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Received Jan 10, 2018; Accepted Apr 3, 2018
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1. Introduction
Basal cell carcinoma (BCC) of the skin is the most common human cancer in Caucasians. Its high incidence can be explained by genetics as inactivation of only one-signal transduction pathway; that is, the sonic hedgehog (SHH) signaling, either by one activating mutation in the SMO gene or by two inactivating mutational events targeting the PTCH1 gene, seems to be sufficient for cancer formation. Consequently, blockade of SHH signaling has been developed as systemic treatment of advanced BCC [1]. Although BCC can induce extensive and lethal local tissue destruction, formation of metastases is exceedingly rare. Metastasis frequency is estimated to range from 0.003% to 0.5% [2]. Low frequency of metastases of BCC stands in contrast to the very high mutation load demonstrated in sporadic BCC and to a lesser extent also in syndromic BCC [3–5]. On the other hand, most mutations demonstrate an UV-signature and one might speculate that a cancer driven mostly by exogenous UV-induced mutations might be less prone to acquire the additional mutations necessary for the metastatic process than a cancer evolving primarily through a mutator phenotype or through marked aneuploidy. Nevertheless, genetic instability in BCC is not excluded, and mutations of the caretaker gene P53 and chromosomal instability have been observed frequently in BCC [3].
We would like to present an additional case of metastatic and fatal BCC in a surprisingly young male patient.
2. Case Presentation
In January 2015, a 55-year-old Caucasian man was admitted to our department with a 12-year history of a slow-growing ulcerating tumor of the left forearm. The patient had no comorbidities and no prior skin cancer history but a 40-year history of cigarette smoking. The only skin cancer risk factor was a Fitzpatrick skin type II. The patient had avoided medical care due to diffuse fear and distrust in the health care system, but within the last couple of months, the patient developed an ulceration of the left axilla which ultimately forced him to seek medical advice.
On initial presentation, we observed an 8 × 15 cm measuring...