Basal cell carcinoma with monster cells

Basal Cell Carcinoma: From Pathophysiology to Novel Therapeutic Approaches

Basal cell carcinoma (BCC) is the most common human cancer worldwide, and is a subtype of nonmelanoma skin cancer, characterized by a constantly increasing incidence due to an aging population and widespread sun exposure. Although the mortality from BCC is negligible, this tumor can be associated with significant morbidity and cost. This review presents a literature overview of BCC from pathophysiology to novel therapeutic approaches. Several histopathological BCC subtypes with different prognostic values have been described. Dermoscopy and, more recently, reflectance confocal microscopy have largely improved BCC diagnosis. Although surgery is the first-line treatment for localized BCC, other nonsurgical local treatment options are available. BCC pathogenesis depends on the interaction between environmental and genetic characteristics of the patient. Specifically, an aberrant activation of Hedgehog signaling pathway is implicated in its pathogenesis. Notably, Hedgehog signaling inhibitors, such as vismodegib and sonidegib, are successfully used as targeted treatment for advanced or metastatic BCC. Furthermore, the implementation of prevention measures has demonstrated to be useful in the patient management.

Electron Microscopy Study of Nodular Basal Cell Carcinoma

The electron microscopic study represent the changes in the skin layers in the malignant tumor, the nodular basal cell epithelioma. Comparisons were made between normal cells found in the normal skin at the periphery of the tumor, the cells located near the tumor and the tumors located in the depth of the carcinoma. The microscopic analysis of the tumor formation revealed the characteristics of the pigmented nodular basal cell epitheliu. To the exterior of the carcinoma were evidenced numerous globular formations limiting the peripheral extension of the tumor, which explains its evolution in years.

Histology of Non-Melanoma Skin Cancers: An Update

Non-melanoma skin cancer (NMSC) is the most frequently diagnosed cancer in humans. Several different non-melanoma skin cancers have been reported in the literature, with several histologic variants that frequently cause important differential diagnoses with other cutaneous tumors basal cell carcinoma (BCC) is the most common malignant skin tumor, with different histologic variants that are associated with a greater or less aggressive behavior and that usually may be confused with other primitive skin tumors. Actinic keratosis, Bowen’s disease, keratoacanthoma, and invasive squamous cell carcinoma (SCC) correspond to the other line of NMSC, that may have only local tumoral behavior, easy to treat and with local management (as in the case of actinic keratosis (AK), Bowen’s disease, and keratoacanthoma) or a more aggressive behavior with a potential metastatic spread, as in case of invasive SCC. Therefore, histopathology serves as the gold standard during daily clinical practice, in order to improve the therapeutical approaches to patients with NMSC and to understand the distinct histopathological features of NMSC. Here, we reported the main pathological features of different non-melanoma skin cancers.

Clinical and pathological features of the giant, invasive basal cell carcinoma of the scalp

BACKGROUND

The giant, invasive basal cell carcinoma of the scalp is a rare clinical form of this tumor that appears on the skin, but may spread to some of the following structures: soft tissues of the scalp, bones, meninges, and the brain. In literature, so far, it is known as the GBCC. It is caused by aggressive BCC subtypes.

METHODS

We will present here a research of clinical and pathological features of 47 pathological specimens in 31 patients where the following features were examined: the dimension of the tumor, the dimension of the tissue segment, tumor area, segmentation area, resection margin width, microscopic resection margin status, tumor invasion level, and the outcome.

RESULTS AND CONCLUSIONS

We have concluded that microscopic resection margin dimensions from 1 to 10 mm are safe and that relapse occurrences in giant, invasive BCCs of the scalp depend on microscopic resection margin dimensions, resection margin status, tumor invasion levels, risky occupation, and risky behavior of the patient.

'Monster cell' melanoma with pulmonary metastasis and cyclin D1 amplification

Markedly pleomorphic epithelioid cells with high mitotic activity, giant cell formation, very large atypical nuclei, multiple nucleoli and abundant cytoplasm characterize 'monster' cells and may indicate aggressive tumor behavior. Very rare reports of melanomas comprised of 'monster cells' or cells with comparable histomorphological features, found in tissue samples from skin, lymph nodes, CNS, oral cavity and ileum have been published in the literature. This case is the first such description in the lung, and it is characterized with a battery of immunohistochemical stains; BRAF mutation status was negative, and fluorescence in situ hybridization analysis revealed increased copy number gains in 11q (cyclin D1), which is associated with poor prognosis in melanoma. The presence of monster cells in melanoma was associated with aggressive behavior in the reported patient.

Desmoplastic Small Cell Tumor With Bizarre Giant Nuclei

A case is reported of an intra-abdominal desmoplastic small cell tumor featuring giant bizarre nuclei, an event not previously recorded in this entity to the best of the authors’ knowledge. The diagnosis was confirmed by immunohistochemistry and molecular genetics. A list is provided of the many other conditions in which this morphologically spectacular but clinically inconsequential nuclear change has been recorded.

Basaloid squamous cell carcinoma with 'monster' cells: a mimic of pleomorphic basal cell carcinoma

Pleomorphic giant or 'monster' cells represent a well-recognized yet uncommon finding associated with basal cell carcinoma (BCC), usually of nodular type. We present a case of basaloid squamous cell carcinoma (basaloid SCC) with 'monster' cells that closely mimicked those described in pleomorphic nodular BCC. Clinically, the lesion presented as a fleshy, hyperkeratotic nodule in an 82-year-old woman. Histopathology revealed a basaloid lesion with lobulated borders and focal retraction artifact but a lack of prominent palisading or stromal mucin. There were areas of necrosis and small foci of keratinization. Striking bizarre monstrous pleomorphic nuclei were widely scattered throughout the lesion. Ber-EP4 immunohistochemistry proved to be negative and epithelial membrane antigen (EMA) expression was moderate to strong in 70% of the basaloid epithelium. Monster cells have not previously been highlighted in cutaneous SCC or in its uncommon cutaneous basaloid variant. The prognostic significance of monster cells is unknown but, given the relative paucity of keratinization in basaloid SCC, these lesions should probably be regarded as poorly differentiated. We have not previously encountered an SCC that so closely resembles nodular BCC with pleomorphic monster cells and believe that this is the first such report in the literature.

Sarcomatoid Basal Cell Carcinoma—Predilection for Osteosarcomatous Differentiation

Primary cutaneous carcinomas rarely show heterologous malignant mesenchymal differentiation. We report 11 cases of sarcomatoid basal cell carcinoma (BCC) with osteosarcomatous differentiation. The patients (7 men and 4 women) ranged in age from 61 to 92 years (median 75 y). The tumors presented as exophytic nodules (0.3 to 7 cm) on the head (n=6), upper limb (n=3), and lower limb (n=2). All lesions were completely excised. Seven patients were alive without evidence of disease (follow-up interval 5 to 24 mo) and 1 patient died of unrelated causes at 7 months without evidence of disease. On histology, the tumors were dermal in location with 2 cases showing focal subcutaneous involvement. Ten tumors were well-circumscribed and 1 tumor showed focally infiltrative edges. Ten tumors revealed conventional BCC associated with varying proportions of osteosarcomatous and undifferentiated sarcomatous stroma. Transition from neoplastic epithelial to mesenchymal cells was seen in 8 cases. One case showed a purely osteoclastic giant cell rich malignant mesenchyme, interpreted as representing early stages of osteosarcomatous transformation. Previously unreported in sarcomatoid BCC, the mesenchymal component of another two cases displayed predominant malignant giant cell tumor like areas and 1 further case disclosed areas reminiscent of telangiectatic osteosarcoma. Pancytokeratins (AE1/3 and MNF116) and smooth muscle actin stained occasional undifferentiated sarcomatous cells in 2 and 3 tumors, respectively. MNF116 and EMA were focally positive in osteosarcomatous tumor cells of 1 case. Although the follow-up interval is short, our data suggest an excellent prognosis for polypoid and exophytic sarcomatoid BCC after complete surgical resection.

Pleomorphic Basal Cell Carcinoma: Case Reports and Review

Pleomorphic basal cell carcinoma is a pathologic variant of basal cell carcinoma characterized by the presence of atypical-appearing, mononuclear or multinucleated giant cells. Including our 3 patients, a total of 52 pleomorphic basal cell carcinomas have been described in 48 individuals. The tumors usually present as a nodule on the head or neck. The nuclei of the giant tumor cells are irregularly shaped, hyperchromatic, and 2 to 10 times larger than the nuclei of the surrounding cancer cells. Atypical mitoses may be present. The pathogenesis of pleomorphic basal cell carcinoma remains to be determined; however, investigations utilizing electron microscopy, immunohistochemistry, image analysis, and flow cytometry have provided additional insight regarding the features of the giant tumor cells and the etiology of this cancer. All of these tumors are aneuploid. Although these aneuploid tumors have alarming microscopic features, their clinical course is similar to that of basal cell carcinomas without pleomorphic giant tumor cells. Therefore, appropriate therapy to ensure adequate treatment of the tumor is recommended. Our patients' pleomorphic basal cell carcinomas were successfully treated by excision using the Mohs micrographic surgical technique.

Metastatic basal cell carcinoma: four case reports, review of literature, and immunohistochemical evaluation

CONTEXT

Metastatic basal cell carcinoma (BCC) is relatively rare and is seldom considered a complication in the routine treatment and follow-up of patients with BCC. Although multiple studies have tried to distinguish aggressive from nonaggressive BCCs, to our knowledge, no consistent clinical, histopathologic, or immunohistochemical features have yet been reported.

OBJECTIVE

To report 4 cases of metastatic BCCs and to evaluate these in addition to known nonmetastatic BCCs with specific immunostains in an attempt to find distinct morphologic or immunohistochemical patterns that could be helpful in identifying aggressive BCCs.

DESIGN

We reviewed 4 cases of metastatic BCCs and recorded the clinical and morphologic findings. We then searched our archives for 14 cases of BCC that followed the usual nonaggressive course. We evaluated these 18 cases with immunohistochemical stains for Ki-67, p53, and bcl-2.

RESULTS

In metastasizing BCC, Ki-67 staining was slightly higher in metastatic sites than in primary sites (average 63% and 51%, respectively). p53 was expressed in 3 of 4 primary sites and 2 of 4 metastatic sites. Bcl-2 was positive in both primary and metastatic sites in 3 of 4 cases. In the 14 cases of nonaggressive BCC, staining for Ki-67 averaged 38%, p53 was positive in 11 cases, and Bcl-2 staining was noted in 13 cases.

CONCLUSIONS

Overall, in the small sample that we evaluated, the immunohistochemical markers for Ki-67, p53, and Bcl-2 did not distinguish between metastatic and nonaggressive BCCs.

Basal cell carcinoma: biology, morphology and clinical implications

Basal cell carcinoma (BCC) is the most common malignant neoplasm of humans. Rising dramatically in incidence in North America, as likely reflects changing habits of the population and a move from more northerly climes to the sunbelt of the Southern and Southwestern United States, the incidence is surely to rise even higher in the future. The last decade has seen significant advances in our understanding of BCC biology and novel approaches to therapy, which hinge upon accurate diagnosis and subclassification by pathologists. The purpose of this review article is to summate the research advances in our understanding of BCC biology and to acquaint pathologists and clinicians to the practical issues in BCC diagnosis and subclassification which flow there from.

Trichoepithelioma With Giant and Multinucleated Neoplastic Epithelial Cells

We report an unusual example of trichoepithelioma containing giant and multinucleated cells in the epithelial compartment. The patient was a 52-year-old woman who presented with a solitary nodule on the scalp measuring 2 cm of apparently long duration. The biopsy revealed a typical trichoepithelioma. The unusual feature was the presence in some epithelial nodules of large epithelial cells with hyperchromatic nuclei and no visible nucleoli that exceed 3 to 5 times the adjacent follicular germinative cells. Often, multinucleated cells were seen. Rare nodules were almost entirely composed of giant/multinucleated cells. The majority of the nodules containing giant cells were situated in the deeper portion of the neoplasm. No mitoses were seen in these giant cells. No enlarged or multinucleated cells were seen in the stroma. The neoplastic epithelial cells were diffusely reactive for bcl-2, including the giant and multinucleated cells. The proliferating rate was low; Ki-67 stained some giant cells. CD34 stained the stroma. We believe that the focal presence of pleomorphic giant cells in trichoepithelioma has no clinical or prognostic implications and does not denote its "malignant transformation".

Monster cells in malignant melanoma

Cells with significantly enlarged nuclei have been described in basal cell carcinomas, dermatofibromas, and pleomorphic fibromas, to name a few. These cells are typically visible using low power microscopy and have been termed "pleomorphic" or "monster cells." They have not been previously described in cutaneous melanomas. We sought to determine the prevalence of monster cells in otherwise conventional biopsies of primary cutaneous melanomas and its association with other histopathologic features of this malignancy. Ninety-nine superficial spreading melanomas, nodular melanomas, and acral lentiginous melanomas/lentigo malignas were retrospectively evaluated for the presence of monster cells, multinucleated giant cells, ulceration, inflammation, and depth of invasion (Breslow level). Thirteen cases of melanoma containing monster cells were found. A statistically significant association was noted between the presence of these cells, the histologic subtype of nodular melanoma (P = 0.0125), ulceration (P = 0.0127), the depth of invasion (P = 0.0103), and the presence of multinucleated giant cells (P = 0.0016). The finding of monster cells is not an uncommon occurrence and is seen more often in nodular melanomas.

Fibroepithelioma of pinkus with tumor giant cells

A case of fibroepithelioma of Pinkus with pleomorphic epithelial giant cells is reported. The lesion was an ovoid polypoid nodule measuring 4 mm x 3 mm x 2 mm and was located close to the right axilla in an 86-year-old woman. The immunohistochemical features of the epithelial giant cells indicate that most of these cells are not cycling. We suggest that these cellular changes may represent a senescent event. Giant cells showed a mean nuclear major diameter more than twice that of small cells. Flow cytometric study of the tumor showed a hypodiploid DNA content and an intermediate grade S-phase fraction of the aneuploid component. To the best of our knowledge, a pleomorphic variant of Pinkus fibroepithelioma has not been reported to date. In fibroepithelioma of Pinkus, the correct diagnosis depends primarily on the architectural pattern of the tumor rather than on its cytologic features.

Basal cell carcinoma with tumor epithelial and stromal giant cells: a variant of pleomorphic basal cell carcinoma

A case of basal cell carcinoma with giant cells of the central epithelial and surrounding stromal components is presented. The lesion was an 8-mm dome-shaped papule on the ear of a 66-year-old man. The giant cells of the epithelial component shared the immunophenotype of the more typical cells of the basal cell carcinoma (keratin, smooth muscle actin, and bcl-2 positive), whereas the stromal giant cells were positive only for bcl-2. This case represents a peculiar variant of pleomorphic basal cell carcinoma, the significance of which is unknown.

Immunohistochemical characterization of pleomorphic giant cells in basal cell carcinoma

Over 20 cases of basal cell carcinomas with pleomorphic giant cells of the mononuclear or multinucleate type have been described. The nature of these cellular and nuclear changes has not been elucidated. Some authors found that these cells have phagocytic properties and others reported an aneuploid DNA content. We have seen mitotic figures in some of these giant cells, and postulate that these cells are capable of proliferation. Twelve cases of basal cell carcinoma with pleomorphic giant cells were examined using monoclonal antibodies recognizing the proliferating cell nuclear antigen (PCNA), Ki-67, and bcl-2 antigens. Expression of proliferation associated antigens in the giant cell population was higher than in the small cell population. Over expression of bcl-2 was detected in both the small and giant cells in all cases. The results demonstrate that the giant tumor cells are cycling and express bcl-2 protein in a manner consistent with basal cell carcinoma. The changes are unlikely to represent a senescent change as seen occasionally in mesenchymal neoplasms.

Basal cell carcinoma with thickened basement membrane: a variant that resembles some benign adnexal neoplasms

Because cutaneous basal cell carcinoma (BCC) is such a common malignancy, its unusual histologic manifestations are important. We identified a variant of BCC in which thickened basement membranes surround aggregations of neoplastic epithelial cells. Thickened basement membranes of similar appearance have previously been observed in benign cutaneous adnexal neoplasms, in basaloid monomorphic adenomas of the salivary gland and in other benign conditions, such as folliculocentric basaloid proliferation. We identified nine BCCs that otherwise met standard criteria, but which also had thick basement membranes surrounding some of the aggregations, and examined them by routine and histochemical staining. The cases included BCC with nodular, micronodular, and infiltrating patterns. Two neoplasms were composed largely of clear cells, suggesting, together with the thickened membranes, outer root sheath differentiation. CD34, which labels keratinocytes of the outer root sheath, marked only the epithelial cells of one of these cases. The thickened membranes were stained by periodic-acid Schiff with and without diastase (PAS-D) and by antibodies to type IV collagen and laminin, with slightly different staining patterns. Intraepithelial droplets within aggregations stained with PAS-D and type IV collagen antibodies. Thickened basement membranes therefore can occur in most of the common growth patterns of BCC. The absence of CD34 staining of epithelial cells in most cases makes it problematic at this time to prove that the thickened membranes indicate trichilemmal differentiation. BCC with thick basement membranes can closely mimic benign neoplasms, such as cylindroma and trichilemmoma, from which they can be distinguished in routinely stained sections. The presence of a continuous thick basement membrane around aggregates of epithelial cells does not in and of itself distinguish between benign and malignant cutaneous epithelial neoplasms.

Pleomorphic basal cell carcinoma

BACKGROUND

A variant of basal cell carcinoma (BCC) with scattered large, pleomorphic cells has previously been reported as "basal cell epithelioma with giant tumor cells" and "basal cell carcinoma with monster cells."

OBJECTIVE

Our purpose was to describe the clinical, histologic, and DNA ploidy findings in BCCs with these cytologic features.

METHODS

Nineteen pleomorphic BCCs from 15 patients were prospectively collected, and other BCCs in these patients were retrospectively reviewed by light microscopy. One lesion was recurrent. Seven of the pleomorphic BCCs and one nonpleomorphic BCC were studied by image analysis.

RESULTS

These pleomorphic BCCs ranged from 2.8 to 12.5 mm in greatest diameter and were most commonly located on the head and neck. Five BCCs were present on the face and scalp of a patient with basal cell nevus syndrome. There have been no subsequent recurrences of the pleomorphic BCCs (follow-up from 3 to 32 months; median, 20 months). All 19 pleomorphic BCCs displayed characteristic features of BCC: peripheral palisading, stromal retraction, mucin production, and apoptosis. All 19 also showed huge pleomorphic mononucleated and multinucleated giant tumor cells. The nuclei of these large cells were often hyperchromatic with prominent nucleoli and abundant cytoplasm, and occasionally with intranuclear cytoplasmic protrusions. In addition, there were frequent and atypical mitoses in 47% of the cases. All pleomorphic BCCs studied by cell image analysis of formalin-fixed, paraffin-embedded tissue were aneuploid. The DNA content of the giant tumor cells was not a multiple of a single DNA value.

CONCLUSION

Pleomorphic BCCs clinically present as typical BCCs. Despite their striking focal cellular atypia, these lesions seem to behave as ordinary BCCs.