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Chin Med J 2010;123(19):2748-2749
2748
Images for diagnosis
Basal cell carcinoma of the scrotum: report of a case and review of
the literature
WANG Jian-wei, MAN Li-bo, HE Feng, HUANG Guang-lin, LI Gui-zhong and WANG Hai-dong
Keywords: scrotum; basal cell carcinoma; risk factors
B
asal cell carcinoma (BCC) is the most common
cancer of the skin. However, BCC occurring on
non-sun-exposed sites, especially the genital regions such
as scrotum and labia, are very rare. An estimated annual
incidence of basal cell carcinoma of the scrotum is 1 per
1 000 000 population.1 Here, we report a man with scrotal
BCC with the lesion for 51 years, the longest one in the
documents. He was successfully treated by
circumferential excision.
CASE REPORT
A 74-year-old Chinese man was hospitalized with the
symptom of itching on the skin of the scrotum for 51
years. Initially, an erythema with itching and
desquamating was found on the middle of the bottom of
the scrotum in 1953. Then the patient left China and went
for working as a photographer for 2 years in Africa
without consulting his doctor. However, the erythema was
broken, an ulcer 2 cm in diameter was surrounded by a
well defined pearly border in the third year after onset.
The necrosis tissues with lots of white and yellow
mucous fluids bring the ulceration odd smell. The
situation got worse in summer and some relief in winter.
As a photographer, he had the history of benzolism. He
did not have history for sexually transmitted disease,
trauma to this area, radiotherapy and chemical or arsenic
exposure. No enlarged lymph node was found in inguinal
areas, and no positive findings of thoracic X-ray, pelvic
CT and abdominal B-ultrasonic scanning. The lesion was
excised with a margin of 2.0 cm of normal skin.
Pathological examination of the specimen verified that
was a basal cell carcinoma (nodular type, Figure). No any
positive findings were found in thoracic X-ray, pelvic CT
and abdominal B-ultrasonic scanning during 3 years’
follow-up.
DISCUSSION
Scrotal carcinomas are uncommon, and less than 5% of
scrotal carcinomas are basal cell origin.2 Although basal
cell carcinoma occurs very rarely in pudendum, to our
knowledge, 47 cases of scrotal BCC have been reported
as series or clinical case reports mainly in the urological
and dermatological literatures.1-15 The average age of the
patients was 66.6 (42–82) years. Clinically the lesions
presented mainly as nodular or ulceration and there was a
Figure. Peripheral palisading basaloid cells invade the deep
dermis (HE, original magnification ×200).
wide variation of 3 months to 51 years, in the duration of
the lesion before presentation.3 Based on data collected in
those literatures, 5 (10.6%) patients have been reported to
develop metastatic scrotal BCC. Metastasis arose 2–3
years after the onset of the primary disease which is
shorter than the average of 11 years mentioned earlier in
metastatic BCC at other sites.14
Exposure to ultraviolet (UV) radiation is considered to be
the major etiological factor in the development of
BCC,3,16,17 and the vast majority of lesions occur on the
sun-exposed sites such as head and neck. However, the
causative factors of BCC in areas not exposed to the sun
are still unclear. It is possible that a generalized reduction
in immunosurveillance with advancing age, or following
excessive UV exposure elsewhere, predispose to their
development.9,11 For example, renal transplant patients
have a 10-fold increased risk of developing BCC as
compared with the general population.17 Whether or not,
ultraviolet is the most important factor in lesion
development and progression. However, the rationale of
the impairment of immune surveillance caused by
ultraviolet radiation is still unclear.
The study of human papillomavirus (HPV) in BCC
specimens has been limited. About 10 cutaneous biopsy
DOI: 10.3760/cma.j.issn.0366-6999.2010.19.026
Urology Department, Beijing Jishuitan Hospital, Beijing 100035,
China (Wang JW, Man LB, He F, Huang GL, Li GZ and Wang
HD)
Correspondence to: Dr. MAN Li-bo, Urology Department, Beijing
Jishuitan Hospital, Beijing 100035, China (Email: mmanlibo@
sohu.com)
Chinese Medical Journal 2010;123(19):2748-2749
samples of scrotal BCC were tested for the presence of
human papilloma virus by in situ hybridization or
PCR,10,18 and failed to reveal DNA of HPV types.
Although HPV DNA has been occasionally detected in
reports of single cases or small series of patient with
BCCs on sites other than the scrotum, a significant
relationship between HPV and BCCs in the general
population has yet to be established.
2749
4.
5.
6.
7.
Human patched, a developmental gene playing an
important role in regulation of cell growth and
differentiation after embryogenesis, is mutated in BCC,16
and inactivation of this gene is probably a necessary if not
sufficient step for tumor formation. Mutations of P53
have been documented in up to 40% of studied BCCs,
72% of the mutations bear the signature of UV light
induction.19
Scrotal carcinoma was the first recognized occupational
cancer as “Chimney sweeper’s Cancer”.17 The disease
was described in chimney sweeps and related to exposure
to soot and dust which contain the active agent as 3–4
benzpyrene. A variety of products, such as mineral oils,
coal tar, petroleum, arsenic, solvents and wool oil, have
been reported to be associated with scrotal BCC. The
history of benzolism of this patient may indicate benzene
is one of the important additional risk factors. Moreover,
radiotherapy, long-standing fungal infection and chronic
irritation may also be involved in carcinogenesis of the
scrotum.
Although some reports revealed the correlation between
chronic ulcer, inflammation and the risk for development
of BCCs or other skin cancer, no such report found as to
chronic ulceration or inflammation on scrotum.20,21 We
know most malignancies arising from chronic wounds
take the form of squamous cell carcinoma, however, a
study of 125 cases found that 25% patients with BCC had
concomitant chronic venous stasis, suggesting a
relationship between venous disease and BCC.22
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Surgical extirpation is currently the standard of cure for
BCC.17 Wider excision than the currently recommended
4-mm clinical margins may be required for removing
tumor lesion more effectively and completely.23
Retrospective study showed a 5-year recurrence rate of
26% for BCC not completely excised compared with a
rate of 14% for BCC completely excised. 17
19.
20.
21.
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(Received May 31, 2010)
Edited by GUO Li-shao