Hand Surgery, Vol. 7, No. 2 ( December 2002) 295–298 © World Scientific Publishing Company

BOWENOID BASAL CELL CARCINOMA OF THE THUMB: A CASE REPORT AND REVIEW OF THE LITERATURE M. Galeano,* M. Colonna,* M. Lentini† and F. Stagno d’Alcontres* *Department of Plastic Surgery and †Department of Human Pathology University Hospital Messina, Italy Received 18 January 2002; Accepted 20 June 2002 ABSTRACT Basal cell carcinoma (BCC) is the most common skin malignancy arising from cells of the basal layer of the epithelium or from the external root sheath of the hair follicle. BCC of the digit is a rare entity. The article presents one such case of bowenoid BCC of the thumb which required amputation at the MP joint. Keywords: Hand Skin Tumours; Bowenoid Basal Cell Carcinoma; Thumb.

INTRODUCTION

6 × 4 cm painful exophytic mass on the dorsal and medial surface (Fig. 1A) of his left thumb just distal to the MP joint, which had infiltrated the first commissura (Fig. 1B). Axillary and epithrochlear nodes were not palpable. X-ray of the hand failed to reveal any abnormality. There was no previous history of significant occupational sun exposure, arsenic injection, nor personal or family history of basal cell nevus syndrome. Medical history included adult-onset diabetes mellitus treated with insulin; about two years previously he had suffered a transient ischaemic attack. He was not taking any medication. Major surgery, including tumour excision and reconstruction was refused by the patient and his relatives, who requested a rapid intervention because of the anaesthesiological risk due to the age. The amputation of the left thumb, under ring block anaesthesia, was performed at the MP joint with regularisation of bone stump at the level of the metacarpal head. The postoperative course was uneventful. Two years after surgery there are no signs of local recurrence. Histological examination revealed bowenoid BCC. The lesion is

Basal cell carcinomas (BCC) are common cutaneous malignancies in sun-exposed sites, such as the head and neck. Involvement of fingers is rare and may occur without a history of prolonged sun exposure. Eisenklam in 1931 reported the first case of BCC of a digit. Since then, only 14 cases have been reported in the Englishlanguage medical literature.2,5,8–10 We report the first case of a bowenoid BCC arising on the dorsal surface of the thumb distal to the MP joint which required amputation at the MP joint. The aetiology of BCC on fingers and the various modalities of treatment are discussed. A review of the literature is also provided.

CASE REPORT An 81-year-old man presented with a history of a small flat lesion of the thumb of his left hand. The lesion had been present for 20 years. Over the years it enlarged and ulcerated, partially infiltrating the first commissura. Clinical examination revealed a

Correspondence to: Dr. Mariarosaria Galeano, Via Scite, 23, I-98124 Messina, Italy. E-mail: [email protected]

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characterised by a plurilobulate proliferation of basaloid cells, loss of continuity of stratum corneum, alterations of epidermis and dermis (Fig. 2). This type of tumour shows basaloid cells in a palisade (Fig. 3A) with central necrosis and atypical nuclei (Fig. 3B), that resemble the cells of Bowen’s disease. The underlying bone, tendons and resection margins were free of tumour.

BCC is a malignant epithelial neoplasm arising from either basal cells or pluripotential adnexal cells of the epidermis. Exposure to electromagnetic energy, particularly that of sunshine, is believed to be an initiating or promoting factor. It is well known that BCC is of higher incidence in geographic regions of more intense sunlight, in areas of the body that are habitually uncovered, and in fair-skinned individuals who lack the protection of melanin. Consequently, about 85% of BCC develop on the face and neck. Two previous studies examining the incidence of BCC on unusual sites have shown that it is quite rare to find BCC on the digits.9 The incidence of this tumour of the hand and forearm has been reported to be between 0.5% and 2.5%.8 On review of the literature, we found 14 cases of BCC on the digits of the hand,

and only five were located in the subungual area of the thumb.2,5,8–10 The aetiology of BCC on finger is unknown. Since ultraviolet radiation exposure would be minimal at these sites, other factors play a role in the development of this tumour. Other predisposing factors include radiation, immunosuppression, xeroderma pigmentosum and arsenic exposure. Unlike squamous cell carcinoma (SCC) of fingers, no occupational risk factors, such as radiation exposure or arsenic ingestion were noted in the BCC case reports. Moreover, no patients in the reported cases had underlying genetically inherited cutaneous disorders that would predispose them to a cutaneous malignancy; neither did our patient. Multiple types of BCC have been described based on the clinicopathologic differences. Subtypes of BCC include superficial, ulcerative, bowenoid, infiltrating, morphea, sclerosing, pigmented, basal-squamous (metatypical), adenoid, cystic, keratotic, and fibroepithelioma.4 Among these subtypes, the bowenoid represents a rare histological variety characterised by the presence of areas with bowenoid dysplasia — large cells irregularly shaped with hyperchromatic multilobulated nuclei, sometimes multinucleated giant cells.3,11 The treatment for hand BCC includes electrodessication and curettage, radiotherapy, excisional surgery and Mohs micrographic surgery. The mainstay of treatment, however, remains surgical excision. Bowenoid BCC

(A)

(B)

DISCUSSION

Fig. 1 Exophytic mass on the dorsal and medial surface of the thumb just distal to the MP joint (A), with infiltration of the first commissura (B).

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Fig. 2 Basaloid proliferation under the epidemis that appears greatly thinned and with the stratum corneum interrupted (haematoxylin-eosin; original magnification 35×).

(A)

(B)

Fig. 3 The basaloid nodules show focal aspects of periferic palisade (arrows). Gigantic cells (arrowheads) characterised by remarkable nuclear eccentricity are present (A). Note an enormous cell (arrowhead) with “bowenoid” nucleus (B). (haematoxylin-eosin; original magnification 88×).

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has a remarkable capacity for local destruction; therefore if it is large, ulcerated and located over a moving part of the hand, it must be dealt with more aggressively by removing the entire anatomic structure, as in our case, to avoid recurrence. After wide, radical removal of large tumours involving the thumb, every effort is recommended to preserve thumb anatomy and function, even by microsurgical technique. In our case, a large excision of the tumour would have requested either a one-stage Morrisontype reconstruction7 or a two-stage “wrap around” sensate local “kite flap”6 or free lateral arm osteocutaneous neurosensory flap.1 These long time-spending operations were refused because of the increased anaesthesiological risk; therefore the amputation, more rapid, oncologically effective, and performed under local anaesthesia, was chosen in consideration of the age of the patient.

References 1. Arnez ZM, Kersnic M, Smith RW, Godina M. Free lateral arm osteocutaneous neurosensory flap for thumb reconstruction. J Hand Surg 1991; 16B: 395–399.

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2. Guana AL, Kolbusz R, Goldberg LH. Basal cell carcinoma on the nailfold of the right thumb. Int J Dermatol 1994; 33: 204–205. 3. Hashimoto K, Mehregan AH. Tumors of the Epidermis. Butterworth Publishers, 1990: 97. 4. Haws MJ, Neumeister MW, Kenneaster DG, Russell RC. Management of nonmelanoma skin tumors of the hand. Clin Plast Surg 1997; 24: 779–795. 5. Hoffman S. Basal cell carcinoma of the nail bed. Arch Dermatol 1973; 108: 828. 6. Marin-Braun F, Merle M, Foucher G. The kite flap. Ann Chir Main 1988; 7: 147–150. 7. Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg 1982; 5: 573–583. 8. Oriba HA, Tauscheck A, Snow SN. Basal-cell carcinoma of the finger: A case report and review of the literature. J Hand Surg 1997; 22: 1103–1106. 9. Robins P, Rabinovitz HS, Rigel D. Basal-cell carcinomas on covered or unusual sites of the body. J Dermatol Surg Oncol 1981; 7A: 803–806. 10. Rudolph RI. Subungual basal cell carcinoma presenting as longitudinal melanonychia. J Am Acad Dermatol 1987; 1: 229–233. 11. Tomomichi O, Egawa K, Higo J, Fallas VH. Basal cell epithelioma with giant tumor cells. J Dermatol 1985; 12: 344–348.

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