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52 PhiliPPine Journal of otolaryngology-head and neck Surgery
CASE
A 52-year-old non-diabetic female presented with a 20-year history of hyperpigmented
lower lip ulcer which gradually involved the mentum, and on punch biopsy revealed basal cell
carcinoma. As a housewife, she had no excessive exposure to sunlight or radiation, and no family
history of cancer. On examination, a non-healing ulcer with hyperpigmented rolled-up borders
had eroded the lower lip and mentum, extending into the alveolus and mandible. Wide excision
with segmental mandibulectomy, bilateral supraomohyoid neck dissection and pectoralis major
myocutaneous flap reconstruction were performed and radiotherapy scheduled 6 weeks after
surgery.
Basal cell carcinoma (BCC) is the most common skin malignancy with estimated annual
incidences of 1 million, over 500,000 and 190,000 in the USA, Europe and Australia, respectively1.
More than 60% of all skin cancers in the Philippines are basal cell carcinoma2.
A slow-growing, locally invasive malignant epidermal tumor, it infiltrates tissues in a
three-dimensional contiguous fashion through the irregular growth of sub-clinical finger-
like outgrowths3. It rarely metastasizes, with morbidity related to local tissue invasion and
destruction4. Most can be treated easily with a high cure rate; however, there are some lesions
that are much more aggressive. Advanced basal cell cancers may be arbitrarily defined as tumors
> 2cm; that invade bone, muscle, or nerves; that have lymph node metastasis; or that require
removal of a cosmetic or functional unit5. Complications are highlighted when lesions occur in
the face, particularly near orifices of the eyes, nose, ears and mouth. As with lesions close to vital
structures, these pose a greater clinical challenge4.
BCCs develop from pluripotential cells in the basal layer of the epidermis. Ultraviolet-induced
mutations in the TP53 tumor-suppressor gene, which resides on chromosome arm 17p, have been
implicated in some cases of BCC. Furthermore, the loss of inhibition of the patched/hedgehog
pathway also appears to play a role in development of BCCs and influences differentiation of a
variety of tissues during fetal development6.
Recognizing the various histological subtypes of BCC is important because aggressive therapy
is often necessary for some variants3. Nodular BCC appear as waxy or pearly papules with central
depression, erosion or ulceration, bleeding or crusting, and rolled (raised) borders. Tumor cells
typically have large, hyperchromatic, oval nuclei and little cytoplasm. Cells appear uniform, with
few mitotic figures. Pigmented BCC contain increased brown or black pigment and are most
common in individuals with dark skin. Superficial BCC appears as scaly patches or papules that
are pink to red-brown, often with central clearing, commonly with a threadlike border, may mimic
psoriasis or eczema, but they are slowly progressive. Micronodular BCC, an aggressive subtype,
is not prone to ulceration, it may appear yellow-white when stretched, firm to touch, and may
have a seemingly well-defined border. Morpheaform and infiltrating BCC present with sclerotic
Basal Cell Carcinoma of the Lip and Mentum
Florence Yul N. Saquian, MD
Department of Otorhinolaryngology
Philippine General Hospital
University of the Philippines Manila
Correspondence: Florence Yul N. Saquian, MD
Department of Otorhinolaryngology
Ward 10, Philippine General Hospital
Taft Ave., Ermita, Manila 1000
Phone (632) 526 4360 Fax (632) 525 5444
Email: goldsaquian@yahoo.com Philipp J Otolaryngol Head Neck Surg 2006; 21 (1,2): 54-56 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
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PhiliPPine Journal of otolaryngology-head and neck Surgery 53
(scarlike) plaques or papules with ill defined borders extending beyond
clinical margins. Ulceration, bleeding, and crusting are uncommon. It
may be mistaken for scar tissue7.
Treatment is based on clinical diagnosis and a pre-operative
biopsy3. A complete history relating the onset and rate of growth of
the lesion as well as sun and radiation exposure should be taken. It is
also necessary to examine and palpate the extent of lesion, with special
attention given to high risk areas. Large extensive lesions may require
radiographic examinations such as MRI or CT to assess soft tissue or
bony involvement, respectively8. The most appropriate treatment
options should be discussed with the patient. Co-morbidities may
influence the choice between surgical and non-surgical treatment.
Elderly patients with symptomatic and high-risk tumors may opt for
less aggressive treatment options, which are palliative in intent3.
Various surgical and non-surgical treatments are currently available.
Non-surgical techniques include thrice-weekly intralesional injection of
human recombinant interferon α-2 for three weeks for low-risk BCCs.
This option is still investigational, unlikely to benefit high-risk tumor
patients, and may be expensive and time-consuming3. Photodynamic
and oral retinoid therapies are other options undergoing investigation
and are not yet widely available3. Radiotherapy is an extremely useful
form of treatment, but faces the same problem of accurately identifying
tumor margins as standard excisional surgery9. It has been used to
treat many types of BCC, including those with bony and cartilaginous
involvement, but is less suitable for treating large tumors in critical
sites, as these are often resistant and require radiation doses that closely
approach tissue tolerance3.
Topical treatment options have been used in patients with
contraindications for surgery and with lesions not entirely amenable
to extirpative excision. 5-flourouracil (5FU) has been used for low-
risk, extrafacial BCC with unexciting results2,3. Imiquimod (an immune
response modifier) 5% cream has been used alone and as adjunct to
Mohs’ microsurgery for the treatment of BCC, with reported regression
but not complete eradication of the tumor. Topical neomycin was also
reported to cause regression in one case3. A prospective study involving
topical application of Cashew nut extract (DeBCC®) on 14 patients with
BCC in different parts of the face had no detected recurrences on follow
– up periods of 11 – 49 months (28.7 months)2.
Excisional surgery removes the tumor entirely with a peripheral
margin of normal tissue. For small lesions in the face, wide excision with
adequate margins is sufficient, and various reconstructive methods
can be used depending on the location of the lesion. Larger lesions
which involve deeper structures such as bone, warrant more radical
approaches to ensure adequate margins10. In our patient, infiltration
of skin, mucosa, muscle, alveolus and mandible led to a segmental
mandibulectomy and subsequent reconstruction.
Mandibular reconstruction aims to reconstitute the mandibular arch.
Anterior defects result in the worst functional defects with the so-called
“Andy Gump” deformity11. The preferred method for reconstructing
anterior mandibular defects uses osseocutaneous free flaps, with the
fibular free flap being most popular. The peroneal vessels act as the
major blood supply to the periosteum in a segmental fashion allowing
Silver anniverSary iSSue vol. 21 noS. 1 & 2 January –June; July – december 2006
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54 PhiliPPine Journal of otolaryngology-head and neck Surgery
for multiple osteotomies, which are required for bone shaping with
anterior defects. For reconstruction of the intra-oral structures, a large
soft tissue paddle based on septal and intramuscular perforators can be
used, and osteointegrated implants can be placed in the bone graft12.
Another option for reconstruction is a pedicled flap, and the more
commonly used is the pectoralis major osteomyocutaneous flap. Its
dominant pedicle is the thoracoacromial artery and vein that runs on
the undersurface of the muscle. The underlying rib is also harvested to
reconstitute the mandible13. The advantages of pedicled flaps include
less morbidity, shorter operative time, and a more definitve blood
supply, which ensures the survival of the skin flap and bone11. However,
these flaps tend to be difficult to harvest and have limited arcs of rotation
and limited bone graft mobility relative to the soft tissue portion of the
flap. The blood supply of the bony portion is often tenuous following
transfer, and the lack of bony bulk limits dental rehabilitation12.
Postoperative management of flap reconstruction includes gentle
cleansing and application of topical antibiotics. Diligent oral hygiene
offsets potential complications from post-operative drooling. Partial
or total flap failure is a common postoperative concern. Partial distal
flap necrosis can be managed expectantly. Cyanosis may be due to
excessive wound tension or vascular pedicle compromise, and should
be explored as necessary15.
ACKNOWLEDGEMENT:
We thank Dr. Camille Sidonie A. Espina for providing the case for discussion.
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