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Ulcus terebrans: an unusual cause of paraparesis
  1. T Birbilis
  1. ZKH Sankt-Jürgen-Strasse, Neurochirurgische Klinik, Sankt-Jürgen-Strasse 1, D-28205 Bremen, Germany;

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    A rare case of progressive paraplegia is described. A 55 year old man was admitted on 18 February 2002, because of gradually increasing weakness in both legs, sensory disturbance below the level of T7, and a significant loss of body weight.

    A physical examination revealed an oval giant ulcerating tumour of the back, measuring 30 cm × 20 cm, which destroyed the skin of the entire thoracic area, the subcutaneous tissue, and the thoracolumbar fascia, and invaded the muscles. The spinous processes of the T5–T8 thoracic vertebrae were exposed centrally (fig 1). The lesion has been growing over a 10 year period and finally developed into an ulcus terebrans. The patient had not received any previous treatment because of his attitude of neglect.

    MRI of the spine showed an advanced ulcerating tumour, which had deeply destroyed larger parts of the back, infiltrating the thoracic spine at T5–8 vertebral level (fig 2A). Axial T1-weighted MRI of the T7 vertebrae demonstrated a tumour mass that extended into the spinal canal, compressed the cord, and involved the vertebral body (fig 2B). The lesion was biopsied and histopathologically diagnosed as an ulcerating basal cell carcinoma. Tumour nests with peripheral palisading invaded deeply into the subcutaneous tissue and were accompanied by vascular invasion. The man refused complete surgical removal. He received palliative irradiation and he was alive at last follow up.

    Basal cell carcinoma, the most common skin cancer, is locally invasive but rarely metastasises.1 Only 10% of all basal cell carcinomas are located on the trunk.

    Small basal cell carcinomas of the trunk are usually regarded as relatively harmless. In contrast, large and ulcerating basal cell carcinomas may become a therapeutic challenge with a less favourable prognosis and high risk of recurrence.2 The development of mutilating giant basal cell carcinomas appears less due to the biological aggressive character of the tumours, but rather to the patients’ attitude of neglect.2

    Figure 1

    An advanced ulcus terebrans of the back due to neglect.