular growth of sub-clinical fingerlike outgrowths3. It rarely metastasizes, with morbidity related to local tissue invasion and destruction4. Most can be treated easily with a high cure rate; however, there are some lesions that are much more aggressive. Advanced basal cell cancers may be arbitrarily defined as tumors > 2cm; that invade bone, muscle, or nerves; that have lymph node metastasis; or that require removal of a cosmetic or functional unit5. Complications are highlighted when lesions occur in the face, particularly near orifices of the eyes, nose, ears and mouth. As with lesions close to vital structures, these pose a greater clinical challenge4. BCCs develop from pluripotential cells in the basal layer of the epidermis. Ultraviolet-induced mutations in the TP53 tumor-suppressor gene, which resides on chromosome arm 17p, have been implicated in some cases of BCC. Furthermore, the loss of inhibition of the patched/hedgehog pathway also appears to play a role in development of BCCs and influences differentiation of a variety of tissues during fetal development6. Recognizing the various histological subtypes of BCC is important because aggressive therapy is often necessary for some variants3. Nodular BCC appear as waxy or pearly papules with central depression, erosion or ulceration, bleeding or crusting, and rolled (raised) borders. Tumor cells typically have large, hyperchromatic, oval nuclei and little cytoplasm. Cells appear uniform, with few mitotic figures. Pigmented BCC contain increased brown or black pigment and are most common in individuals with dark skin. Superficial BCC appears as scaly patches or papules that are pink to red-brown, often with central clearing, commonly with a threadlike border, may mimic psoriasis or eczema, but they are slowly progressive. Micronodular BCC, an aggressive subtype, is not prone to ulceration, it may appear yellow-white when stretched, firm to touch, and may have a seemingly well-defined border. Morpheaform and infiltrating BCC present with sclerotic Basal Cell Carcinoma of the Lip and Mentum Florence Yul N. Saquian, MD