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A 58-year-old Caucasian male presented with an ulcerative, bleeding lesion on his nasal supratip, which had been present for approximately one year. The patient stated that it had progressively grown and become more painful over the course of the year (Figure 3A).

The patient stated that he began to have rhynophymic changes to his nose approximately 15 years prior. He denied a history of previous skin cancers. The patient had a significant sun exposure history and seldom wore sun block. He had a 36 pack year history of tobacco use and only drank alcohol socially.

On physical exam he was noted to have rhinophyma of the nose in addition to the above lesion (Figure 3A). No other suspicious skin lesions were identified.

A shave biopsy was performed of the lesion, which revealed nodular type BCCA extending to all margins as well as histologic changesassociated with rhinophyma (Figure 1).

The patient was educated on the diagnosis as well as his treatment options, including the risks, benefits, and pitfalls of each possible treatment.

We elected to perform a wide local excision of the lesion with intra-operative frozen sections followed by tangential excision and dermabrasion of the entire nose (Figures 2-4).

Negative margins were obtained, symmetry and homogeneity of the nasal skin was achieved, and the patient was very pleased with the results (Figures 2-4).

A review of the literature reveals only 28 reported cases of synchronous BCCA and rhinophyma (not counting our own patient).2, 6-8 Most of these cases represent occult BCCA (BCCA incidentally found upon review of a rhinophyma specimen); thus, to our knowledge, this is one of the few cases of known synchrony prior to treatment. The number of times that a pre-operative diagnosis of BCCA is made within rhinophyma is likely inversely proportional to the severity of the rhinophyma. As our patient with a fairly mild rhinophyma demonstrates, it is easier to identify a lesion over a moderately disfiguring rhinophyma background.

The traditional reconstructive options after excision of BCCA from the nasal tip include healing by secondary intention, skin grafting, and local flap rotation. Although these options are viable on patients without rhinophyma, these options in rhinophymic patients would demonstrate more noticeable scarring, poor tissue match, and poor wound healing, respectively. Additionally, given the rare, but documented, association between rhinophyma and occult BCCA,1-8 failure to treat the surrounding rhinophymic skin leaves this risk unaddressed.

Although there are no data to definitively identify rhinophyma as a premalignant lesion, one must assume that if a patient develops BCCA on one area of a rhinophymic nose then that patient is more likely to develop another lesion on the same rhinophymic background.

In patients with both BCCA and rhinophyma, the surgeon must be attentive to adequate cancer resection, adequate resection of rhinophyma (which may be harboring an occult BCCA or serve as the precursor to BCCA), and obtaining an acceptable aesthetic result.

The synchronous presence of known BCCA and rhinophyma in the same patient is exceedingly rare. We find the most curative and aesthetic treatment in such a case to be wide local excision with intra-operative frozen sections followed by tangential excision and dermabrasion of the rhinophyma afflicted nose.

Our case demonstrates that both cancer cure and an optimal aesthetic result can be achieved by this novel treatment option.

The final stage of acne rosacea progression is a condition affecting the nasal integument known as rhinophyma. Hallmarks of the disease include massive hypertrophy and hyperplasia of the sebaceous glands, fibrosis, follicular plugging, and telangiectasia.2 Interestingly, the incidence of rhinophyma in the general population is not well documented and seems to vary by region as well as by ethnicity. One study out of Tunisia, for example, quoted an incidence of 0.2%.4

Basal cell carcinoma (BCCA) is the most common skin cancer in humans and commonly presents on the head and neck. Although numbers differ from source to source, about 86% of BCCA lesions occur initially in the head and neck, with 25% of all primary lesions occuring on the nose.9 Similar to rhinophyma, the overall incidence of BCCA also varies by region and ethnicity. One report out of Scotland, for example, deduces that the incidence of BCCA of the nose in the general population is merely 0.6%.1

A definitive correlation between BCCA and rhinophyma has yet to be established, and the synchronous presence of both of these conditions in the same patient is rare. In fact, one may logically conclude that the prevalence of both conditions simultaneously in the general population must be less than 0.6% (the incidence of BCCA of the nose alone in the general population). 2 However, Brubaker, et. al. were able to postulate a 5% incidence of BCCA in patients with rhinophyma.11

Most documented cases of synchrony with BCCA are made incidentally upon review of an excised rhinophyma specimen.

While focal transformation from the hyperplastic and hypertrophic cellular changes associated with rhinophyma to BCCA has been hypothesized to explain the rare association of these two conditions, 3 one cannot fully exclude the usual BCCA risk factors (e.g. sun exposure) or a combination thereof as the etiology. Although it has been suggested, there are no data in the literature that delineate rhinophymaas a premalignant lesion.

Resection of a BCCA from a nose afflicted with rhinophyma creates reconstructive challenges. Tamir et. al. purports the use of Mohs’ surgery to deal with such a scenario,5 but this technique does not address the rhynophymic background. Plenk, et. al., on the other hand, purports the use of radiotherapy to treat both conditions simultaneously. 10 However, radiotherapy carries risks and side effects of its own. When considering the best procedure to eradicate both conditions, one must contend with both adequate cancer resection as well as aesthetic outcome.

INTRODUCTION

1. Curnier A, Choudhary S. Rhinophyma: dispelling the myths. Plast Reconst Surg. 2004; 114: 351–354.

2. Leyngold, Mark, et. al. Basal Cell Carcinoma and Rhinophyma. Annals of Plastic Surgery.2008; 61: 410-12.

3. Novick NL, Kest E, Gordon M. Advances in the biology and carcinogenesis of basal cell carcinoma. N Y State J Med. 1988 Jul;88(7):367-70.

4. Khaled, A, et. al. Rosacea: 244 Tunisian cases. Tunis Med. 2010; 88(8): 597-601.5. Tamir, G, et. al. Mohs’ surgery as an approach to treatment of multiple skin cancer in

rhinophyma. J Cutan Med Surg. 1999. 3(3): 169-71.6. Kwah, R, et. al. Wound management in a patient with rhinophyma and basal cell

carcinoma. J Amer Acad Derm. 2011. 65: 11-12.7. Lazzeri, D, et. al. Malignancies Within Rhinophyma: Report of Three New Cases and

Review of the Literature. Aesthetic Plast Surg. 2011.8. Nambi, G, et. al. An unusual type of basal cell carcinoma in a giant rhynophyma. J Plast

Reconst Aesthet Surg. 2008. 61: 1400-1.9. Willey, A, et. al. Cummings: Otolaryngology: Head & Neck Surgery, 5th edition. 2005.

Chapter 20: Recognition and Treatment of Skin Lesions. 283-5.10. Plenk HP (1995) Rhinophyma, associated with carcinoma, treated successfully with

radiation. Plast Reconstr Surg 95(3):559–562.11. Brubaker DB, Hellstom RH (1977) Carcinoma arising in rhinophyma. Arch Dermatol

113(6):847–848

CONCLUSIONS

DISCUSSIONCASE PRESENTATION

REFERENCES

Figure 2. Frontal view of intra-operative wide local excision. Performed prior to tangential excision with dermabrasion. The basal cell carcinoma has been excised with adequate peripheral margins; however, the deep margin remains positive necessitating further excision to the level of the left lower lateral cartilage (Figure 3B). Taken with the permission of the patient by Parker A. Velargo, MD; 2010.

Figure 1. Typical characteristics of basal cell carcinoma arising inrhinophyma. (H&E: left low power, right high power). Prepared by Megan Kempe, MD, University of Tennessee, Department of Pathology; 2011.

Figure 3. Frontal view of clinical progression. A. Pre-operative. Note the erythematous area on the supratip, which is positive for basal cell carcinoma. B. Intra-operative. Status post wide local excision and tangential excision with dermabrasion. Note the exposed portion of the left lower lateral cartilage, which was necessary to obtain clear margins. C. 6 months post-operative. Note the overall smoother appearance of the nose. The area with exposed cartilage from carcinoma resection has healed nicely and now matches the surrounding tissues. Taken with the permission of the patient by Parker A. Velargo, MD; 2010.

Parker A. Velargo, MD; Merry E. Sebelik, MD, FACSUniversity of Tennessee Department of Otolaryngology/ Head & Neck Surgery, VAMC-Memphis

Basal Cell Carcinoma & Rhinophyma: A Novel Treatment Option

ABSTRACT

CONTACTParker A. Velargo, MDUniversity of Tennessee Dept. of Otolaryngology/ Head & Neck SurgeryEmail: pvelargo@uthsc.eduPhone: 901-448-5885Website: www.uthsc.edu/otolaryngology

Objectives:Resection of basal cell carcinoma (BCCA) from a background of advanced rhinophyma can present a reconstructive challenge, thus a novel surgical treatment option is presented.The Objective of this study is to report a case of synchronous rhinophyma and BCCA, review the literature, and discuss surgical options available.

Study Design:This study is a case report with review of the literature.

Methods:A review of the literature reveals only 28 reported cases of synchronous BCCA and rhinophyma.7 Most of these cases represent occult BCCA; thus, to our knowledge, this is one of the few cases of known synchrony prior to treatment.

Results:The traditional repair options after excision of BCCA from the nasal tip include healing by secondary intention, skin grafting,and local flap rotation. In patients with rhinophyma these options are less than ideal. As a novel alternative, wide local excision of the lesion with intra-operative frozen section margin control was carried out followed by single-stage tangential excision and dermabrasion of the nasal skin involved with rhinophyma. Negative margins were obtained, symmetry and homogeneity of the nasal skin was achieved, and the patient was very pleased with the results. Before and after photodocumentation, and representative histologic sections are presented.

Conclusions:The reported synchronous presence of known BCCA and rhinophyma is exceedingly rare. Our case demonstrates that both cancer cure and an optimal aesthetic result can be achieved by this novel treatment option.

Figure 4. Lateral view of clinical progression. A. Pre-operative. Note the erythematous area on the supratip, which is positive for basal cell carcinoma. B. Intra-operative. Status post wide local excision and tangential excision with dermabrasion. Note the exposed portion of the left lower lateral cartilage, which was necessary to obtain clear margins. C. 6 months post-operative. Note the overall smoother appearance of the nose. The area with exposed cartilage from carcinoma resection has healed nicely and now matches the surrounding tissues. Taken with the permission of the patient by Parker A. Velargo, MD; 2010.