Skip to main content

Micronodular basal cell carcinoma of the scrotum: a case report and review of the literature

Abstract

Introduction

Basal cell carcinoma is the most common nonmelanotic skin cancer. It has variable clinical and histological subtypes that vary in their aggressiveness and liability to recurrence and metastasis. Chronic ultraviolet radiation exposure is considered to be the main risk factor for developing basal cell carcinoma; therefore, it typically arises on sun-exposed skin, mainly the head and neck.

Case presentation

We present the case of a 55-year-old Caucasian male who presented with a lesion on the scrotum for 2 years. The lesion was clinically presumed benign and initially treated with curettage. Microscopic examination revealed an incompletely resected micronodular basal cell carcinoma with sebaceous differentiation. Therefore, a second excisional biopsy was performed to completely excise the incidentally discovered malignant tumor.

Conclusion

We report the first case of micronodular basal cell carcinoma arising on the scrotum. The goal of our article is to draw clinicians’ attention to the possible involvement of unexposed skin with basal cell carcinoma, and we highlight the importance of accurate diagnosis and prompt treatment due to the aggressive nature of micronodular basal cell carcinoma.

Peer Review reports

Introduction

Nonmelanotic skin cancer (NMC) is the most common cancer in the world. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) represent 99% of all NMCs, with BCC being the most prevalent. However, accurate data about their prevalence are scarce, mainly because they are not reported separately in national cancer registries and many cases are not fully tracked due to the successful treatment of the tumor via surgery or ablation [1, 2].

BCC usually arises on chronically photoexposed areas in the elderly; it has been rarely reported to occur on unexposed skin such as the trunk or genitalia.

We report the case of a 55-year-old man who presented with a tumor-like lesion on the scrotum for 2 years. The lesion was excised and subsequently determined to be a micronodular BCC of the scrotum. To the best of our knowledge, this is the first reported case of micronodular BCC occurring on the scrotum.

Case presentation

A 55-year-old Caucasian man presented to the outpatient clinic with a soft lesion on the left side of the scrotum, present for 2 years.

On inspection, the lesion appeared as a bluish-black nodule with rolled edges and a smooth surface. It measured 7 mm in diameter and was raised 4 mm above the surrounding skin level (Fig. 1).

Fig. 1
figure1

A pigmented nodule on the left scrotum measuring 7 mm in diameter

According to the patient, the nodule was not painful, but due to its location in an intertriginous area that is liable to continuous friction and moisture, the lesion was prone to recurrent irritation leading to oozing, maceration, and foul odor.

The lesion started as a punctate black macule on the left side of the scrotum. The patient made several failed attempts to remove it with a razor blade.

The rest of the physical examination was unremarkable, and no lymphadenopathy was present.

Based on the patient’s history, physical examination, and the location of the lesion, the lesion was suspected to be an angiokeratoma. Consequently, it was removed by shave biopsy and sent for microscopic examination.

Microscopic examination revealed small nests of basaloid cells extending from the epidermis and infiltrating the reticular dermis (Fig. 2a). Peripheral palisading of the nuclei was minimal, and retraction artifact was almost absent.

Fig. 2
figure2

Microscopic view (hematoxylin and eosin stain) of the lesion showing a aggregates of small nests of basaloid cells with absent retraction artifacts. Melanin granules (brown pigment granules) can be easily seen within and outside the basaloid nests (low-power magnification). b High-power microscopic view depicting clusters of basaloid cells with sebaceous duct-like formations consisting of vacuolated cells with foamy cytoplasm, suggestive of sebaceous cells

High-power magnification revealed multiple basaloid cells with large hyperchromatic nuclei and numerous mitotic figures. Worthy of notice is the presence of heavy pigmentation within the tumor nests and the melanophages in the surrounding stroma.

Furthermore, multiple foci of sebaceous differentiation were noted within the basaloid nests (Fig. 2b).

These microscopic findings led to the diagnosis of scrotal pigmented micronodular BCC with sebaceous differentiation.

The deep surgical margin was positive for malignant cells; therefore, the patient underwent a subsequent surgical procedure to completely excise the tumor.

On follow-up, 4 months later, no signs of recurrence were noted.

Discussion

Basal cell carcinoma is the most frequently occurring cancer in humans. It arises from the basal layer of the epidermis and grows slowly over multiple years.

Key risk factors for developing BCCs have been recognized, including ultraviolet radiation, fair complexion, chronic arsenic exposure, ionizing radiation, personal or family history for BCC, and genetic predisposition [3, 4].

In our case, the patient had no personal or family history of BCC and no prior exposure to ionizing radiation or other carcinogens. The location of the carcinoma on the scrotum in our case renders ultraviolet exposure an unlikely culprit.

Basal cell carcinoma has multiple histological subtypes, and they can be classed according to their risk of recurrence into low-risk and high-risk subtypes. The nodular, superficial, fibroepithelial, pigmented, and infundibulocystic BCC are classified as low-risk subtypes, while the infiltrative, micronodular, morpheaform, and basosquamous BBC as well as BCC with sarcomatoid differentiation are considered as the higher-risk subtypes [5]. However, histological patterns may overlap.

Nodular BCC is the most common variant, characterized clinically by rolled edges, surface telangiectasia, and a central ulcer, giving rise to what is known as the rodent ulcer.

The micronodular variant is an aggressive type of BCC that is liable to recurrence and difficult to eradicate. It occurs most frequently in the head and neck area [6]. Clinically, micronodular BCC typically presents as a poorly defined infiltrated flat lesion that rarely ulcerates.

Approximately 80–85% of BCC occur on the head and neck, while 15% develop on the trunk [7]. According to a classic review conducted by Rabbari and Mehregan, less than 0.5% of BCCs were located in the genital area [8].

Less than a hundred cases of BCC arising on the perianal and the genital area have been reported in the literature [9].

Solimani and colleagues reported three cases of nodular BCC on the scrotum occurring during a span of 10 years in their institution [10], whereas Chen et al. conducted a recent population-based analysis of genital BCCs and identified 255 male cases, of which 190 had scrotal BCC (74.5%). An interesting finding was that penile BCC had poorer prognosis than scrotal [11].

We highlight herein 14 case reports of scrotal BCC, reported over the past 20 years; the patients’ details, tumor morphology, and microscopic classification are summarized in Table 1.

Table 1 Case reports published in the past 20 years of BCC arising on the scrotum

The average age of patients was 67.6 years (49 87 years), and the most commonly reported clinical morphology was ulcerated nodule with pearly borders. The average age of the lesion at presentation was 6.5 years (3 months to 51 years).

Unlike our case, the reported lesions were infrequently pigmented at presentation.

To our knowledge, there are no reported cases of micronodular BCCs arising from the scrotal dermis. Our article is thus the first reported case of such a rare location and histological type.

Conclusion

The presence of BCC in an unusual anatomical location represents a diagnostic challenge for clinicians. Our report adds to the growing body of literature on the unusual sites of basal cell carcinoma. Although the majority of BCCs occur in sun-exposed areas, a diagnosis of BCC should never be excluded merely due to the absence of sun exposure. Clinicians need to be aware of the variable morphologic features of BCC and its possible occurrence in unusual sites, such as the genital area. Prompt diagnosis and proper treatment of BCC is crucial to spare the patient long-term consequences and preserve appropriate quality of life.

Availability of data and materials

Not applicable.

Abbreviations

BCC:

Basal cell carcinoma

NMC:

Nonmelanotic skin cancer

SCC:

Squamous cell carcinoma

References

  1. 1.

    Eisemann N, Waldmann A, Geller AC, et al. Non-melanoma skin cancer incidence and impact of skin cancer screening on incidence. J Invest Dermatol. 2014;134(1):43–50. https://doi.org/10.1038/jid.2013.304.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Ciążyńska M, Kamińska-Winciorek G, Lange D, et al. The incidence and clinical analysis of non-melanoma skin cancer. Sci Rep. 2021;11:4337. https://doi.org/10.1038/s41598-021-83502-8.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    van Dam RM, Huang Z, Rimm EB, et al. Risk factors for basal cell carcinoma of the skin in men: results from the health professionals follow-up study. Am J Epidemiol. 1999;150(5):459–68. https://doi.org/10.1093/oxfordjournals.aje.a010034 (PMID: 10472945).

    Article  PubMed  Google Scholar 

  4. 4.

    Ramachandran S, Fryer AA, Smith A, et al. Cutaneous basal cell carcinomas: distinct host factors are associated with the development of tumors on the trunk and on the head and neck. Cancer. 2001;92(2):354–8. https://doi.org/10.1002/1097-0142(20010715)92:2%3c354::aid-cncr1330%3e3.0.co;2-f (PMID: 11466690).

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Elder DE, Massi D, Scolyer RA, Willemze R. WHO classification of skin tumours 4th ed, Lyon, France, IARC; 2018:66–71. World Health Organization Classification of Tumours; vol 11.

  6. 6.

    Betti R, Menni S, Radaelli G, Bombonato C, Crosti C. Micronodular basal cell carcinoma: a distinct subtype? Relationship with nodular and infiltrative basal cell carcinomas. J Dermatol. 2010;37(7):611–6. https://doi.org/10.1111/j.1346-8138.2009.00772.x.

    Article  PubMed  Google Scholar 

  7. 7.

    Ogueta IC, Fuentes CS, Madison A, et al. Basal cell carcinoma at an unusual location: case report. J Dermat Cosmetol. 2018;2(1):60–1. https://doi.org/10.15406/jdc.2018.02.00040.

    Article  Google Scholar 

  8. 8.

    Rahabari H, Mehregan AH. Basal cell epitheliomas in usual and unusual sites. J Cut Pathol. 1979;6(5):425–31.

    Article  Google Scholar 

  9. 9.

    Carr AV, Feller E, Zakka FR, Griffith RC, Schechter S. A case report of basal cell carcinoma in a non-sun-exposed area: a rare presentation mimicking recurrent perianal abscess. Case Rep Surg. 2018. https://doi.org/10.1155/2018/9021289.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Solimani F, Juratli H, Hoch M, Wolf R, Pfützner W. Basal cell carcinoma of the scrotum: an important but easily overlooked entity. J Eur Acad Dermatol Venereol. 2018;32(6):e254–5. https://doi.org/10.1111/jdv.14823 (Epub 2018 Mar 6 PMID: 29377295).

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Chen X, Hou Y, Chen C, Jiang G. Basal cell carcinoma of the external genitalia: a population-based analysis. Front Oncol. 2021;26(10): 613533. https://doi.org/10.3389/fonc.2020.613533.PMID:33585236;PMCID:PMC7874071.

    Article  Google Scholar 

  12. 12.

    Takahashi H. Non-ulcerative basal cell carcinoma arising on the genitalia. J Dermatol. 2000;27(12):798–801. https://doi.org/10.1111/j.1346-8138.2000.tb02285.x (PMID: 11211798).

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Vandeweyer E, Deraemaecker R. Basal cell carcinoma of the scrotum. J Urol. 2000;163(3):914 (PMID: 10688013).

    CAS  Article  Google Scholar 

  14. 14.

    Chave TA, Finch TM. The scrotum: an unusual site for basal cell carcinoma. Clin Exp Dermatol. 2002;27(1):68. https://doi.org/10.1046/j.0307-6938.2001.00965.x (PMID: 11952677).

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Ribuffo D, Alfano C, Ferrazzoli PS, Scuderi N. Basal cell carcinoma of the penis and scrotum with cutaneous metastases. Scand J Plast Reconstr Surg Hand Surg. 2002;36(3):180–2. https://doi.org/10.1080/028443102753718087 (PMID: 12141208).

    Article  PubMed  Google Scholar 

  16. 16.

    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(9):678–80. https://doi.org/10.1111/j.1365-4632.2004.02178.x (PMID: 15357751).

    Article  PubMed  Google Scholar 

  17. 17.

    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(1):54–6. https://doi.org/10.1111/j.1365-4632.2004.02372.x (PMID: 15663663).

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Ouchi T, Sugiura M. Polypoid basal cell carcinoma on the scrotum. J Dermatol. 2008;35(12):804–5. https://doi.org/10.1111/j.1346-8138.2008.00576.x (PMID: 19239566).

    Article  PubMed  Google Scholar 

  19. 19.

    Rao GR, Amareswar A, Kumar YH, Prasad TS, Rao NR. Pigmented basal cell carcinoma of the scrotum: an unusual site. Indian J Dermatol Venereol Leprol. 2008;74(5):508–9. https://doi.org/10.4103/0378-6323.44322 (PMID: 19052423).

    Article  PubMed  Google Scholar 

  20. 20.

    Jianwei W, Libo M, Jianwei W, Liqun Z, Lihua G. Basal cell carcinoma of the scrotum with a lesion of 51 years’ duration. Int J Dermatol. 2012;51(6):752–4. https://doi.org/10.1111/j.1365-4632.2010.04637.x (Epub 2011 Dec 16 PMID: 22171695).

    Article  PubMed  Google Scholar 

  21. 21.

    Li J, Zheng H. Erosive plaque on scrotum. JAMA. 2014;312(3):288–9. https://doi.org/10.1001/jama.2013.286242 (PMID: 25027145).

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Delto JC, Garces S, Sidhu AS, Ghaffaripour T, Omarzai Y, Nieder AM. Giant fungating basal cell carcinoma of the scrotum. Urology. 2016;91:e1-2. https://doi.org/10.1016/j.urology.2016.01.030 (Epub 2016 Feb 12 PMID: 26876464).

    Article  PubMed  Google Scholar 

  23. 23.

    Hernández-Aragüés I, Baniandrés-Rodríguez O. Basal cell carcinoma of the scrotum. Actas Urol Esp. 2016;40(9):592–3. https://doi.org/10.1016/j.acuro.2016.04.013 (Epub 2016 Jun 11. PMID: 27297865).

    Article  PubMed  Google Scholar 

  24. 24.

    Padoveze EH, Ocampo-Garza J, Di Chiacchio NG, Cernea SS, Di Chiacchio N, Ocampo-Garza SS. Mohs micrographic surgery for basal cell carcinoma of the scrotum. Int J Dermatol. 2018;57(6):750–2. https://doi.org/10.1111/ijd.13989 (Epub 2018 Apr 6 PMID: 29624672).

    Article  PubMed  Google Scholar 

  25. 25.

    Han S, Zhang Y, Tian R, Guo K. Basal cell carcinoma arising from the scrotum: an understated entity. Urol Case Rep. 2020;3(33): 101332. https://doi.org/10.1016/j.eucr.2020.101332.PMID:33102034;PMCID:PMC7573964.

    Article  Google Scholar 

Download references

Acknowledgements

We would like to express our deep gratitude to our colleagues at the University Hospital of Dermatology and Venereology for providing their valuable expertise and insight.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Affiliations

Authors

Contributions

MY analyzed and interpreted the patient’s data and drafted the manuscript. LK performed the literature review and drafted the manuscript. HA and AB supervised the project, reviewed the original draft, and provided critical feedback. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Lamia Kouba.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Younes, M., Kouba, L., Almsokar, H. et al. Micronodular basal cell carcinoma of the scrotum: a case report and review of the literature. J Med Case Reports 15, 512 (2021). https://doi.org/10.1186/s13256-021-03124-6

Download citation

Keywords

  • Basal cell carcinoma
  • Micronodular
  • Scrotum
  • Case report