Extensive Cranial Infiltration by Basal Cell Carcinoma

To the Editor: Basal cell carcinoma (BCC) is characterized by limited local destruction and infiltrative growth. After incomplete excision, the tumor biology of BCC changes. In particular, BCCs of the central face can be at risk of aggressive growth, tissue destruction, and ulceration. They can even cause the loss of an eye. Invasive BCC is the third most common tumor responsible for orbital exenteration after squamous cell carcinoma and sebaceous gland carcinoma. In some cases, complete surgical tumor removal may become impossible. On the other hand, chemotherapy has been of limited value, although newer developments in this field are promising for primary BCC. A 90-year-old man was referred to our hospital because of relapsing BCC of his left orbita. His medical history started in 1980 when a BCC of the medial eyelid portion was removed. By histopathologic examination, the lesion showed the typical pattern of epithelial growth with peripheral palisading tumor cells and peritumoral clefts. Although he underwent surgery, the details of the operation were missing. One can only assume that the primary excision was incomplete since he had several cycles of cryocontact therapy until 1984. In 1994, the BCC recurred, with the need for surgical intervention. This was followed by exenteration of the left orbita in 1998 because of infiltrative growth. In 1999 and 2003, again surgery was necessary owing to tumor recurrences. On admission, we found a patient showing widespread exenteration of the orbita and partial resection of the lateral wall of the nasal sinus (Figure 1). Skin biopsies taken from several sites were tumor free, but magnetic resonance imaging disclosed massive tumor infiltration of the contralateral orbita, nasal sinus, and paranasal sinuses (right frontal sinus and the ethmoidal sinuses) (Figure 2A). The right eye was in danger of being infiltrated by the tumor. Therefore, active treatment was necessary. Complete surgery was impossible, which is why we considered radiotherapy. Owing to the close proximity of the main tumor mass to the organs of the right-sided optical pathway, even the most sophisticated planning seemed to be unable to deliver a curative dose to the tumor without unacceptable risk of blindness. Therefore, we performed palliative radiotherapy with daily fractions of 2 Gy up to a total dose of 50 Gy. Three-dimensional planning ensured protection of both the chiasma opticum and the nervus opticus of the right side (Figure 2B). The treatment was well tolerated, and the patient showed a clinical response. Six weeks after the end of treatment, complete clearance of the ulcerations occurred. The patient showed no signs of subacute adverse effects, especially no impairment of vision. Further follow-up is needed. BCC has a high cure rate when complete surgical excision is possible. Especially in the face, safety margins should be controlled by microsurgery or Mohs’ surgery because such tumors have a higher risk of recurrence, with a possible worsening of prognosis. If the excision is incomplete, orbital infiltration and even cerebral infiltration are possible. A follow-up of at least 5 years is recommended because there is a recurrence rate of about 2%, even in cases of complete excision with Mohs’ surgery. From the Departments of Dermatology and Radiology and the Radiotherapy Unit/Radiotherapy Outpatient Clinic, Hospital DresdenFriedrichstadt, Dresden, Germany.