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Basal cell carcinoma of the vermilion zone of the lower lip: a report of 3 cases
ORAL ONCOLOGY
PERGAMON
Oral Oncology 34 (1998) 30%312
Case report
Basal cell carcinoma
of the vermilion zone of the lower lip: a report of 3 cases
H.A. Oriba”**, S. Sandermannb,
L. Kircikb,
S.N. Snow b
aThe Cleveland Clinic Foundation, Department of Anatomic Pathology L25, 9500 Euclid Avenue, Cleveland, OH 44195, U.S.A. bUniversity of Wisconsin Hospitals & Clinics, Department of Surgery, Division of Mohs Surgery, 2880 University Avenue, Madison, WI 53705-0902. U.S.A.
Received 18 July 1997; accepted
14 October
1997
Abstract Three cases of basal cell carcinomas (BCCs) of the vermilion zone of the lower lip are reported. The possible histopathogenesis of these BCCs is discussed. All lesions were treated by Mohs micrographic surgery. 0 1998 Elsevier Science Ltd. All rights reserved. Keywords:
BCC; Vermilion;
Mucosa;
Mohs micrographic
surgery
1. Introduction
2. Case reports
Basal cell carcinoma (BCC) accounts for approximately 65-75% of malignant skin tumour [l]. More than 80% of BCCs are on the head and neck area, with most of the tumours arising in the centrofacial and upper two-thirds of the face [2]. Other sites of predilection are the trunk, the lower third of the face, the external ear, retroauricular and scalp areas. In contrast, the vermilion zone and mucosal surface of the lips are generally thought to be rarely involved primarily by BCCs [3,4]. Since BCCs are thought to arise from pilar structures, their appearance on mucosal surfaces is perplexing. In a study of 669 facial BCCs and squamous cell carcinomas (SCCs), the upper cutaneous lip was clearly favoured by BCCs, whereas most malignancies of the lower lip were SCCs [2]. The relation of BCC of the upper to the lower cutaneous lip was 11: 1 in women and 14: 1 in men. We report 3 cases of BCC on the vermilion zone of the lower lip treated by Mohs micrographic surgery (MMS), which has been previously described for SCC
2.1. Case 1
[5,61.
* Corresponding 6769.
author.
Tel.: 001 216 444 6782; fax: 001 216 445
136%8375/98/%19.00 0 1998 Elsevier Science Ltd. All rights reserved PII: S1368-8375(97)00084-5
A 91-year-old woman presented with a 2.Ocm ulcerated nodule on the vermilion zone of the left-hand side of the lower lip (Fig. 1). The lesion developed as a bloody blister situated on the vermilion zone 3 years ago and started to enlarge and ulcerate about 1 year ago. There was no history of previous trauma, smoking, tobacco chewing or drinking. Biopsy showed a solid BCC with infiltrative features (Fig. 2). The tumour was removed by MMS in two stages. The residual defect measured 4x 5.2 cm. The vermilion zone and skin were closed primarily. There was no sign of recurrence 3 years later when the patient died of an unrelated cause. 2.2. Case 2 A 69-year-old man was found to have a circumscribed, pearly nodule on the left lateral lower lip near the oral commissure (Fig. 3). The size of the lesion was 0.8 cm. The patient had a history of multiple facial basal cell carcinomas and actinic keratoses. His past medical history was significant for colon cancer resection 1 year ago. Microscopic examination confirmed the clinical diagnosis of solid BCC of the circumscribed type (Fig. 4). A tumour-free margin was obtained by MMS
310
H.A. Oriba et al./Oral Oncology 34 (1998) 309-312
in three stages. The postoperative defect of 1.5x2.0 cm was closed primarily. He had no recurrence at his loyear follow-up examination. 2.3. Case 3 A 73-year-old woman presented with a biopsy-proven BCC of the left lower lip. One year previously a lesion at
the same site had been treated in a non-histological controlled excision. At the present examination, there was a crust-covered papule of 0.3 cm size located on the left lower lip at the vermilion zone. The lesion was removed by MMS. Histopathological examination showed a micronodular BCC in the first and second layers, whereas in the subsequent three layers there was a more follicular pattern of the BCC. The tumour extended laterally into the mucosal surface of the lower lip. The final defect measured 1.4x 1.2cm and was closed primarily side to side. There was no evidence of recurrence at the 4-year follow-up.
3. Discussion BCCs are rarely encountered on oral mucosa. The first reported case of BCC was described as arising on the dorsum of the tongue and the soft palate [7]. Shortly thereafter, a BCC in the anterior part of the mandibular alveolar process was described [8]. Other BCCs arising
Fi.g. 1. Basal cell carcinoma
of the left lower vermilion
zone (case 1).
Fig. 3. Basal cell carcinoma missure (case 2).
Fig. 2. Photomicrograph of biopsy specimen (case 1) showing discrete collections of small cells in various sized masses and as elongated strands (haematoxylin-eosin stain; original magnification x40).
of the left lower vermilion
zone by com-
Fig. 4. Photomicrograph of biopsy specimen (case 2) showing discrete collections of small cells with darkly staining, uniform nuclei and scant cytoplasm with peripheral palisading (haematoxylin-eosin stain; original magnification x40).
H.A. Oriba et al.lOral Oncology 34 (1998) 309-312
in the oral cavity have been reported on the gingiva and hard palate [g-12]. Some authors have questioned the existence of BCCs of the oral mucosa and consider these cases as to be ameloblastomas [13,14]. The number of cases involving the vermilion zone of the lower lip without touching the contiguous skin is very limited [15-191. 2 cases of BCC on the mucosal surface of the lower lip were encountered in a series of 1025 patients presenting with skin cancer [20]. Our cases represent 3 additional BCCs that were localised to the vermilion zone. BCC involving the vermilion mucosa and adjacent skin of the lower lip is also quite rare [21,22], but this may be due to under-reporting. The vermilion zone is unique epithelium. It is a modified mucosa, acting as the transitional zone between the glabrous skin and the squamous mucous membrane, with a dominant stratum lucidum and thin stratum corneum. All three structures, the labial skin, the vermilion zone and the oral mucosa are of ectodermal origin. Unlike other cutaneous sites, the vermilion zone is normally devoid of hair follicles and sweat glands. Sebaceous glands are also excluded, except under the condition of Fordyce spots, which are ectopic sebaceous glands. Also, uniquely positioned by the vermilion zone are minor salivary glands. Hence, occasionally a basal cell adenoma must be considered in the differential diagnosis. There have been a number of views proposed to explain the histogenesis of BCC of the lip region. Ectopit epithelial implantation from trauma was proposed for a BCC of the vermilion zone with trichoepitheliomalike features [ 151. Matrix cells of skin appendages and epidermis are considered pluripotential with the unrestrained ability to differentiate into all the possible structures of the skin [1,11,23]. The possible spread of BCC from a primary cutaneous site near the vermilion border should always be considered in cases of BCC situated on the vermilion zone. However, this explanation would be unsatisfactory in cases where the lesions are located strictly on the vermilion zone or mucosal surface of the lip without obvious involvement of the cutaneous lip. In our cases, sequential Mohs layer failed to demonstrate contiguous spread of BCC from the cutaneous origin. Finally, a rare possibility to consider would be a metastasising BCC. One such case has been reported in the vulvar area [24]. The goal of treatment should be complete excision of the neoplasm. We used MMS for treatment of these lesions, which allows for complete histological examination of all margins. Other modalities that have been utilised include wide excision, radiotherapy or cryotherapy. We advocate MMS for treatment of primary BCCs of the lip because of its high cure rate, tissue conserving nature and its ability to be performed in an ambulatory setting using only local anaesthesia.
311
We present 3 further cases of this common skin cancer in a very uncommon site. None of our patients had a previous history of radiation therapy or hereditary genetic predisposition for skin cancers. The histogenesis of BCCs from mucosal sites remains unclear. They were all treated by Mohs micrographic surgery without any complications or recurrences.
References [l] Hashimoto E, Mehregan AH. Tumors of the Epidermis. Boston: Butterworths, 1990. [2] Geisenhainer U. Basaliome im Lippenbereich, Haeufigkeit, Lokalisation, Geschlechts- und Altersverteilung (Basal cell carcinomas in the lip region: frequency, localisation, sex and age distribution). Hautarzt 1970;21:167-170. [3] Fitzpatrick PJ. Cancer of the lip. Journal of Otolaryngology 1984;13:32-36. [4] Mackie RM. Epidermal skin tumors. In: Champion RH, Burton JL, Ebling FJC, editors. Textbook of Dermatology. Oxford: Blackwell Scientific, 1992. p. 1489. [S] Mohs FE, Snow SN. Microscopically controlled surgical treatment for squamous cell carcinoma of the lower lip. Surgery Gynecology and Obstetrics 1985;160:3741. [6] Mehregan DA, Roenigk RK. Management of superficial squamous cell carcinoma of the lip with Mohs micrographic surgery. Cancer 1990;66:463468. [7] Saint CFM. Embryology of stomodeum and its bearing on tumours of tongue and salivary glands. South African Journal of Clinical Science 1951;2:1-17. [S] Thoma KH, Goldman HM. Oral Pathology. St Louis: C.V. Mosby, 1960. [9] Lawson BF, Griffin JW, Waldron CA. Basal cell carcinoma of the gingiva: report of a case. Oral Surgery, Oral Medicine and Oral Pathology 1967;24:648653. [lo] Williamson JJ, Cohney BC, Henderson BM. Basal cell carcinoma of the mandibular gingiva. Archives of Dermatology 1967;95:76-80. [ll] Liroff KP, Zeff S. Basal cell carcinoma of the palatal mucosa. Journal of Oral Surgery 1972;30:73&733. [12] Peters RA, Gingrass RP, Reyes CN, Hintz CS. Basal cell carcinoma of the oral cavity: report of a case. Journal of Oral Surgery 1972;30:6366. [13] Waldron CA. Comment on basal cell carcinoma of the oral cavity. Journal of Oral Surgery 1972;30:66. [14] Urmacher, Pearlman S. An uncommon neoplasm of the oral mucosa. American Journal of Dermatopathology 1983;5:601-604. [ 151 Keen RR, Elzay RP. Basal cell carcinoma from mucosal surface of lower lip: report of a case. Journal of Oral Surgery 1964;22:453455. [16] Kelly DE, Klein KM, Harrigan WF. Lip reconstruction following resection for an unusual basal-cell carcinoma. Oral Surgery 1975;40:19-26. [17] White SW, Davis RA, Rodman OG. Surgical management of basal cell carcinoma of the lower lip. Journal of Dermtologic Surgery and Oncology 1980;6:751-754. [18] Hume WJ, Turner EP. Basal cell carcinoma of lip mucosa. British Journal of Oral Surgery 1982;20:248-255. [19] Van der Wal KGH, Mulder JW, Beetstra A. Basal-cell carcinoma of the vermilion border of the upper lip. International Journal of Oral Surgery 1982;11:77-79. 1201 Welton DG, Elliott JA, Kimmelstiel P. Epithelioma: clinical and histologic data on 1025 lesions. Archives of Dermatology 1949;60:277-293.
312
H.A. Oriba et aLlOral Oncology 34 (1998) 309-312
[21] Weitzner S, Heutel W. Multicentric basal cell carcinoma of vermilion mucosa and skin of lower lip: report of a case. Oral Surgery, Oral Medicine and Oral Pathology 1968;26:269-272. [22] Weitzner S. Basal cell carcinoma of the vermilion mucosa and skin of the lip. Oral Surgery, Oral Medicine and Oral Pathology 1975;39:634637.
[23] Pinkus H. Factors involved in skin carcinogenesis. Journal of the American Academy of Dermatology 1979;1:267275. [24] Jiminez HT, Fenoglio CM, Richart RM. Vulvar basal cell carcinoma with metastasis: a case report. American Journal of Obstetrics and Gynecology 1975;121:28.5.
PERGAMON
Oral Oncology 34 (1998) 30%312
Case report
Basal cell carcinoma
of the vermilion zone of the lower lip: a report of 3 cases
H.A. Oriba”**, S. Sandermannb,
L. Kircikb,
S.N. Snow b
aThe Cleveland Clinic Foundation, Department of Anatomic Pathology L25, 9500 Euclid Avenue, Cleveland, OH 44195, U.S.A. bUniversity of Wisconsin Hospitals & Clinics, Department of Surgery, Division of Mohs Surgery, 2880 University Avenue, Madison, WI 53705-0902. U.S.A.
Received 18 July 1997; accepted
14 October
1997
Abstract Three cases of basal cell carcinomas (BCCs) of the vermilion zone of the lower lip are reported. The possible histopathogenesis of these BCCs is discussed. All lesions were treated by Mohs micrographic surgery. 0 1998 Elsevier Science Ltd. All rights reserved. Keywords:
BCC; Vermilion;
Mucosa;
Mohs micrographic
surgery
1. Introduction
2. Case reports
Basal cell carcinoma (BCC) accounts for approximately 65-75% of malignant skin tumour [l]. More than 80% of BCCs are on the head and neck area, with most of the tumours arising in the centrofacial and upper two-thirds of the face [2]. Other sites of predilection are the trunk, the lower third of the face, the external ear, retroauricular and scalp areas. In contrast, the vermilion zone and mucosal surface of the lips are generally thought to be rarely involved primarily by BCCs [3,4]. Since BCCs are thought to arise from pilar structures, their appearance on mucosal surfaces is perplexing. In a study of 669 facial BCCs and squamous cell carcinomas (SCCs), the upper cutaneous lip was clearly favoured by BCCs, whereas most malignancies of the lower lip were SCCs [2]. The relation of BCC of the upper to the lower cutaneous lip was 11: 1 in women and 14: 1 in men. We report 3 cases of BCC on the vermilion zone of the lower lip treated by Mohs micrographic surgery (MMS), which has been previously described for SCC
2.1. Case 1
[5,61.
* Corresponding 6769.
author.
Tel.: 001 216 444 6782; fax: 001 216 445
136%8375/98/%19.00 0 1998 Elsevier Science Ltd. All rights reserved PII: S1368-8375(97)00084-5
A 91-year-old woman presented with a 2.Ocm ulcerated nodule on the vermilion zone of the left-hand side of the lower lip (Fig. 1). The lesion developed as a bloody blister situated on the vermilion zone 3 years ago and started to enlarge and ulcerate about 1 year ago. There was no history of previous trauma, smoking, tobacco chewing or drinking. Biopsy showed a solid BCC with infiltrative features (Fig. 2). The tumour was removed by MMS in two stages. The residual defect measured 4x 5.2 cm. The vermilion zone and skin were closed primarily. There was no sign of recurrence 3 years later when the patient died of an unrelated cause. 2.2. Case 2 A 69-year-old man was found to have a circumscribed, pearly nodule on the left lateral lower lip near the oral commissure (Fig. 3). The size of the lesion was 0.8 cm. The patient had a history of multiple facial basal cell carcinomas and actinic keratoses. His past medical history was significant for colon cancer resection 1 year ago. Microscopic examination confirmed the clinical diagnosis of solid BCC of the circumscribed type (Fig. 4). A tumour-free margin was obtained by MMS
310
H.A. Oriba et al./Oral Oncology 34 (1998) 309-312
in three stages. The postoperative defect of 1.5x2.0 cm was closed primarily. He had no recurrence at his loyear follow-up examination. 2.3. Case 3 A 73-year-old woman presented with a biopsy-proven BCC of the left lower lip. One year previously a lesion at
the same site had been treated in a non-histological controlled excision. At the present examination, there was a crust-covered papule of 0.3 cm size located on the left lower lip at the vermilion zone. The lesion was removed by MMS. Histopathological examination showed a micronodular BCC in the first and second layers, whereas in the subsequent three layers there was a more follicular pattern of the BCC. The tumour extended laterally into the mucosal surface of the lower lip. The final defect measured 1.4x 1.2cm and was closed primarily side to side. There was no evidence of recurrence at the 4-year follow-up.
3. Discussion BCCs are rarely encountered on oral mucosa. The first reported case of BCC was described as arising on the dorsum of the tongue and the soft palate [7]. Shortly thereafter, a BCC in the anterior part of the mandibular alveolar process was described [8]. Other BCCs arising
Fi.g. 1. Basal cell carcinoma
of the left lower vermilion
zone (case 1).
Fig. 3. Basal cell carcinoma missure (case 2).
Fig. 2. Photomicrograph of biopsy specimen (case 1) showing discrete collections of small cells in various sized masses and as elongated strands (haematoxylin-eosin stain; original magnification x40).
of the left lower vermilion
zone by com-
Fig. 4. Photomicrograph of biopsy specimen (case 2) showing discrete collections of small cells with darkly staining, uniform nuclei and scant cytoplasm with peripheral palisading (haematoxylin-eosin stain; original magnification x40).
H.A. Oriba et al.lOral Oncology 34 (1998) 309-312
in the oral cavity have been reported on the gingiva and hard palate [g-12]. Some authors have questioned the existence of BCCs of the oral mucosa and consider these cases as to be ameloblastomas [13,14]. The number of cases involving the vermilion zone of the lower lip without touching the contiguous skin is very limited [15-191. 2 cases of BCC on the mucosal surface of the lower lip were encountered in a series of 1025 patients presenting with skin cancer [20]. Our cases represent 3 additional BCCs that were localised to the vermilion zone. BCC involving the vermilion mucosa and adjacent skin of the lower lip is also quite rare [21,22], but this may be due to under-reporting. The vermilion zone is unique epithelium. It is a modified mucosa, acting as the transitional zone between the glabrous skin and the squamous mucous membrane, with a dominant stratum lucidum and thin stratum corneum. All three structures, the labial skin, the vermilion zone and the oral mucosa are of ectodermal origin. Unlike other cutaneous sites, the vermilion zone is normally devoid of hair follicles and sweat glands. Sebaceous glands are also excluded, except under the condition of Fordyce spots, which are ectopic sebaceous glands. Also, uniquely positioned by the vermilion zone are minor salivary glands. Hence, occasionally a basal cell adenoma must be considered in the differential diagnosis. There have been a number of views proposed to explain the histogenesis of BCC of the lip region. Ectopit epithelial implantation from trauma was proposed for a BCC of the vermilion zone with trichoepitheliomalike features [ 151. Matrix cells of skin appendages and epidermis are considered pluripotential with the unrestrained ability to differentiate into all the possible structures of the skin [1,11,23]. The possible spread of BCC from a primary cutaneous site near the vermilion border should always be considered in cases of BCC situated on the vermilion zone. However, this explanation would be unsatisfactory in cases where the lesions are located strictly on the vermilion zone or mucosal surface of the lip without obvious involvement of the cutaneous lip. In our cases, sequential Mohs layer failed to demonstrate contiguous spread of BCC from the cutaneous origin. Finally, a rare possibility to consider would be a metastasising BCC. One such case has been reported in the vulvar area [24]. The goal of treatment should be complete excision of the neoplasm. We used MMS for treatment of these lesions, which allows for complete histological examination of all margins. Other modalities that have been utilised include wide excision, radiotherapy or cryotherapy. We advocate MMS for treatment of primary BCCs of the lip because of its high cure rate, tissue conserving nature and its ability to be performed in an ambulatory setting using only local anaesthesia.
311
We present 3 further cases of this common skin cancer in a very uncommon site. None of our patients had a previous history of radiation therapy or hereditary genetic predisposition for skin cancers. The histogenesis of BCCs from mucosal sites remains unclear. They were all treated by Mohs micrographic surgery without any complications or recurrences.
References [l] Hashimoto E, Mehregan AH. Tumors of the Epidermis. Boston: Butterworths, 1990. [2] Geisenhainer U. Basaliome im Lippenbereich, Haeufigkeit, Lokalisation, Geschlechts- und Altersverteilung (Basal cell carcinomas in the lip region: frequency, localisation, sex and age distribution). Hautarzt 1970;21:167-170. [3] Fitzpatrick PJ. Cancer of the lip. Journal of Otolaryngology 1984;13:32-36. [4] Mackie RM. Epidermal skin tumors. In: Champion RH, Burton JL, Ebling FJC, editors. Textbook of Dermatology. Oxford: Blackwell Scientific, 1992. p. 1489. [S] Mohs FE, Snow SN. Microscopically controlled surgical treatment for squamous cell carcinoma of the lower lip. Surgery Gynecology and Obstetrics 1985;160:3741. [6] Mehregan DA, Roenigk RK. Management of superficial squamous cell carcinoma of the lip with Mohs micrographic surgery. Cancer 1990;66:463468. [7] Saint CFM. Embryology of stomodeum and its bearing on tumours of tongue and salivary glands. South African Journal of Clinical Science 1951;2:1-17. [S] Thoma KH, Goldman HM. Oral Pathology. St Louis: C.V. Mosby, 1960. [9] Lawson BF, Griffin JW, Waldron CA. Basal cell carcinoma of the gingiva: report of a case. Oral Surgery, Oral Medicine and Oral Pathology 1967;24:648653. [lo] Williamson JJ, Cohney BC, Henderson BM. Basal cell carcinoma of the mandibular gingiva. Archives of Dermatology 1967;95:76-80. [ll] Liroff KP, Zeff S. Basal cell carcinoma of the palatal mucosa. Journal of Oral Surgery 1972;30:73&733. [12] Peters RA, Gingrass RP, Reyes CN, Hintz CS. Basal cell carcinoma of the oral cavity: report of a case. Journal of Oral Surgery 1972;30:6366. [13] Waldron CA. Comment on basal cell carcinoma of the oral cavity. Journal of Oral Surgery 1972;30:66. [14] Urmacher, Pearlman S. An uncommon neoplasm of the oral mucosa. American Journal of Dermatopathology 1983;5:601-604. [ 151 Keen RR, Elzay RP. Basal cell carcinoma from mucosal surface of lower lip: report of a case. Journal of Oral Surgery 1964;22:453455. [16] Kelly DE, Klein KM, Harrigan WF. Lip reconstruction following resection for an unusual basal-cell carcinoma. Oral Surgery 1975;40:19-26. [17] White SW, Davis RA, Rodman OG. Surgical management of basal cell carcinoma of the lower lip. Journal of Dermtologic Surgery and Oncology 1980;6:751-754. [18] Hume WJ, Turner EP. Basal cell carcinoma of lip mucosa. British Journal of Oral Surgery 1982;20:248-255. [19] Van der Wal KGH, Mulder JW, Beetstra A. Basal-cell carcinoma of the vermilion border of the upper lip. International Journal of Oral Surgery 1982;11:77-79. 1201 Welton DG, Elliott JA, Kimmelstiel P. Epithelioma: clinical and histologic data on 1025 lesions. Archives of Dermatology 1949;60:277-293.
312
H.A. Oriba et aLlOral Oncology 34 (1998) 309-312
[21] Weitzner S, Heutel W. Multicentric basal cell carcinoma of vermilion mucosa and skin of lower lip: report of a case. Oral Surgery, Oral Medicine and Oral Pathology 1968;26:269-272. [22] Weitzner S. Basal cell carcinoma of the vermilion mucosa and skin of the lip. Oral Surgery, Oral Medicine and Oral Pathology 1975;39:634637.
[23] Pinkus H. Factors involved in skin carcinogenesis. Journal of the American Academy of Dermatology 1979;1:267275. [24] Jiminez HT, Fenoglio CM, Richart RM. Vulvar basal cell carcinoma with metastasis: a case report. American Journal of Obstetrics and Gynecology 1975;121:28.5.