Journal of Skin Cancer

Journal of Skin Cancer / 2012 / Article

Case Report | Open Access

Volume 2012 |Article ID 839561 | 4 pages | https://doi.org/10.1155/2012/839561

Basal Cell Carcinoma in Type 2 Segmental Darier's Disease

Academic Editor: Daniela Massi
Received11 Mar 2011
Revised17 May 2011
Accepted17 May 2011
Published31 Jul 2011

Abstract

Background. Darier's disease (DD), also known as Keratosis Follicularis or Darier-White disease, is a rare disorder of keratinization. DD can present as a generalized autosomal dominant condition as well as a localized or segmental postzygotic condition (Vázquez et al., 2002). Clinical features of DD include greasy, warty papules and plaques on seborrheic areas, dystrophic nails, palmo-plantar pits, and papules on the dorsum of the hands and feet. Objective. We report a case of basal cell carcinoma developing in a patient with type 2 segmental DD. Conclusion. According to the current literature, Type 2 segmental disease is a rare presentation of Darier's disease with only 8 previous cases reported to date. In addition, nonmelanoma skin cancer (NMSC) arising from DD is rarely reported; however, there may be an association between DD and risk of carcinogenesis.

1. Introduction

Darier’s disease (DD), also known as Keratosis Follicularis or Darier-White disease, is a rare disorder of keratinization. The disease is caused by a loss-of-function mutation in the ATP2A2 gene on chromosome 12q23-24 that encodes the sarco/endoplasmic reticulum calcium ATPase (SERCA2). This loss of function leads to a disruption of Ca2+ homeostasis within the keratinocytes,specifically depletion of Ca2+ stores in endoplasmic reticulum. Ultimately, the mutation leads to impaired cell-to-cell adhesion with the common histological findings of suprabasal acantholysis and dyskeratosis of cells in the epidermis [1]. DD can present as a generalized autosomal dominant condition as well as a localized or segmental postzygotic condition [2]. Clinical features of DD include greasy, warty papules and plaques on seborrheic areas, dystrophic nails, palmo-plantar pits, and papules on the dorsum of the hands and feet.

2. Observation

A 34-year-old woman with type 2 skin presented to clinic for evaluation of a lesion in the left popliteal fossa that had been present for approximately 1.5 years and frequently bled.

Past medical history was significant for DD which was diagnosed at 12 years of age. This was initially localized to the left side of the body but over the previous ten years had gradually become bilateral. She managed her disease with only emollients and sun protection but as a teenager had tried topical steroids, topical retinoids, and a short course of accutane. She was otherwise well and not on any medication. She denied a past history of excess sun exposure or blistering burns. Neither of her two children or parents were affected by DD.

Examination revealed hundreds of erythematous to light brown scaly 2-3 mm diameter papules involving the head and neck, trunk, and extremities. These formed large linear plaques which were more prominent on the left half of the body and followed Blaschko lines (Figures 1 and 2). Similar acrokeratosis verruciformis-like warty papules as well as larger verrucous papules and plaques were noted on the dorsal hands and periungal areas. Several fingernails demonstrated longitudinal erythronychia and distal nicking of the nail plate (Figure 3).

An erythematous shiny telangiectatic papule measuring 7 mm in diameter was noted within a linear collection of papules in the left popliteal fossa (Figure 4). A biopsy of the papule confirmed this to represent a nodular basal cell carcinoma (Figure 5) surrounded by characteristic suprabasal acantholysis and dyskeratosis seen in DD (Figures 6 and 7).

3. Discussion

We present a case of DD with well-defined segmental involvement superimposed on a milder, diffuse manifestation. The DD case is unusual due to both the distribution of the disease as well as the presence of basal cell carcinoma (BCC).

Over 50 cases of segmental DD have been reported in the last 100 years and have been variably referred to as localized, zosteriform, linear, segmental, or unilateral. In 1997, Happle proposed a categorization of mosaic forms of autosomal dominant skin disorders [3] that includes two forms of segmental DD. Type 1 segmental manifestation presents as distinct lesions of equal severity to a nonmosaic presentation on a background of normal skin. It is believed that type 1 represents an early postzygotic mutation resulting in heterozygosity. The type 2 segmental form manifests as well-defined areas of DD occurring on the background of a less severe nonmosaic phenotype. The segmental areas of involvement can present unilaterally or as coexisting bands of either excessive or absent involvement. This latter phenotypic presentation is a result of twin spotting. Our patient’s presentation is consistent with the type 2 segmental form. Genetically, type 2 segmental DD is a result of a heterozygous germline mutation compounded by a postzygotic mutation, such as mitotic recombination, nondisjunction, or deletion that leads to a homozygous or hemizygous population of cells for the underlying mutation. To date, 8 cases of type 2 segmental DD have been described in the literature [411] (Table 1).


Chester and Brown [4]Esche et al. [5]Happle et al. [6] Itin et al. [7] Itin and-Happl [8]Yusuf et al. [9]de la Torre Fraga [10]Rodríguez-Pazos et al. [11]Presented

Age255345521712245034
SexFemaleMaleMaleFemaleMaleMaleFemaleMaleFemale
Side of involvement and areas of segmental distributionRight side involving: Shoulder, chest, abdomen, retroauricular, and intraauricularFace and trunkLeft side involving: retroauricular, scapular, pectoralis major, and lumbar regionsRight side
involving:
arm and leg
Twin spot
phenomenon
involving: back
N/AN/ATwin spot phenomenonLeft side involving: head, neck, trunk, and extremities

Additionally, this case is unusual due to the presence of BCC in an area receiving minimal sun exposure. Given the patient’s young age and the lack of significant risk factors for non-melanoma skin cancer (NMSC), the development of BCC is unusual and raises suspicion of a link between DD and cutaneous malignancy. A literature review was undertaken to identify any association between DD and BCC or any other cutaneous malignancy. The review revealed that NMSC occurring in DD has rarely been described. Since 1981, 13 cases of NMSC in patients with DD have been reported: 7 squamous cell carcinomas (SCC), 5 BCC, and 1 adenexal tumor. Of the 5 cases of BCC, 2 of the cases had previously received grenz-ray therapy and/or superficial radiotherapy [12, 13], while no risk factors were associated with the other 3 cases [1315] (Table 2).


Case  1 [12]Case  2 [14]Case  3 [13]Case  4 [13]Case  5 [15]Case  6Average Presentation

Age42384748363455
SexMaleMaleMaleMaleFemaleFemaleM2.1 : F1
Tumor and Site(a) BCC Leg
(b) BCC Neck
(c) BCC Arm
(a) BCC left lower eyelid
(b) BCC left forehead
(a) BCC cheek
(b) Multiple BCC on face chest and back (4 years post-grenz-rays)
(a) BCC ear
(b) BCC scalp
(c) BCC
supraclavicular
fossa
(d) BCC sacrum
BCC cheekBCC popliteal fossa70% head
25% trunk
5% penis, vulva, or perianal skin

While no molecular link between DD and BCC has been described, the imbalance of cellular survival and apoptosis due to the DD mutation or other genodermatosis may contribute to the presentation. Darier’s disease is caused by a loss-of-function mutation in the ATP2A2 that leads to a disruption of Ca2+ homeostasis within the keratinocytes. A decreased SERCA activity leads to an upregulation of the transient receptor potential canonical 1 Ca channel that increases cell proliferation and resistance to apoptosis [16]. Additionally, it has been demonstrated that patients with DD have reduced expression of the antiapoptotic proteins Bcl-2 and Bcl-XL [17] which may activate apopotosis and lead to increased cell turnover. Further, alteration of ATP2A2 gene has been reported in the development of various other human carcinomas including colon and lung cancers [18]. Finally, a genetic predisposition to cancer in a related genodermatosis, Hailey-Hailey disease, has been demonstrated in murine models. Specifically, mice were bred with a mutated ATP2C1 gene leading to a similar loss in the golgi Ca2+ pump as in DD. The aged heterozygous mice demonstrated an increased incidence of malignancy. It was proposed by Okunade et al. that the loss of the golgi Ca2+ pump lead to Golgi stress and expansion which increased apoptosis and ultimately causes a genetic predisposition to cancer [19].

Although the literature is scarce and our understanding of the relationship between carcinomas and DD is developing, the case presented illustrates a possible association between DD and BCC.

Author Contributions

Dr. Lynne Robertson and Dr. Maxwell B. Sauder had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Robertson and Sauder, acquisition of data: Robertson and Sauder, analysis and interpretation of data: Robertson and Sauder, drafting of the manuscript: Robertson and Sauder, critical revision of the manuscript for important intellectual content: Robertson and Sauder, and study supervision: Robertson.

Acknowledgment

Special thanks to Dr. M. Trotter for providing the histopathology pictures.

References

  1. A. Hovnanian, “Chapter 49. Acantholytic disorders of the skin: Darier-White disease, acrokeratosis verruciformis, grover disease, and Hailey-Hailey disease,” in Fitzpatrick's Dermatology in General Medicine, 7e, K. Wolff, L. A. Goldsmith, S. I. Katz, B. Gilchrest, A. S. Paller, and D. J. Leffell, Eds., McGraw-Hill, New York, NY, USA, http://www.accessmedicine.com/content.aspx?aID=2965611. View at: Google Scholar
  2. J. Vázquez, C. Morales, L. O. González, M. L. Lamelas, and A. Ribas, “Vulval squamous cell carcinoma arising in localized Darier's disease,” European Journal of Obstetrics Gynecology and Reproductive Biology, vol. 102, no. 2, pp. 206–208, 2002. View at: Publisher Site | Google Scholar
  3. R. Happle, “A rule concerning the segmental manifestation of autosomal dominant skin disorders: review of clinical examples providing evidence for dichotomous types of severity,” Archives of Dermatology, vol. 133, no. 12, pp. 1505–1509, 1997. View at: Google Scholar
  4. B. J. Chester and L. Brown, “Darier’s disease resembling linear verrucous epidermal nevus,” Archives of Dermatology, vol. 80, pp. 625–626, 1959. View at: Google Scholar
  5. C. Esche, A. Pier, M. Zumdick, J. Krutmann, and T. Ruzicka, “Morbus Darier im Verlauf der Blaschko-Linien,” Zeitschrift für Hautkrankheiten, vol. 70, no. 10, pp. 758–760, 1995. View at: Google Scholar
  6. R. Happle, P. H. Itin, and A. M. Brun, “Type 2 segmental Darier disease,” European Journal of Dermatology, vol. 9, no. 6, pp. 449–451, 1999. View at: Google Scholar
  7. P. H. Itin, S. A. Büchner, and R. Happle, “Segmental manifestation of Darier disease. What is the genetic background in type 1 and type 2 mosaic phenotypes?” Dermatology, vol. 200, no. 3, pp. 254–257, 2000. View at: Google Scholar
  8. P. H. Itin and R. Happle, “Darier disease with paired segmental manifestation of either excessive or absent involvement: a further step in the concept of twin spotting,” Dermatology, vol. 205, no. 4, pp. 344–347, 2002. View at: Publisher Site | Google Scholar
  9. S. M. Yusuf, A. Z. Mohammed, and A. E. Uloko, “Type 2 segmental Darier's disease in a twelve-year-old Nigerian male—a case report,” Nigerian Journal of Medicine, vol. 18, no. 4, pp. 413–415, 2009. View at: Google Scholar
  10. C. de la Torre Fraga, “Enfermedad de Darier segmentaria tipo 2,” Medicina Cutánea Ibero-Latino-Americana, vol. 37, pp. 262–265, 2009. View at: Google Scholar
  11. L. Rodríguez-Pazos, S. Gomez-Bernal, M. Loureiro, and J. Toribio, “Type 2 segmental Darier disease with twin spot phenomenon,” Journal of the European Academy of Dermatology and Venereology, vol. 25, no. 4, pp. 496–497, 2011. View at: Publisher Site | Google Scholar
  12. D. L. Latour, R. A. Amonette, and G. F. Bale, “Darier's disease associated with cutaneous malignancies,” Journal of Dermatologic Surgery and Oncology, vol. 7, no. 5, pp. 408–412, 1981. View at: Google Scholar
  13. I. Hamadah and D. J. Grande, “The use of Mohs surgery in facial tumors in a patient with Darier's disease,” Journal of Dermatologic Surgery and Oncology, vol. 17, no. 12, pp. 950–953, 1991. View at: Google Scholar
  14. R. P. Rapini and F. C. Koranda, “Darier's disease and basal-cell carcinoma,” Journal of Dermatologic Surgery and Oncology, vol. 8, no. 8, p. 634, 1982. View at: Google Scholar
  15. S. Sönmez Ergün, U. Atılganoğlu, Y. Balsever Kural, and N. Büyükbaban, “Darier’s disease associated with basal cell carcinoma,” Istanbul Tip Fakültesi Dergisi, vol. 71, p. 4, 2008. View at: Google Scholar
  16. B. Pani, E. Cornatzer, W. Cornatzer et al., “Up-regulation of transient receptor potential canonical 1 (TRPC1) following Sarco(endo)plasmic Reticulum Ca ATPase 2 gene silencing promotes cell survival: a potential role for TRPC1 in Darier's disease,” Molecular Biology of the Cell, vol. 17, no. 10, pp. 4446–4458, 2006. View at: Publisher Site | Google Scholar
  17. E. Pasmatzi, G. Badavanis, A. Monastirli, and D. Tsambaos, “Reduced expression of the antiapoptotic proteins of Bcl-2 gene family in the lesional epidermis of patients with Darier's disease,” Journal of Cutaneous Pathology, vol. 34, no. 3, pp. 234–238, 2007. View at: Publisher Site | Google Scholar
  18. B. Korošec, D. Glavač, T. Rott, and M. Ravnik-Glavač, “Alterations in the ATP2A2 gene in correlation with colon and lung cancer,” Cancer Genetics and Cytogenetics, vol. 171, no. 2, pp. 105–111, 2006. View at: Publisher Site | Google Scholar
  19. G. W. Okunade, M. L. Miller, M. Azhar et al., “Loss of the Atp2c1 Secretory Pathway Ca-ATPase (SPCA1) in mice causes Golgi stress, apoptosis, and midgestational death in homozygous embryos and squamous cell tumors in adult heterozygotes,” Journal of Biological Chemistry, vol. 282, no. 36, pp. 26517–26527, 2007. View at: Publisher Site | Google Scholar

Copyright © 2012 Lynne Robertson and Maxwell B. Sauder. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


More related articles

1692 Views | 583 Downloads | 2 Citations
 PDF  Download Citation  Citation
 Download other formatsMore
 Order printed copiesOrder

Related articles

We are committed to sharing findings related to COVID-19 as quickly and safely as possible. Any author submitting a COVID-19 paper should notify us at help@hindawi.com to ensure their research is fast-tracked and made available on a preprint server as soon as possible. We will be providing unlimited waivers of publication charges for accepted articles related to COVID-19. Sign up here as a reviewer to help fast-track new submissions.