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Basosquamous carcinoma and keratotic BCC, how to define?


Dr. Mona Abdel-Halim

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Several histopathological types of BCC have been described in dermatopathology text books. However basosquamous carcinoma and keratotic BCC have confusing definitions that vary in different text books and sometimes I find this discrepancy irritating!!!

According to Weedon's skin pathology, a keratotic BCC is a BCC in which the islands show squamous differentiation and central keratinization, while in McKee's pathology of the skin, it is a BCC which contain horn cysts and in some cases may mimic a trichoepithelioma. This definition applies in Weedon's skin pathology to infundibulocystic BCC!!

On the other hand, basosquamous carcinoma according to Weedon's skin pathology is a BCC with three types of cells: basaloid, squamoid and metatypical (large pale cells), while in McKee's pathology of the skin, it is a BCC with areas of squamous differentiation and is also described as metatypical BCC.

I know that basosquamous carcinoma carries a risk of distant metastasis, hence I feel it is important to be accurate in defining a lesion as basosquamous carcinoma. But how to manage this without the presence of a unified definition in dermatopathology text books??

From my own interpretation of illustrations and photos in different textbooks, I came up to this conclusion which I am using in my reporting that I want to share with you and I want you to tell me: am I understanding this right or wrong? A tumor composed of simultaneous (biphasic) existence of areas of a typical BCC and areas of a typical SCC will be called basosquamous carcinoma. On the other hand, a BCC in which some of the islands show squamoid differentiation and central keratinization will be called a keratotic BCC. Am I on the right track???
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Mark A. Hurt MD

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In my experience, I have never had any use for the concept of either phrase. At the risk if being a naysayer or sounding simplistic, someone is going to have to provide me with some kind of compelling reason to accept either concept. Every time I have encountered a neoplasm that could be entertained to be in the differential of SCC vs BCC, my experience has been that ultimately the lesion had the biology of BCC, SCC, Merkel cell CA, or sebaceous carcinoma, or I was uncertain. Criteria for basosquamous CA or keratotic BCC seem to be arbitrary. For practical purposes, I think it is important to know whether the carcinoma infiltrates fat, nerve, vessels, or margins. These parameters will have real meaning.
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Dr. Richard Carr

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I do use the term basosquamous carcinoma but never without qualification and a comment on biological behavior. These are my categories.
1. BCC (basosquamous with malignant squamous component): has areas of typical BCC (BerEP4 strong, EMA always negative in the BCC-like component) that transitions merges / blends intimately with the malignant squamous component. Our threshold for this diagnosis is high ~1% of all BCC we report i.e. the malignant squamous component has to be high grade and totally indistinguishable from a high grade SQC in a reasonable area of the tumour (e.g. a whole low power field x5).
2. Basaloid SQC: can simulate BCC very closely and we even published a case with monster cells (mimic of pleomorphic nodular BCC) that did subsequently metastasise (it was quite small too). EMA present in the basaloid epithelium often and BerEP4 can be weak to moderate and relatively widespread. But these tumours lack the hallmarks of bone fide BCC i.e. prominent palisading with mucin in the retraction space.
3. Collision tumours: Have the morphology and IHC of the separate diagnoses SQC and BCC uncommon but have several examples.
4. Basosquamous carcinoma NOS: in the [u][b]rare[/b][/u] cases that I cannot place it in to categories 1. to 3. or into another diagnosis like high grade adenosquamous carcinoma (porocarcinoma high grade) etc. I think this is actually very uncommon and I explain that it needs to be managed as a high grade SQC.
I lump keratotic (central keratinisation in islands so not usually a problem with distinguishing from 1.) and infundibulocystic/TE-like BCC with nodular BCC (the latter can be exceedingly difficult to distinguish from TE especially on the central face. In my experience by very wary about reporting a TE-like lesions in a superficial biopsy from the central face on the sun-damaged, pale, skin of 50+ age group, 19 out of 20 will be TE-like BCCs and can have trapped reactive Merkel cells in this location although we do find CD10 useful - if in any doubt advise conservative complete excision).
Lastly I would not trust any paper on "metastatic BCC / basosquamous BCC" that did not confirm the diagnosis with IHC (and I am not aware of any such paper other than case reports). Many cases of so-called metastatic basosquamous (BCC) are probably basaloid SQC that are simply mimicking BCC.
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Dr. Richard Carr

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Forgot to say I usually disregard superficial metatypical / atypical squamous component (in BCC) just deep to ulceration which is very common indeed. Normally the deeper aspect of the underlying BCC is one of the usually types.
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