|Year : 2010 | Volume
| Issue : 2 | Page : 115-118
|Basal cell carcinoma over chest wall (Sternum) treated with dufourmentel flap: Report of a case with review of literature
Vishal K Jain1, Sachin S Verma2, Archana S Verma3, Kavita R Munjal4, Bhavesh Swarnakar5
1 Department of Surgery, SAIMS Medical College, Indore, India
2 Department of Plastic Surgery, Bombay Hospital, Indore, India
3 Department of Medicine, MGM Medical College, Indore, India
4 Department of Pathology, SAIMS Medical College, Indore, India
5 Department of Skin and Veneral Disease, Kaya Clinic, Indore, India
Click here for correspondence address and email
|Date of Web Publication||4-Sep-2010|
| Abstract|| |
Basal cell carcinoma (BCC) is the most common malignancy of the skin, accounting for approximately 70-80% of all cutaneous cancers. The commonest site of basal cell carcinoma is the face; 80% arise above a line from the corner of the mouth to the ear lobe. The lifetime ultraviolet radiation damage is the most important factor in its pathogenesis, and the vast majority is observed on sun-exposed skin. BCCs can develop in sun-protected areas, but its occurrence is rare. Here we are reporting a case of rare site of BCC with review of literature in a 65-year-old male who presented with a lesion over anterior chest wall. A clinical diagnosis of BCC was made and patient was subjected to excision biopsy. Biopsy revealed it to be a BCC and it was treated with a Dufourmentel flap.
Keywords: Basal cell carcinoma, dufourmentel flap, rhomboid transposition flap, sternum
|How to cite this article:|
Jain VK, Verma SS, Verma AS, Munjal KR, Swarnakar B. Basal cell carcinoma over chest wall (Sternum) treated with dufourmentel flap: Report of a case with review of literature. J Cutan Aesthet Surg 2010;3:115-8
|How to cite this URL:|
Jain VK, Verma SS, Verma AS, Munjal KR, Swarnakar B. Basal cell carcinoma over chest wall (Sternum) treated with dufourmentel flap: Report of a case with review of literature. J Cutan Aesthet Surg [serial online] 2010 [cited 2019 Apr 22];3:115-8. Available from: http://www.jcasonline.com/text.asp?2010/3/2/115/69026
| Introduction|| |
Basal cell carcinoma (BCC) is the most common malignancy of the skin, accounting for approximately 70-80% of all cutaneous cancers.  The lifetime ultraviolet radiation damage is the most important factor in its pathogenesis, and the vast majority is observed on sun-exposed skin, with nearly 85% occurring in the head and neck.  Although BCCs can develop in sun-protected areas, genital involvement is very rare, accounting for fewer than 1% of all cases.  Here we are reporting anterior chest wall (sternal region) as a rare site of occurrence of BCC. The surgical management of the condition is also discussed.
| Case Report|| |
A 65-year-old male patient presented to the department of dermatology with a lesion over his anterior chest wall (sternal region) of 2 years. It was painless, with no other associated symptoms like itching or bleeding. Lesion was gradually increasing in size. A provisional clinical diagnosis of BCC [Figure 1] was made and referred to surgery department for excision.
Patient was planned for surgery and was subjected to excision biopsy [Figure 2] under local anesthesia. Lesion was excised completely taking wide margins all around. A defect of 5 cm Χ 4 cm was created [Figure 3]. Being a large defect, it could not be closed with primary repair; therefore it was covered with local duformentel flap/rhomboid transposition flap [Figure 4]. Postoperative course was uneventful and stitches were removed on 10th postoperative day. Histopathology report revealed it to be a BCC of 2.5 cm Χ 2.5 cm Χ 1 cm with free margins. The patient is on regular follow up for 1 year and is currently asymptomatic.
| Discussion|| |
BCC is one of the commonest of all malignant tumors, but it accounts for less than 1% deaths due to malignant disease. It has a very low rate of metastasis - the incidence is ranging from 0.0028% to 0.54%.
There has been a progressive increase in the incidence of skin cancers, particularly that of cutaneous melanomas over the last few decades. 
Both BCC and squamous cell carcinoma (SCC) are common in whites but rare in blacks and Indians. Contrast to one-third malignancies of nonmelanoma skin cancer in whites, in Indians only 1-2% of cancer occurs on skin.  Also, these cancers mainly affect sun-exposed areas like neck and face (88-90%). 
BCC is the commonest form of skin cancer worldwide, but various studies from India have consistently reported SCC as the most prevalent skin malignancy.  Although complete data of incidence are not available, various cancer registries in India reported cumulative incidence of skin cancer varying from 0.5 to 2 per 100 000 population. 
The commonest site of BCC is the face; 80% arise above a line from the corner of the mouth to the ear lobe. Occurrence of BCC on the scrotum is extremely rare, accounting for less than 0.05% to 0.19% of all BCC cases. ,, Very few cases of BCC on the pudendum have been reported in the literature. ,,,, Literatures cite posterior neck,  scrotum,  palm,  nipple,  areola,  shotgun scar,  buttock, perineum, axilla, genital region,  conjunctiva  and Submandibular gland  as unusual or rare site of BCC. We are reporting another rare site as anterior chest wall (sternal region). Only few cases have been reported in the literature of BCC on chest wall. ,
Although, surgery is the mainstay of treatment for all the three common skin cancers, the extent of surgery, both local and regional, varies. Adequate surgery is most important to prevent recurrence. Adequate surgical margin is very important, particularly for melanoma, where margin depends upon the thickness (depth of infiltration) of cancer. 
Simple surgical excision is effective for all types of BCCs. The cure rate approaches 99% when the histological margins are clear. Recommended margin is 5 mm; recurrence is more when the margin of resection is less than 4 mm. , Moh's micrographic surgery has been implied for recurrent lesions or those located in vital areas such as eyelid, digits, penis, nose, etc., but it requires a dedicated surgeon pathologist and onsite facility for pathology examination, which is not present is most of the centers.
Surgical margin and possibility of requirement of reconstruction are directly related to each other and there is always a critical trade-off between them. Any compromise of the adequacy of surgical margin increases the chances of recurrence. A reconstructive procedure is always preferred to a potentially suboptimal surgical excision.  Here in our case, we used dufourmental flap to close the defect.
A rhombus is classically defined as an oblique-angled equilateral parallelogram, whereas a rhomboid differs in that it has uneven adjacent sides. The term rhomboid is frequently used in facial reconstruction literature to mean either rhombus like or to describe one of the popular transposition flaps used to repair rhombus-shaped defects.
In 1946, Limberg first described a technique for closing a 60° rhombus-shaped defect with a transposition flap. Dufourmentel modified this technique in 1962 to close defects with any acute angle. Webster published a third significant modification in 1978.  The Webster, or 30° flap, uses a 30° angulation of the distal flap end along with an M-plasty closure at the defect base.
Transposition flaps are useful when the size or shape of a lesion does not permit direct closure using a standard fusiform incision. For example, attempting to close a wide defect primarily requires an ellipse with either long limbs or blunt angles. Lengthy limbs create long scars and remove healthy tissue unnecessarily, whereas blunt ends often create an unpleasant standing-cone or dog-ear appearance.
Considerations when designing any local flap are lesion diameter, amount of normal skin that needs to be discarded, scar orientation with respect to relaxed skin tension lines, arc of skin rotation, and the vector of maximal tension after closure. Rhomboid flaps have been used in reconstruction of the cheek, temple, lips, ears, nose, chin, eyelids, and neck. The aesthetic and mechanical properties of these flaps, however, make them especially useful for reconstruction of small defects in the lower cheek, mid-cheek, and upper lip.
Rhomboid flaps are full-thickness local flaps with a random blood supply. Rather than depending on an axial blood vessel for nourishment, rhomboid flaps rely upon the dermal-subdermal plexus of blood vessels.
The surgeon must not violate the dermis when undermining this or any other random flap because the chances for partial or complete flap necrosis increases.
The role of adjuvant therapy is limited in skin cancers. Although radiotherapy can be used as primary mode of treatment for BCC and SCC located at certain sites such as the nose, lip, eyelid, and canthus, where surgery is either technically difficult or likely to yield poor cosmesis. Radiotherapy has a very limited role in the management of melanoma.  Postoperative radiotherapy is indicated in patients with advanced lesions, positive margins, lymph node metastasis, in-transit metastases in melanoma, and for palliation. 
| Conclusion|| |
BCC is a common surface malignancy and thus more amenable not only to early detection, but also to a potential cure. Face remains the most common site of BCC. As in our Case, a high index of suspicion is required to diagnose BCC at rare sites like anterior chest wall. With the help of appropriately designed flaps like Dufourmentel flap, good primary closure of defect with excellent cosmetic results can be achieved.
| References|| |
|1.||Olbricht S, Noe JM. Cutaneous carcinomas. In: Georgiade GS, Riefkohl R, Barwick W, editors. Textbook of plastic, maxillofacial and reconstructive surgery. 2 nd ed. Baltimore: Williams Wilkins; 1992. p. 141-7. |
|2.||de Giorgi V, Salvini C, Massi D, Raspollini MR, Carli P. Vulvar basal cell carcinoma: Retrospective study and review of literature. Gynecol Oncol 2005;97:192-4. |
|3.||Mulayim N, Foster Silver D, Tolgay Ocal I, Babalola E. Vulvar basal cell carcinoma: Two unusual presentations and review of the literature. Gynecol Oncol 2002;85:532-7. |
|4.||Howe HL, Wingo PA, Thun MJ, Ries LA, Rosenberg HM, Feigal EG, et al. Annual report to the nation on the status of cancer (1973 through 1998), featuring cancers with recent increasing trends. J Natl Cancer Inst 2001;93:824-42. |
|5.||Kumar N, Saxena YK. Two cases of rare presentation of basal cell and squamous cell carcinoma on the hand. Indian J Dermatol Venereol Leprol 2002;68:349-51. [PUBMED] |
|6.||Fink JA, Akelman E. Nonmelanotic malignant skin tumors of the hand. Hand Clin 1995;11:255-64. |
|7.||Godbole VK, Toprani HT, Shah HH. Skin cancer in Saurashtra. Indian J Pathol Bacteriol 1968;11:183-9. |
|8.||National Cancer Registry Programme, Indian Council of Medical Research. Consolidated report of the population based cancer registries;1990-96. |
|9.||Kinoshita R, Yamamoto O, Yasuda H, Tokura Y. Basal Cell Carcinoma of the scrotum with lymph node metastasis: Report of a case and review of the literature. Int J Dermatol 2005;44:54-6. |
|10.||Gibson GE, Ahmed I. Perianal and genital basal cell carcinoma: A clinicopathologic review of 51 cases. J Am Acad Dermatol 2001;45:68-71. |
|11.||Park SH, Lee SY, Kim SM, Choi HJ, Yum SK, Kim Hu, et al. A case of basal cell carcinoma on post traumatic scar of the scrotum. Korean J Dermatol 2006;49:1151-3. |
|12.||Sundaram S, Kuruvilla S, Rekha A, Ravi A. Common tumour, uncommon site. Indian J Surg 2004;66:240. |
|13.||Izikson L, Vanderpool J, Brodsky G, Mihm MC Jr, Zembowicz A. Combined basal cell carcinoma and Langerhans cell histiocytosis of the scrotum in a patient with occupational exposure to coal tar and dust. Int J Dermatol 2004;43:678-80. |
|14.||Rapis T, Zanakis SN, Letsa IF, Karamanos AP. Basal cell carcinoma of the posterior neck, reconstructed with lower trapezius island musculocutaneous flap: Case report in an unusual site of occurrence. J BUON 2003:397-401. |
|15.||Schleicher SM, Milstein HJ, Ilowite R. Basal cell carcinoma of the scrotum. Cutis 1997;59:116. |
|16.||Salomγo P, Kopke LF, MacHado-Pinto J. Palmar basal cell carcinoma: Case report and literature review. Dermatol Surg 1999;25:908-10. |
|17.||Avci O, Pabuηηuoπlu U, Koηdor MA, Unlό M, Akin C, Soyal C, et al. Basal cell carcinoma of the nipple - an unusual location in a male patient. J Dtsch Dermatol Ges 2008;6:130-2. |
|18.||Ferguson MS, Nouraei SA, Davies BJ, McLean NR. Basal cell carcinoma of the nipple-areola complex. Dermatol Surg 2009;35:1771-5. |
|19.||Kandamany N, Monk B. Basal cell carcinoma presenting late in a shotgun scar. Am J Clin Dermatol 2009;10:271-2. |
|20.||Betti R, Bruscagin C, Inselvini E, Crosti C. Basal cell carcinomas of covered and unusual sites of the body. Int J Dermatol 1997;36:503-5. |
|21.||Apte PV, Talib VH, Patil SD. Basal cell carcinoma of conjunctiva. Indian J Ophthalmol 1975;23:33-4. [PUBMED] |
|22.||Sharma R, Saxena S, Bansal R. Basal cell adenocarcinoma: Report of a case affecting the submandibular gland. J Oral Maxillofac Pathol 2007;11:56-9. |
|23.||Ηelebi C, Latifoglu O, Demirkan F, Cenetoglu S, Atabay K, Uluoglu O. Extensive basal cell carcinoma on the right thoracic wall and its distant metastases. Eur J Plast Surg 1995;18:175-8. |
|24.||Lorenzini M, Gatti S, Giannitrapani A. Giant basal cell carcinoma of the thoracic wall: A case report and review of the literature. Br J Plast Surg 2005;58:1007-10. |
|25.||Morton DL, Wanek L, Nizze JA, Elashoff RM, Wong JH. Improved long-term survival after lymphadenectomy of melanoma metastatic to regional nodes: Analysis of prognostic factors in 1134 patients from the John Wayne Cancer Clinic. Ann Surg 1991;214:491-9. |
|26.||Gendleman MD, Victor TA, Tsitsis T. Nonmelanoma skin cancer. In: Winchester DP, Jones RS, Murphy GP, editors. Cancer Surgery for the general Surgeon. New York: Lippincott Williams and Wilkins; 1999. p. 111-35. |
|27.||Goldberg LH. Basal cell carcinoma. Lancet 1996;347:663-7. |
|28.||van Aalst JA, McCurry T, Wagner J. Reconstructive considerations in the surgical management of melanoma. Surg Clin North Am 2003;83:187-230. |
|29.||Goldschimidt H, Breneman JC, Breneman DL. Ionizing radiation therapy in dermatology. J Am Acad Dermatol 1994;30:157-82. |
|30.||Vora SA, Garner SL. Role of radiation therapy for facial skin cancers. Clin Plast Surg 2004;31:33-8. |
Vishal K Jain
Department of Surgery, SAIMS, Indore
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
| Article Access Statistics|
| Viewed||6347 |
| Printed||131 |
| Emailed||0 |
| PDF Downloaded||143 |
| Comments ||[Add] |