PMC6612392_01
Clinical image of the patient's fungating right shoulder mass, noted on presentation and measuring 6.1 x 5.5 cm. This had reportedly been present many years, with 2 years of noted increasing size, drainage, and friability.
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In the ED, workup revealed a large (6.1 x 5.5 cm) fungating right shoulder mass (Figure 1), and the X-ray of her pelvis showed a pathologic fracture of the right iliac wing.
Microscopic findings of the right shoulder mass (a-e) and right iliac crest metastasis (f). (a) Low power image shows ulcerated BCC adjacent to normal skin. The tumor consists of large nodules and irregular angulated nests of tumor cells with peripheral palisading and surrounding myxoid stroma infiltrating into the deep dermis (hematoxylin-eosin, original magnification 40x). (b) Some areas of the BCC show histologic pattern of nodular subtype (hematoxylin-eosin, original magnification 100x). (c) Other areas of BCC show histologic pattern of morpheaform subtype (hematoxylin-eosin, original magnification 100x). (d) Foci of perineural invasion by BCC in the deep dermis (hematoxylin-eosin, original magnification 100x). (e) Foci of lymphovascular invasion by BCC (hematoxylin-eosin, original magnification 200x). (f) The right iliac crest biopsy shows metastatic BCC wrapping around bone trabeculae with morphological features similar to the right shoulder mass (hematoxylin-eosin, original magnification 200x).
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The pathology for this was reported as "metastatic carcinoma morphologically consistent with patient's known basal cell carcinoma of the skin" (Figure 2(f)). There was evidence of perineural invasion and one focus suspicious for lymphovascular invasion (Figures 2(a)-2(e)).
Images from a Tc-99m-MDP bone scan showing multiple focal areas of increased tracer uptake consistent with metastases in the skull, right zygomatic arch, anterior and posterior ribs, right scapula and clavicle, lumbar spine, pelvis, and bilateral femoral shafts.
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In addition to the previously imaged osseous lesions, a technetium bone scan performed on HD4 demonstrated metastatic lesions in the right and left mid femoral shafts (Figure 3).