Basal Cell Carcinoma: Looks Can Be Deceiving

October 23, 2013

Basal cell carcinoma often has a distinct appearance: a waxy bump that is pearly or translucent, with a rolled border is classic. But its appearance can raise suspicion for other conditions-mainly melanoma. Here are some examples of typical and atypical BCCs.

Morphologic manifestations: The almost translucent papule on the upper lip of an 86-year-old woman has a few small blood vessels traversing its surface. These are all typical morphologic features of basal cell carcinoma.

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Morphologic manifestations: This non-tender, subtle “indentation” in the forehead of a 78-year-old man is also basal cell carcinoma, but it lacks the characteristic pearly, telangiectatic morphology.

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Variations in pigmentations: This asymptomatic smooth and translucent lesion on the upper arm of a construction worker suggests a basal cell carcinoma. Such lesions can be variably pigmented, especially when the patient’s skin tone is dark. This patient was Hispanic.

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Variations in pigmentation: This relatively small (1 cm) nodule on the arm of a 57-year-old man displays an underlying erythema as well as punctuate superficial dark black pigmentation. While this morphology strongly suggests a dysplastic nevus or even a melanoma, pigmented basal cell carcinoma can appear in this manner. A small punch biopsy confirmed basal cell carcinoma with focal hypermelanosis.

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Variations in pigmentation: When this lesion was seen on the face of a 54-year-old farm worker, cutaneous melanoma was the immediate concern. This neoplasm proved to be a pigmented basal cell carcinoma-a rare form that has no greater tendency toward malignancy than nonpigmented types. This is one of at least 5 variants of BCC, which account for more than 75% of skin cancers.

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Bleeding and serosanguineous discharge: This firm, round tumor with fine telangiectatic vessels and an ulcerated center covered by necrotic material and serosanguineous discharge is a basal cell carcinoma-the most common malignant tumor involving the ocular adnexa. It accounts for 90% of all eyelid cancers.

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Bleeding and serosanguineous discharge: This very small papule with a single spot of dried blood at one side was found on the nose of a 69-year-old man. The man reported that the spot bled intermittently, although it had not grown. A key point is that almost no benign disorder that affects nasal skin should bleed. A small shave biopsy revealed basal cell carcinoma.

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Lesion borders and pigmentation changes: An 82-year-old woman ascribed this persistent “sore” to repeatedly and frequently blowing her nose during a recent upper respiratory tract infection. Close examination revealed a thin but distinct rolled and pearly border surrounding the crusted ulceration. A biopsy demonstrated micronodular basal cell carcinoma.

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Lesion borders and pigmentation changes: A 75-year-old Hispanic woman presented with a slowly growing, asymptomatic facial lesion of about 3 years’ duration. The persistent, irregularly shaped plaque involved both the pinna and preauricular skin and had a prominent rolled border; multiple discrete, darkly pigmented nodules; and central regression with fibrosis. A biopsy revealed nests of typical basal cell carcinoma with massive deposition of melanin within the tumor cells. Basal cell carcinoma can sometimes simulate melanoma and manifest unusual coloration on dark-skinned persons.

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