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Calcifications Associated With Basal Cell Carcinoma: Prevalence, Characteristics, and Correlations

Slodkowska, Elzbieta A MD*; Cribier, Bernard MD, PhD; Peltre, Bernard MSc; Jones, David M MD*; Carlson, J Andrew MD, FRCPC*

The American Journal of Dermatopathology: August 2010 - Volume 32 - Issue 6 - p 557-564
doi: 10.1097/DAD.0b013e3181ca65e2
Original Study

Background: Carcinoma-associated calcifications (Ca2+) are a common phenomenon. In the skin, basal cell carcinomas (BCC) can be associated with Ca2+.

Objective: To examine the prevalence, characteristics, and clinicopathologic correlations of BCC associated with Ca2+.

Material and Methods: Eighty-three BCC with Ca2+ were retrieved, 27 (11.1%) of which were identified from a review of 243 consecutive BCC. Ca2+ were classified into 4 types: type 1, Ca2+ within BCC epithelium; type 2, Ca2+ in BCC keratocysts; type 3, BCC tumor necrosis with Ca2+; and type 4, free Ca2+ adjacent to BCC. Clinical and pathologic features were assessed and compared with BCC without Ca2+. Expression of hair-associated proteins (hair keratins (K31, K32, and K35) and matrical transcription factors (LEF1, HOXC13, and β-catenin) were examined in a subset of BCC with Ca2+ and compared with matched controls without Ca2+.

Results: Compared with BCC without Ca2+, BCC with Ca2+ were significantly more likely to show a nodular keratinizing phenotype with keratocyst formation, background solar elastosis, active regression, and areas of tumor necrosis (all P ≤ 0.03). Comparing all BCC, high-risk BCC (mostly infiltrative) had significantly higher frequency of Ca2+ than low-risk (mostly nodular) BCC (44% vs. 25%; P = 0.009). The median and mean number of Ca2+ deposits per specimen were 2 and 3 ± 4, range 1-30. In decreasing frequency, type 2 Ca2+ (58%), type 4 (53%), type 3 (14%), and type 1 (10%) were found. In 9 cases (11%), type 2 and type 4 Ca2+ were linearly arranged, ostensibly after a follicular or eccrine duct tract. In 5 cases (6%), initial histologic sections showed type 4 dermal Ca2+ without evidence of BCC; level sections revealed BCC in the adjacent tissue. Neither BCC with nor BCC without Ca2+ showed evidence of matrical differentiation by immunophenotypic analysis.

Conclusions: A minority of BCC exhibits Ca2+ that are associated with BCC-related keratin and/or necrosis. Like other follicular-derived tumors (trichilemmal cyst, pilomatricoma, and trichoepithelioma), BCC produce keratins that are ostensibly predisposed to calcification but are not related to matrical differentiation (mature hair keratin formation). Either due to transtumor elimination or due to tumor regression, Ca2+ are frequently found free in solar elastotic or fibrotic dermis: a histologic clue in sun-damaged skin to the presence of BCC in the surrounding dermis.

From the *Division of Dermatology and Dermatopathology, Department of Pathology, Albany Medical College, Albany, NY; and †Dermatologique Clinique, Les Hopitaux Universtaires de Strasbourg, Strasbourg Cedex, France.

Presented in part at the 46th Annual meeting of the American Society of Dermatopathology, October 1-4, 2009, Chicago, IL.

Reprints: J. Andrew Carlson, MD, FRCPC, Division of Dermatopathology and Dermatology, Department of Pathology, Albany Medical College, MC-81, Albany, NY 12208 (e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.