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Basal cell carcinoma of the lip
BASAL
CELL
CARCINOMA
OF THE
EDWARD L. SLEEPER, A.B., D.D.S.,M.Sc.D.,”
LIP
BOSTON, MASS.
T
HE basal cell carcinoma is a locally malignant tumor frequently occurring on the face and characterized by the appearance of a slow-growing, painless nodule usually having a pearly gleam and being well circumscribed. It may develop on a previous area of hyperkeratosis or from apparently normal skin. Frequently, areas of ulceration appear which fail to heal, forming a scale over the surface which can be picked off, only to expose a raw surface again. This process may occur over a period of many years in the more slowly growing lesions, One type of basal cell carcinoma is believed to develop from the epithelium of hair follicles, and the tumor microscopically shows a characteristic picture. Although growth may be slow with no tendency to metastasize, the tumor may invade deeper structures and completely erode soft tissues, cartilage, and bone, and if not excised may cause the death of the patient by invasion of contiguous structures. F. D., a 71-year-old retired business man, presented himself to the Tufts College Dental Clinic on Nov. 29,1950, with a chief complaint of an ulcer of the lower lip which failed to heal. Four years prior to this time, a scaly area appeared on his lip which was painless and which he picked off. This left a raw surface which eventually crusted over. He picked the crust off again, and the same process repeated itself. This occurred over several years, during which time the lesion never completely healed. This area grew in size and became indurated, and he finally presented himself for treatment. Physical examination at the time revealed a 1 by 1 cm., hard, bluish, pearly, nontender, noninflamed, ulcerated area of the left side of the lip, which had rolled edges with an ulcerated crater in the center (Fig. 1). There was no evidence of senile keratosis elsewhere on his face, and all other structures appeared normal. A clinical diagnosis of basal cell carcinoma was made, and an excision biopsy was performed. On Nov. 30, 1950, the left side of the patient’s face was prepared and draped. Xylocaine, 0.5 C.C. of a 2 per cent solution, with 1 :lOO,OOO epinephrine, was injected int,o the area to be operatecl upon. By means of a scalpel, an elliptical This incision was made which completely skirted the lesion on the surface. was carved deep through the subcutaneous tissues to the triangularis and This section was removed, and clinically quadratus labii inferioris muscles. there was an adequate margin of normal tissue on the periphery and at the depth of the incision. The skin and subcutaneous tissues were then undermined for a distance of about 2.5 cm. around the entire periphery for mobilization of the skin surface. Bleeding was not a factor, and the skin edges were *Assistant
Professor
of
Oral
Surgery,
Tufts
1064
College
Dental
School.
brought into perfect approximation using 000 Dermalon sutures. A smal I dressing was applied and the patient told to return for postoperative care IIealing was uneventful with an almost invisible linear sear rcsnlting. The biopsy report from the laboratory was as follows: “Sections shop sheets of tightly packed epithelial cells apparently derived from the hair follicles. The over-lying keratinized stratified squamous epithelium is thinned out and ulcerated. The tumor is invading the nuclerlping corium and is co111 posed of small, hyperchromatic cells which show no tendency to corniCy. Hair follicles and sebaceous glands are cortspiclr Mitoses are very infrequent. ous and adipose tissue and striated muscle fibers are to be -found at the ba+ of the section. In several areas, the tumor cstcntls almost to the cut surface.” (Figs. 2, 3, and 4,) Xicroscopic
diagnosis:
Basal cell carcinoma.
Although there was an adequate margin of normal tissue at both ends of the incision (E’ig. 2), it was felt that there was not this margin of safet,y on the sides; for although tumor tissue was not cut through, it was too close to the free margin to be considered completely excised. (Fig. 5). Since the operation was a simple atraumatic procedure, it was decided 10 excise the area in question, and on Jan. 8, 1951, the same type of operation as was done previously was performed, excising the scar and securing an anpare adequat,e margin of safety. The specimen was submitt,ed to the laboratory, and serial cross sections over an area of 5 mm. in the suspected area yielded no evidence of tumor. The report was as follows : “Sections are composed of skin in which a mild chronic inflammatory reaction and a foreign body giant cell reaction may be discerned. The dermis shows extensive hyalinization of the connective tissue. There is no evidence of residual neoplasm.” (I.‘igs. 6 and 7.) Yllicroscopic
&agnosis:
“Scar
tissue with
chronic
inflammation.”
Fig.
2.
Fig.
3.
Fig.
4.
3. --T,ow-power safety at Fig. 3.-Medium-power with a basal type cell Fig. 4.-High-power prominent hyperchromatic margin
Fig.
of
its and
view depth
showing
and
at
tllc
tunlol’
invalling
the
corium,
with
both ends. view of area of ulceration showing tumor invasion a chronic inflammatory reaction. view of Fig. 3 showing characteristic basal type cells scanty cytoplasm, and one or more nucleoli.
an
adequate
of
corium
with
larger
Fig. edge wesent.
Fig’. EL-Cross on one side Fig. B.-Cross
6.
section in the middle of the lesion to be considered adequately excised. section of tissue from the secon~l
shouting operation
tumor slwwing
tissl .IC too no
evidence
close
to of
thP
tu nror
2. Failure to heal always implies that something is wrong and always requires an explanation as to why no healing is taking place. This ahsenct: of healing may be due to some granulomatous or infilt>rating proct ‘ss, infection, 01’ neoplasm.
1668
EDWARD
1~. SIZEPER
3. In excising any lesion, an adequate margin of normal tissue should be had on all sides, as well as the depth. 4. All specimens removed, whether normal appearing or not, should be sent to the laborat,ory for microscopic examination, 5. If tumor is cut through, another operation is necessary to excise it completely, if possible.
foreig3ody the dermis.
i.-High-power giant
cells
view present.
of
Fig. There
6 showing is extensive
zt mild chronic hyalinization
inflammatory reaction of the connective tissue
and of
6. In this patient, whose tumor was small and very slow growing, and in whom no tumor tissue was cut through, it was felt that the original margin of safety was not ideal, and that, since the operation was a relatively minor one, complete excision should be performed. 7. Apparently normal healing at the surface should not be construed as representing evidence that no more tumor is present. It must be remembered that tumors grow in depth as well as laterally, and that remaining tumor tissue deep in the wound may not necessarily interfere with normal surface healing, but may continue to invade deeper structures. Hence, close observation of the patient is necessary. 25
DAY
STATE
ROAD.
CELL
CARCINOMA
OF THE
EDWARD L. SLEEPER, A.B., D.D.S.,M.Sc.D.,”
LIP
BOSTON, MASS.
T
HE basal cell carcinoma is a locally malignant tumor frequently occurring on the face and characterized by the appearance of a slow-growing, painless nodule usually having a pearly gleam and being well circumscribed. It may develop on a previous area of hyperkeratosis or from apparently normal skin. Frequently, areas of ulceration appear which fail to heal, forming a scale over the surface which can be picked off, only to expose a raw surface again. This process may occur over a period of many years in the more slowly growing lesions, One type of basal cell carcinoma is believed to develop from the epithelium of hair follicles, and the tumor microscopically shows a characteristic picture. Although growth may be slow with no tendency to metastasize, the tumor may invade deeper structures and completely erode soft tissues, cartilage, and bone, and if not excised may cause the death of the patient by invasion of contiguous structures. F. D., a 71-year-old retired business man, presented himself to the Tufts College Dental Clinic on Nov. 29,1950, with a chief complaint of an ulcer of the lower lip which failed to heal. Four years prior to this time, a scaly area appeared on his lip which was painless and which he picked off. This left a raw surface which eventually crusted over. He picked the crust off again, and the same process repeated itself. This occurred over several years, during which time the lesion never completely healed. This area grew in size and became indurated, and he finally presented himself for treatment. Physical examination at the time revealed a 1 by 1 cm., hard, bluish, pearly, nontender, noninflamed, ulcerated area of the left side of the lip, which had rolled edges with an ulcerated crater in the center (Fig. 1). There was no evidence of senile keratosis elsewhere on his face, and all other structures appeared normal. A clinical diagnosis of basal cell carcinoma was made, and an excision biopsy was performed. On Nov. 30, 1950, the left side of the patient’s face was prepared and draped. Xylocaine, 0.5 C.C. of a 2 per cent solution, with 1 :lOO,OOO epinephrine, was injected int,o the area to be operatecl upon. By means of a scalpel, an elliptical This incision was made which completely skirted the lesion on the surface. was carved deep through the subcutaneous tissues to the triangularis and This section was removed, and clinically quadratus labii inferioris muscles. there was an adequate margin of normal tissue on the periphery and at the depth of the incision. The skin and subcutaneous tissues were then undermined for a distance of about 2.5 cm. around the entire periphery for mobilization of the skin surface. Bleeding was not a factor, and the skin edges were *Assistant
Professor
of
Oral
Surgery,
Tufts
1064
College
Dental
School.
brought into perfect approximation using 000 Dermalon sutures. A smal I dressing was applied and the patient told to return for postoperative care IIealing was uneventful with an almost invisible linear sear rcsnlting. The biopsy report from the laboratory was as follows: “Sections shop sheets of tightly packed epithelial cells apparently derived from the hair follicles. The over-lying keratinized stratified squamous epithelium is thinned out and ulcerated. The tumor is invading the nuclerlping corium and is co111 posed of small, hyperchromatic cells which show no tendency to corniCy. Hair follicles and sebaceous glands are cortspiclr Mitoses are very infrequent. ous and adipose tissue and striated muscle fibers are to be -found at the ba+ of the section. In several areas, the tumor cstcntls almost to the cut surface.” (Figs. 2, 3, and 4,) Xicroscopic
diagnosis:
Basal cell carcinoma.
Although there was an adequate margin of normal tissue at both ends of the incision (E’ig. 2), it was felt that there was not this margin of safet,y on the sides; for although tumor tissue was not cut through, it was too close to the free margin to be considered completely excised. (Fig. 5). Since the operation was a simple atraumatic procedure, it was decided 10 excise the area in question, and on Jan. 8, 1951, the same type of operation as was done previously was performed, excising the scar and securing an anpare adequat,e margin of safety. The specimen was submitt,ed to the laboratory, and serial cross sections over an area of 5 mm. in the suspected area yielded no evidence of tumor. The report was as follows : “Sections are composed of skin in which a mild chronic inflammatory reaction and a foreign body giant cell reaction may be discerned. The dermis shows extensive hyalinization of the connective tissue. There is no evidence of residual neoplasm.” (I.‘igs. 6 and 7.) Yllicroscopic
&agnosis:
“Scar
tissue with
chronic
inflammation.”
Fig.
2.
Fig.
3.
Fig.
4.
3. --T,ow-power safety at Fig. 3.-Medium-power with a basal type cell Fig. 4.-High-power prominent hyperchromatic margin
Fig.
of
its and
view depth
showing
and
at
tllc
tunlol’
invalling
the
corium,
with
both ends. view of area of ulceration showing tumor invasion a chronic inflammatory reaction. view of Fig. 3 showing characteristic basal type cells scanty cytoplasm, and one or more nucleoli.
an
adequate
of
corium
with
larger
Fig. edge wesent.
Fig’. EL-Cross on one side Fig. B.-Cross
6.
section in the middle of the lesion to be considered adequately excised. section of tissue from the secon~l
shouting operation
tumor slwwing
tissl .IC too no
evidence
close
to of
thP
tu nror
2. Failure to heal always implies that something is wrong and always requires an explanation as to why no healing is taking place. This ahsenct: of healing may be due to some granulomatous or infilt>rating proct ‘ss, infection, 01’ neoplasm.
1668
EDWARD
1~. SIZEPER
3. In excising any lesion, an adequate margin of normal tissue should be had on all sides, as well as the depth. 4. All specimens removed, whether normal appearing or not, should be sent to the laborat,ory for microscopic examination, 5. If tumor is cut through, another operation is necessary to excise it completely, if possible.
foreig3ody the dermis.
i.-High-power giant
cells
view present.
of
Fig. There
6 showing is extensive
zt mild chronic hyalinization
inflammatory reaction of the connective tissue
and of
6. In this patient, whose tumor was small and very slow growing, and in whom no tumor tissue was cut through, it was felt that the original margin of safety was not ideal, and that, since the operation was a relatively minor one, complete excision should be performed. 7. Apparently normal healing at the surface should not be construed as representing evidence that no more tumor is present. It must be remembered that tumors grow in depth as well as laterally, and that remaining tumor tissue deep in the wound may not necessarily interfere with normal surface healing, but may continue to invade deeper structures. Hence, close observation of the patient is necessary. 25
DAY
STATE
ROAD.