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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 27  |  Issue : 2  |  Page : 307-310

Basal cell carcinoma of the auricle: A common lesion at an uncommon location


Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Barwala, Haryana, India

Date of Submission08-Mar-2015
Date of Acceptance04-Oct-2015
Date of Web Publication21-Nov-2015

Correspondence Address:
Aravinda Konidena
Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Barwala, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.170167

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   Abstract 

Basal cell carcinoma is the most common skin cancer, accounting approximately for 70% of all skin malignancies. It develops most frequently on the exposed surfaces of the skin, middle third of the face, and the scalp. Though it is a slow-growing tumor that rarely metastasizes, it can cause significant local destruction with disfigurement if neglected or treated inadequately. We present one such interesting case of a 70-year-old female patient with a non-healing ulcer involving the left ear and the retroauricular area since 2 years. An incisional biopsy was performed from the left pinna, which was conclusive of nodular basal cell carcinoma. The clinical presentation, differential diagnosis, along with appropriate review of literature are presented in the context that dental surgeons might often be the first health care professionals to come in contact with patients suffering from abnormalities in the orofacial region.

Keywords: Basal cell carcinoma, malignancy, pinna, skin


How to cite this article:
Kataria AP, Konidena A, Puri G, Gupta R. Basal cell carcinoma of the auricle: A common lesion at an uncommon location. J Indian Acad Oral Med Radiol 2015;27:307-10

How to cite this URL:
Kataria AP, Konidena A, Puri G, Gupta R. Basal cell carcinoma of the auricle: A common lesion at an uncommon location. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2019 Aug 23];27:307-10. Available from: http://www.jiaomr.in/text.asp?2015/27/2/307/170167


   Introduction Top


Cancer of the auricle accounts for around 6% of all cutaneous malignancies, out of which 50-60% are squamous cell carcinoma, 30-40% are basal cell carcinoma (BCC), and 2-6% are malignant melanomas. [1] Basal Cell Carcinoma is a locally invasive, slow-growing, non-melanotic malignant skin cancer that rarely metastasizes, frequently causing significant disfigurement, hence known as rodent ulcer. [2] It develops most frequently on the exposed surfaces of the skin, middle third of the face, and the scalp in the middle-aged or elderly persons. The most important etiological features include genetic predisposition and sun exposure (ultraviolet radiation), apart from risk factors like increasing age, male gender, immunosuppression, arsenic exposure, and high dietary fat intake. [2] Dental surgeons may often be the first health care professionals to encounter patients with orofacial abnormalities, owing to the frequency of dental complaints or dental checkups, thus being consecrated with an opportunity to identify abnormal findings of this region. Gross general examination and orofacial examination must be made a common practice with every patient, so as to not to miss crucial findings.


   Case Report Top


A 70-year-old female patient reported to the Department of Oral Medicine and Radiology with the complaint of missing teeth since 2 months and a bleeding wound in the left ear region since 2 years. She reported difficulty in mastication due to gradual loosening of teeth and subsequent extraction over a period of 2 years with a few teeth remaining in the upper jaw. Upon enquiring about the bleeding wound of the ear, she stated that she noticed a small growth in the left ear region 2 years back which was slightly painful, associated with bleeding occasionally, but there was no difficulty in hearing or loss of sensation over the left ear region and the surrounding skin [Figure 1].
Figure 1: Ulcerated nodule in the preauricular region

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She was a known hypertensive and diabetic, and under medication since the last 7 and 9 years, respectively. She underwent uneventful extractions under local anesthesia 2 years back. There was no loss of appetite or weight loss, but she had disturbed sleep due to painful wound of the ear. General examination revealed a dark-skinned individual with moderate built and nourishment without any signs of pallor, clubbing, cyanosis, jaundice, pedal edema, or lymphadenopathy.

Extraorally, there were two ulcers seen, one each on the pre- and postauricular regions of the left ear. The ulcer on the preauricular region was a single, large, irregular ulcer of size 2.5 × 2 cm with black crustation. The lesion showed erythematous areas along with scarring and puckering causing distortion of pinna. The lesion extended anteriorly up to 0.5 cm before pre-tragus area, posteriorly up to anterior border of scaphoid fossa, superiorly up to the hairline and superior border of helix, and inferiorly to the ear lobule. Margins of the ulcers were raised and everted. The floor was covered with yellowish slough and the surrounding skin was erythematous with no discharge. In the postauricular region, there was a solitary, oval, erythematous ulcer seen with a size of approximately 2 cm × 1 cm, and with raised, everted blackish margins extending up to lower one-third of the pinna. The floor was erythematous without any discharge [Figure 2]. On palpation, both the ulcers were tender, with indurated edges and base, and were bleeding on touch. There was no associated preauricular, postauricular, submandibular, or cervical lymphadenopathy.
Figure 2: Ulcer in the postauricular region

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Intraoral examination revealed complete and partially edentulous mandibular and maxillary alveolar ridges, respectively [Figure 3] and [Figure 4]. Based on the history and clinical examination, a provisional diagnosis of chronic non-healing ulcer of the left ear was given, and BCC, malignant melanoma, squamous cell carcinoma, and deep mycotic infection were considered under the differential diagnosis.
Figure 3: Intraoral picture of maxillary arch

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Figure 4: Intraoral picture of mandibular arch

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Routine hematological investigations, and orthopantomograph (OPG) and posteroanterior (PA) skull radiograph did not reveal any abnormality [Figure 5] and [Figure 6]. Incisional biopsy was taken from the preauricular ulcer under local anesthesia. Histopathology showed cell islets with a typical peripheral palisading of the cells, chaotic arrangement of the cells in the central region, and cystic appearance, consistent with nodular BCC [Figure 7]. Hence, the final diagnosis of nodular BCC with T 2 N 0 M × was given. The patient was referred to an oncology center for further management.
Figure 5: PA view

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Figure 6: Panoramic view of the patient

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Figure 7: Histopathologic picture

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   Discussion Top


Basal cell carcinoma, a low-grade neoplasm, mainly affects the sun-exposed areas and appears in the head in 80% of cases, especially in the malar region and the nose. [1],[2] The other photoexposed areas such as the trunk and extremities are less affected, and in 4% of patients, the lesions may appear on genitals and perianal area. The incidence of BCC is about 2000 cases/100,000 population with an increase in risk reported for the Caucasian race: 33-39% for men and 23-28% for women. [3] Though BCC is characterized by slow progression and insignificant rate of metastases (only 0.0028-0.5%), it can result in considerable local destruction or disfigurement. [4] Facial BCCs, however, are of concern due to proximity to many areas of functional and cosmetic importance, high recurrence rates, and greater degree of subclinical spread. [5] Therefore, early diagnosis and appropriate therapy are essential. [3],[5] Our patient also presented with BCC of the ear causing considerable local destruction and disfigurement.

Pathogenesis

UV irradiation (especially UVB 290-320 nm) causes oxidative stress in the skin, which leads to lipid peroxidation and DNA hydroperoxide formation that is usually cleared by glutathione S transferase (GST). However, polymorphisms in GST may result in impaired detoxification. Furthermore, alterations in melanocortin 1 receptor gene, UV ray induced production of pyrimidine dimers, and loss of heterozygosity of both tumor suppressor (protective) genes - TP53 and PTCH - result in BCC. Autosomal dominant nevoid BCC is associated with mutations in PTCH1 gene located in 9q 22.3. Besides intrinsic genetic predisposition and immunosuppression, ionizing radiation, arsenic, and industrial chemical substances are other exogenous carcinogens responsible for BCC. [6]

Clinical variants of BCC [3]

Nodular BCC

This most common form presents as exophytic, elevated nodules that may extend into the ulcerative or cystic pattern. It is termed as ulcus rodens when big-sized lesions with central necrosis are seen. Our patient presented with this variant. Ulceration was seen in our case.

Cystic BCC

Presents as one or more cystic nodes with different sizes and located peripheral to the centrally placed tumor nests.

Morpheaform BCC

This form is commonly seen as an ill-defined infiltrated plaque with slightly shining surface. The nests and cluster of tumor cells are surrounded by thick fibrotic stroma.

Infiltrated BCC

Clinically, it manifests as a whitish, compact, ill-defined plaque and is seldom associated with paraesthesia or hyperesthesia due to perineural infiltration, when located on the face. This lesion presents histologically as a deep infiltration of thin bundle of basaloid cells with nest-like configuration located between the collagenous fibers on the dermis.

Micronodular

Clinically, this variant may present as elevated or flat infiltrated tumors. They rarely ulcerate and have yellow whitish color when they are flat.

Superficial BCC

It occurs as erythematous plaque with different sizes from several millimeters to more than 10 cm.

Pigmented BCC

Various forms of BCC, namely, nodular, micronodular, multifocal, and superficial BCC, presenting with pigmentation varying from dark brown to black are known as pigmented BCC. In the present case, there was blackish discoloration seen as a superficial crust.

Management

Prognostic factors deciding the line of management include tumor size, site, definition of clinical margin, histological aggression, immunosuppression, and failure of previous treatment. [2] The management of BCC includes surgical and non-surgical options. Surgical treatment options (causing excision or destruction of the tumor) available for BCC include surgical/laser excision, Moh's surgery (most preferred), electric cauterization/curettage, and cryotherapy. Telfer et al. reported that surgical management with evaluation of surgical margins histologically had the lowest overall failure rates. [2] Some studies had various outcomes with non-surgical modalities like topical chemotherapy with 5-fluorouracil, imiquimod, interferon alpha, and photodynamic therapy. [2],[3],[5] Radiotherapy (RT) is effective in primary BCC, surgically recurrent BCC, as an adjuvant therapy and is the choice in patients with high-risk BCC who are unable to sustain the surgery. Facial BCCs are treated effectively by RT, except for those involving the upper eyelid and bridge of the nose due to potential side effects of damage to the lens and radionecrosis. [2]


   Conclusion Top


Though BCC is a relatively frequent disease with slow progress, it should not be underestimated. Early diagnosis would facilitate timely management and better prognosis. Detailed examination of the orofacial region by dental surgeons may aid the early recognition of such aggressive lesions and their appropriate management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Vuyk HD, Cook TD. Auricular reconstruction after Moh's surgery. A review. Face 1997;5:9-21.  Back to cited text no. 1
    
2.
Telfer NR, Colver GB, Morton CA; British Association of Dermatologists. Guidelines for the management of basal cell carcinoma. Br J Dermatol 2008;159:35-48.  Back to cited text no. 2
    
3.
Dourmishev LA, Rusinova D, Botey I. Clinical variants, stages, and management of basal cell carcinoma. Indian Dermatol Online J 2013;4:12-7.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Mehta KS, Mahajan VK, Chauhan PS, Sharma AL, Sharma V, Abhinav C, et al. Metastatic basal cell carcinoma: A biological continuum of basal cell carcinoma? Case Rep Dermatol Med 2012;2012:157187.  Back to cited text no. 4
    
5.
Smith V, Walton S. Treatment of facial basal cell carcinoma: A review. J Skin Cancer 2011;2011:380371.  Back to cited text no. 5
    
6.
Tilli CM, Van Steensel MA, Krekels GA, Neumann HA, Ramaekers FC. Molecular aetiology and pathogenesis of basal cell carcinoma. Br J Dermatol 2005;152:1108-24.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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