Histology is important in cutaneous radiation to ensure the
diagnosis is correct since different neoplasms are treated using different
protocols. It is also important to ensure the lesion is encompassed in the
field of therapy and that the energy and penetration is appropriate for the
neoplasm at hand. For instance, superficial lesions may be treated differently
than deep lesions.
The goals of cutaneous radiation therapy are to ensure the
treatment will eradicate the cancer while delivering a therapeutic dose with
minimal side effects. It is also very important that cutaneous radiation
therapy not induce neoplasia.
This article focuses on several examples of challenges in
diagnosis including metatypical basal cell carcinoma, combined squamous cell
carcinoma and basal cell carcinoma, squamous cell carcinoma in situ, primary
cutaneous carcinosarcoma, trichilemmal verruca, and inverted follicular
keratosis. Additionally, the benefits and challenges of stereotactic radiation
therapy (SRT) are touched upon.
Metatypical basal
cell carcinoma is a variant of a basal cell carcinoma (BCC) that is an
intermediate between nodular cystic BCC and squamous cell carcinoma (SCC).
Histologically speaking, the cells are enlarged and are pleomorphic while
lacking peripheral palisading. Abundant basophilic cytoplasm is present, but
there is often no retraction artifact and a fibrous stoma may not be present.
Metatypical BCC may simulate Merkel cell carcinoma, and even though it looks dangerous,
it behaves like BCC. In terms of treatment, metatypical BCC is amenable to
stereotactic radiation therapy.
Stereotactic radiation therapy—an advanced and modernized
form of radiation therapy—allows high doses of radiation to be delivered to a
small, focused area. It differs from conventional radiation in that it is able
to exclude the surrounding normal tissues. SRT uses high-energy x-ray beams to
shrink or control the growth of abnormal cells by either killing the cells
directly or by disrupting the ability of the cells to grow.
In combined squamous
cell carcinoma and basal cell carcinoma, an initial biopsy will show SCC or
BCC, but upon subsequent evaluation of the excision specimen, there is evidence
of both BCC and SCC. There are three possible reasons for this:
1. Collision tumor of coincidental BCC and SCC
2. Altered differentiation of BCC on
recurrence may assume more aggressive histologic characteristics with squamous
appearance
3. True basosquamous differentiation
It is
important to recognize these reasons and ensure the biopsy is representative to
avoid under-treatment.
Squamous cell carcinoma in situ is generally
easily diagnosable even though there may be several variants clinically and histologically.
One variant is pagetoid Bowen’s disease, which may stimulate Paget’s disease
and melanoma in situ. SCC in situ
may be able to be treated with a superficially penetrating beam. The most
important challenge in diagnosing SCC in situ is to define the border, which
may be very indistinct.
Primary cutaneous carcinosarcoma is a
rare, biphasic tumor of malignant epithelial and mesenchymal components. The
epithelial aspect may be keratinocytic, resembling BCC or SCC or adnexal. The
sarcomatous component may resemble atypical fibroxanthoma,
osteosarcoma, chondrosarcoma, leiomyosarcoma, rhabdomyosarcoma, or
fibrosarcoma. Keratinocytic carcinosarcoma has a better prognosis than adnexal
types (70% versus 25% 5-year survival rate). Primary cutaneous carcinosarcoma
is a more aggressive lesion than SCC that requires surgical excision and not
SRT.
Trichilemmal verruca may stimulate BCC
histologically while verruca with squamous eddies (inverted follicular
keratosis) may simulate SCC histologically. Trichilemmal verruca presents as a
pink to whitish scar-like plaque of the trunk, extremities, head, and neck
area. It is important not to
over-diagnose, which could lead to over-treatment.
Inverted follicular keratosis (verruca with
squamous eddies) may be confused with SCC because of whorls of
keratinocytes in nests that may be asymmetrically distributed. There are
usually few if any mitoses present with no atypia. Inverted follicular
keratosis is clinically usually not suggestive of SCC. If it doesn’t fit
clinically and diagnosis comes back malignant, be sure to obtain a second
opinion.
SRT is an
excellent treatment option for many different conditions, but it does come with
challenges. For example, reimbursement pressures and “turf” wars create
unfortunate circumstances for dermatologists who want to use SRT. Some use SRT inappropriately due to
inadequate training and supervision. To avoid confusion as to when to use SRT, we
at Cockerell Dermatopathology place a note on the report stating that the
neoplasm in question is one that could be treated with SRT appropriately.
An accurate
and complete diagnosis is essential to SRT use. If you perform SRT, establish a
relationship with a dermatopathology laboratory that understands SRT and will
be involved in the treatment planning.
References
Cockerell C. (2015). The importance of histopathology in
cutaneous radiotherapy. [PowerPoint Presentation]
Stony Brook Cancer Center (2015). SRS and SRT: Stereotactic RadioSurgery
and RadioTherapy. Retrieved December 2, 2015, from https://cancer.stonybrookmedicine.edu/diagnosis-treatment/radiation-oncology/treatment-technology/srs.