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Year : 2020  |  Volume : 28  |  Issue : 3  |  Page : 192-194

Basosquamous cell carcinoma bone metastasis on coracoid process

1 Department of Orthopaedics and Traumatology, Keçiören Health Practice and Research Center, University of Health Sciences, Ankara, Turkey
2 Department of Plastic and Recontructive Surgery, Keçiören Health Practice and Research Center, University of Health Sciences, Ankara, Turkey

Date of Submission14-Jul-2019
Date of Acceptance01-Dec-2019
Date of Web Publication26-May-2020

Correspondence Address:
Dr. Yuksel Ugur Yaradilmis
Pinarbasi M Afacan S No 18/12, Keçiören, 06380, Ankara
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_66_19

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Although basal cell carcinoma (BCC) is the most commonly encountered skin carcinoma, metastasis rarely develops. Fewer than 300 cases of metastasis due to BCC have been presented in the literature. The coracoid process is a small area, and metastases are rarely seen in this bone localization. The case here presented is a 56-year-old male with coracoid process metastasis as a distant metastasis of basosquamous cell carcinoma (BSC) located in the face. This locally aggressive lesion due to BSC had been treated surgically five times by the plastic surgeon and was consulted by our clinic with the positron emission tomography-computed tomography report in respect of coracoid process involvement. A clean surgical margin was obtained with excision of the coracoid process. The conjoint tendon was fixed again with an anchor suture to the base of the coracoid, from which the tumor had been cleaned. The constant shoulder score was determined as 100 points after surgery.

Keywords: Basosquamous carcinoma, case report, coracoid process, metastasis

How to cite this article:
Yaradilmis YU, Tekin F, Demirkale I, Karapekmez FE. Basosquamous cell carcinoma bone metastasis on coracoid process. Turk J Plast Surg 2020;28:192-4

How to cite this URL:
Yaradilmis YU, Tekin F, Demirkale I, Karapekmez FE. Basosquamous cell carcinoma bone metastasis on coracoid process. Turk J Plast Surg [serial online] 2020 [cited 2020 Sep 22];28:192-4. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/3/192/284965

  Introduction Top

Although basal cell carcinoma (BCC) is frequently encountered, metastasis is rarely seen.[1] However, in the uncommon event of the development of metastatic BCC (mBCC), it leads to high morbidity and mortality.[2] There are many different subtypes of BCC, and the basosquamous type is more prominent with morphological and infiltrative characteristics in terms of metastasis. Some authors have emphasized that basosquamous carcinoma is most prone to metastasis.[3] In contrast, some authors stated that subtyping was not an important factor in metastasis, but risk factors for metastasis were size of >10 cm in the primary tumor, localization in the head and neck, and multiple, recurrent, untreated for a long time or inappropriately treated lesions.[4] BCC can metastasize at approximately equal rates with lymphogen or hematogenous routes. Metastasis is most commonly observed in lymph nodes (40%–83%), lung (35%–53%), and bone (20%–80%) tissues.[4],[5]

Von Domarus and Stevens reported a case series consisting of five new and 170 cases in the literature and reached the locations of metastasis in 110 patients. Extremity metastases were observed in 12 patients, including upper extremity in five patients and lower extremity involvement in seven patients.[2]

Metastasis of BCC located in the coracoid process, as seen in the current patient, is the first such case in literature. There have been two previously reported cases of coracoid process involvement in metastatic breast cancer.[6] The presentation and outcome of a patient with coracoid process involvement due to basosquamous type of BCC are reported in this paper.

  Case Report Top

A 59-year-old male, civil servant with no additional disease was referred to our clinic by the Plastic and Reconstructive Surgery Clinic with complaints of right shoulder pain. On positron emission tomography-computed tomography (PET-CT) examination, increased activity was observed in the coracoid process. The patient had a history of BCC in the vicinity of the right jaw (lesion size 7 cm) in 2016, and he had undergone surgical treatment five times for excision and curative treatment in the plastic surgery clinic. This aggressive lesion was diagnosed as basosquamous cell carcinoma (BSC) histopathologically in the plastic surgery clinic. PET-CT imaging and radiotherapy were planned after the latest surgery. Increased activity and suspicion of malignancy were observed in the coracoid process, according to the PET-CT imaging results. Orthopedic examination of the patient revealed a painful point localized in the coracoid process. The patient stated that the pain could not be alleviated by rest and had been present for 1 year, gradually increasing. There was no skin lesion, localized swelling, heat increase, or redness on examination of the localization of the pain. There was no finding on direct X-rays [Figure 1]. The lesion was detected on magnetic resonance imaging and the margins of the tumor were defined [Figure 1]. Open incisional biopsy was performed to clarify the diagnosis before definitive treatment. The final pathology report of the biopsy reported metastasis of BSC. Surgery was planned due to the coracoid process involvement.
Figure 1: (a) Posteroanterior radiographic projections of the right shoulder do not reveal any signs of fracture or other underlying pathology; (b) magnetic resonance imaging detected a focal lesion on the coracoid process

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Surgical technique

With the patient in the beach-chair position, entry was made with a vertical incision over the coracoid process. The biopsy scar was excised. The conjoint tendon was identified, and the metastatic lesion in the coracoid process was reached. The choroidal process was excised, and a clean surgical margin was obtained with the examination of the intraoperative frozen section. The conjoint tendon was fixed with a suture at the base of the choroid [Figure 2].
Figure 2: (a) Basal cell carcinoma on the face, (b) preoperative planning and biopsy scar, (c) fixation of the conjoint tendon with suture-anchor, (d) exised coracoid process (size 4 cm)

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Passive exercise was started on the 1st postoperative day and active exercise on the 14th day. Postoperative 6th month radiographs are shown in [Figure 3]. The postoperative follow-up period was 18 months. In the final functional evaluations, the constant shoulder score was determined as 100 and the Oxford shoulder score as 48.
Figure 3: Postoperative 6th month radiograph

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  Discussion Top

Although BCC is the most common skin carcinoma, the incidence of metastasis has been reported as 0.01% in pathological specimens, 0.028% in dermatological patients, and 0.1% in patients in surgical centers.[7] Rowe et al. determined risk factors in terms of metastasis as patients with multiple, recurrent lesions localized in the head and neck region, patients with lesions untreated for a long time or incorrectly treated, patients with perineural spread or with vascular invasion, and patients with a primary tumor >10 cm.[4] Of these factors, An et al. particularly emphasized the importance of the tumor size. The risk of metastasis has been found to be 1%–2% at the border of a 3 cm tumor, whereas the risk rises to 20% in tumor size of 5 cm and is expected to be 50% when the tumor is >10 cm. BCC has many subtypes according to the histopathological classification. mBCC is a prominent basosquamous cancer. This subtype is named metatropic, with the appearance of all BCC neoplastic squamous differentiating foci, a general infiltrative growth pattern, and an increased risk of distant metastasis.[8] Some authors have emphasized that basosquamous type of BCC is the type most prone to metastasis.[3] Although basosquamous cell tumors seem to have a high metastasis rate, there are also authors who claim that the histopathological subgroup has no predictive value for the risk of metastasis.[4] In the current case, the lesion on the face was initially 7 cm in diameter and showed recurrence and perineural involvement. This primary lesion with a high risk factor for metastasis was histopathologically reported as basosquamous carcinoma. The metastatic lesion was found to comply with Lattes criteria for BCC. PET-CT imaging did not show any metastasis except in the coracoid process region. The shoulder function scores of the patient were near-normal at 1 year after the diagnosis of metastatic lesion.

Tumoral formations in the coracoid process frequently lead to shoulder pain and may be confused with other shoulder pathologies, resulting in misdiagnosis. Ogose et al. examined tumoral lesions of the coracoid process in a series of 18 cases and stated that patients usually have normal X-ray findings and metastatic lesions can be diagnosed with the use of advanced imaging techniques when there are complaints of persistent pain. Tumors located in the coracoid process are generally primary bone tumors (chondrosarcomas, osteoblastomas, and chondroblastomas).[9] In a review of the literature, two cases of primary breast carcinoma and one case of primary hepatocellular carcinoma were seen with coracoid process metastases.[6],[10] One of the patients with metastatic breast cancer underwent excisional biopsy and the other patient was treated conservatively. The shoulder function scores of the patients were not recorded.[6]

  Conclusion Top

The current case report has two striking features. One is that the metastatic tumor in this case was BCC, which is a rare metastatic tumor type. The second was that metastasis in the coracoid process is an unusual localization for BCC. Treatment of the metastatic lesion was successful with preservation of the coracoid process and high shoulder function scores obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Telfer NR, Colver GB, Bowers PW. Guidelines for the management of basal cell carcinoma. British Association of Dermatologists. Br J Dermatol 1999;141:415-23.  Back to cited text no. 1
von Domarus H, Stevens PJ. Metastatic basal cell carcinoma. Report of five cases and review of 170 cases in the literature. J Am Acad Dermatol 1984;10:1043-60.  Back to cited text no. 2
Lo JS, Snow SN, Reizner GT, Mohs FE, Larson PO, Hruza GJ. Metastatic basal cell carcinoma: Report of twelve cases with a review of the literature. Journal of the American Academy of Dermatology 1991;24:715-9.  Back to cited text no. 3
Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 1989;15:315-28.  Back to cited text no. 4
Ting PT, Kasper R, Arlette JP. Metastatic basal cell carcinoma: report of two cases and literature review. J Cutan Med Surg 2005;9:10-5.  Back to cited text no. 5
Benson EC, Drosdowech DS. Metastatic breast carcinoma of the coracoid process: two case reports. J Orthop Surg Res 2010;5:22.  Back to cited text no. 6
Tilli CM, Van Steensel MA, Krekels GA, Neumann HA, Ramaekers FC. Molecular aetiology and pathogenesis of basal cell carcinoma. Br J Dermatol 2005;152:1108-24.  Back to cited text no. 7
Martin RC 2nd, Edwards MJ, Cawte TG, Sewell CL, McMasters KM. Basosquamous carcinoma: Analysis of prognostic factors influencing recurrence. Cancer 2000;88:1365-9.  Back to cited text no. 8
Ogose A, Sim FH, O'Connor MI, Unni KK. Bone tumors of the coracoid process of the scapula. Clin Orthop Relat Res 1999;358:205-14.  Back to cited text no. 9
Md Radzi AB, Tan SS. A case report of metastatic hepatocellular carcinoma in the mandible and coracoid process: A rare presentation. Medicine (Baltimore) 2018;97:e8884.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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