Two cases of rare presentation of basal cell and squamous cell carcinoma on the hand

Neeta Kumar, YK Saxena

 Department of Radiotherapy, Lady Hardinge Medical College and associated Smt. S. K. Hospital, New Delhi, India

Correspondence Address:
Neeta Kumar
C/O Dr. Pratik Kumar, Dept of NMR, AIIMS, New Delhi - 110 029
India

Introduction

Both basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are common in whites but rare in blacks and Indians. Contrast to one-third malignancies of non-melanoma skin cancer in whites, in Indians only 1 to 2 percent of cancer occurs on skin. Also, these cancers mainly affect sun exposed areas like neck and face (88--90%). [1] Here we present the two cases of SCC and BCC both occurring simultaneously over the same hand. This unilateral distribution is a rare phenomenon and has not been documented earlier.

Case 1

A 39-year-old Muslim male, having albinism by birth; fruit hawker by occupation came with the complaint of a small pea-sized, purple, pigmented lesion, covered with transparent scales and centrally depressed area on dorsum of left arm gradually increasing in size for 8-9 years. He also had large keratotic bleeding points over dorsal surface of the left middle finger and developed lymph node mass in left submandibular region for 2-3 years. In addition he had various small keratotic eruptions all over both hands, face and neck for past 9-10 years. Initially all the lesions over skin, face and neck were asymptomatic. But for last 6-7 months the lesions on the arm and left submandibular lymph node mass were painful. Local application of various medicines including 8-methoxy psoralen and UV radiation brought no relief. Upon histopathological examination BCC was confirmed and staged as T2N1M0 4x6 cm[2] sized hard fixed mildly tender lymph node with well defined margin and normal skin overlying left sub mandibular region was proved to be metastatic basal cell carcinoma on biopsy.

Edge biopsy of left middle finger lesion revealed it to be squamous cell carcinoma. Clinical examination found it in stage T2N0M0.

He had occupational sun exposure as a fruit vendor since 19 years of age. He had 240 working days per year on an average and received about 8 hrs of sun exposure during each working day. This accounts 38, 400 accumulated hours of sun exposure.

During investigations he was found normotensive, nondiabetic person with negative HIV test. His malignancy workup revealed normal hoemogram, blood chemistries, liver and kidney function tests. His chest X-ray, ultrasonography did not reveal any abnormality.

Case 2

This 55-year-old Hindu male was also a fruit hawker and was having wheatish skin complexion without albinism. He attended skin OPD with complaint of slow growing swelling with central dipping over base of the right thumb since 8-9 years which recently started causing pain. He was also having actinic eruptions with itching sensastion for 9-10 years and did not respond to various treatments including 8-methoxy psoralen and U. V radiation applied on it for about an year as dermatologist suspected it to be psoriasis. One ulcerative growth also started over his ventral surface of right forearm 2 years back and grew faster to become cauliflower-like. Physical examination revealed a healthy male with actinic eruptions over both arms and one large (4x6cm2) exophytic growth over ventral surface of right forearm and pedunculated mass 2x3 cm2 over dorsal surface of the base of right thumb.

Sensorimot or functions of thumb were not hampered. Edge biopsy of exophytic growth revealed squamous cell carcinoma and FNAC of pedunculated growth was BCC.

The work up of both cases showed normal haemogram, blood chemistries, liver and kidney function tests. X-ray of chest, ultrasound and CT scan could not reveal any lyrnphadenopathy and organomegaly. Here presented both cases were middle aged fruit vendors from 19-20 years of their ages. Both had U. V radiation induced actinic keratoses for last 9-10 years period. Other risk factors for BCC and SCC such as burn, trauma, chronic irritation, contact with chemical carcinogen, immunological factors, viruses, DNA repair defect, were ruled out in both these cases.

Both our cases had no similar history in family. Both had history of BCC for 8-9 years and SCC for about 2-3 years. Actinic eruptions were present from initiation of malignant changes in both the cases. ln the differential diagnoses warts, keratoacanthoma, molluscum contagiosum, eczema, psoriasis, Bowen′s disease, Kaposi′s sarcoma, Bazex syndrome (presenting as follicular atrophoderma with multiple basal cell carcinoma on face and extremities), linear unilateral basal cell nevus etc were ruled out in both cases. Wide surgical excision of big lesions and local application of 5-FU on rest lesions gave remission apparently in both cases. Case-1 took 20 years of exposure while case-2 who was not having albinism took 36 years of sun exposure to develop cancer in same occupation.

Discussion

Hyde (1906)[2] recognised UV radiation as a carcinogen which is currently believed to be the most important cutaneous carcinogen with both intiating and promoting effects especially at 290-320 nm wave length. Potential increase in environmental UV radiation due to depleted ozone layer in space may increase the incidence of skin cancer. UV radiation induces a specific clone to suppressor T lymphocyte. Presence of UV induced suppressor cells are associated with rapid and accelerated development of tumour on consequent exposure. This causes structural and functional damage to Langerhans cells as well as production of free radical induced alteration in DNA.

Both the present cases were fruit hawkers with almost similar work-style and sun-exposure hours. Case I with albinism took 38, 400 accumulated hours of sun exposure in comparison to 67, 000 accumulated hours in case II without albinism to develop the skin cancer. This indicates the significance of tanning capacity viz-a-viz development of skin cancer and this tanning capacity is said to be inversely related to the risk of carcinogenesis. There is a great variance among reports of risk to sun exposure for both BCC and SCC in literature and it ranges 1. 4 times risk at about 35, 000 hours of sun-exposure in an Australian study and 1. 6 times risk for about 54, 000 hours for SCC in an European study. [3],[4] Environmental and occupational parameters along with pigmentary factors of skin has an important role to play in this context. However, it has been suggested that even relatively short period of sun-exposure has associated risk of BCC and beyond a certain level of exposure this risk does not increase further, whereas development of SCC requires prolonged exposure to sun-light. [4],[5]

The contribution of SCC in the development of BCC simultaneously by acting synergistically with actinic damage has been suggested in some observations and it seems to operate here as well.

Site of BCC was also unusual in both present cases as BCC is quite uncommon on dorsal forearms or hands despite the fact that these parts of the body receive a significant amount of sun--radiation. [1] BCC has a particular predilection for upper central part of the face as occurrence site, [4] and as large as 88% BCC may be found in head and neck region.

Summarily both these cases had given us opportunity to evaluate the role of carcinogens, etiopathogenesis and behaviour of a rare presentation of non-melanoma skin cancer in context of a tropical environment.

1.	Fink JA, Akelman E. Non melanotic malignant skin tumors of the hand. Hand Clin 1995;11: 255- 264. [Google Scholar]
2.	Hyde JN. Influence of light in the production of the cancer of the skin. Am J Med Sci 1906;131 :1-22. [Google Scholar]
3.	Paymaster JC, Talwalkar G V, Gangadharan P Carcinomas and malignant melanomas of the skin in western India. J Royal College of Surgeons 1971; 16:166-173. [Google Scholar]
4.	Rosso S, Zanetti R, Martinez C, et al. The Multicentre South European Study' healios'. II: Different sun-exposure pattern in the aetiology of basal cell and squamous cell carcinoma of the skin. Br J Cancer 1996;731447-1454. [Google Scholar]
5.	Vitasa BC, Taylor HR, Strickland PT, et al. Association of nonmelanoma skin cancer and actinic keratosis with cumulative solar ultraviolet exposure in Maryland water men. Cancer 1990;65:2011-2017. [Google Scholar]