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Unusual clinical and dermoscopic features in two cases of pigmented basal cell carcinoma

2005; Elsevier BV; Volume: 53; Issue: 6 Linguagem: Inglês

10.1016/j.jaad.2005.05.045

1097-6787

Angela Ferrari, Linda De Angelis, Ketty Peris,

Cancer and Skin Lesions

To the Editor: Characteristic dermoscopic features of pigmented basal cell carcinoma (BCC) are brownish-gray to gray-black leaflike areas, large blue-gray ovoid nests, multiple blue-gray globules, and spoke-wheel areas.1Menzies S.W. Westerhoff K. Rabinovitz H. Kopf A.W. McCarthy W.H. Katz B. Surface microscopy of pigmented basal cell carcinoma.Arch Dermatol. 2000; 136: 1012-1016Crossref PubMed Scopus (292) Google Scholar However, rare cases have been described in which pigmented BCC displayed features normally found in melanocytic lesions such as blue-whitish veil, multiple brown dots, pseudopods, and pigment network.1Menzies S.W. Westerhoff K. Rabinovitz H. Kopf A.W. McCarthy W.H. Katz B. Surface microscopy of pigmented basal cell carcinoma.Arch Dermatol. 2000; 136: 1012-1016Crossref PubMed Scopus (292) Google Scholar We report two cases of pigmented BCC characterized by equivocal clinical aspects and dermoscopic features typical of melanocytic lesions.Case 1A 16-year-old girl was referred to our clinic for an asymptomatic, firm, 7.4-mm, blue-brown nodule with well-defined and regular border, located on the right side of her neck (Fig 1, A, insert). The lesion, which had been present for 18 months, had slowly enlarged and undergone a change in color during the last 8 months. The patient had no family history of BCC or melanoma.The clinical diagnosis of the lesion was dermal nevus. Dermoscopic analysis showed numerous brown to blue-gray dots/globules, an irregular blue-gray area, and gray-brown elongated structures irregularly distributed at the periphery of the lesion, which were reminiscent of streaks, leaflike areas, or large blue-gray ovoid nests (Fig 1, A). Although the presence of brown dots/globules was highly suggestive of a melanocytic lesion, the equivocal peripheral elongated structures made the diagnosis uncertain.Histopathologic examination showed typical features of pigmented BCC (Fig 1, B).Case 2A 44-year-old woman presented with an asymptomatic, 2.6-cm, well-defined brown to black plaque with irregular border, located on the left parietal region (Fig 2, A, insert). The patient had noticed the lesion 2 months earlier but she was unable to give more information about its duration and/or changes. The patient had no personal or family history of BCC or melanoma. The clinical differential diagnoses were atypical Clark nevus and melanoma.Fig 2Case 2. A, Dermoscopic analysis shows diffuse light to dark brown pigmentation overlaid with brown to blue-gray dots/globules, and blue-gray areas (insert: clinical image). B, Histopathologic examination reveals typical features of pigmented basal cell carcinoma. (Hematoxylin-eosin stain, original magnification: ×2.)View Large Image Figure ViewerDownload (PPT)Dermoscopic analysis showed a diffuse light-to-dark brown pigmentation overlaid with brown to blue-gray dots/globules and blue-gray areas irregularly distributed within the lesion (Fig 2, A). The dermoscopic diagnosis was melanoma, although the lesion lacked other features highly suggestive of melanoma such as atypical pigment network, blue-whitish veil, and atypical vascular pattern. Histopathologic examination was suggestive of pigmented BCC (Fig 2, B).Based on clinical and dermoscopic appearances, we misdiagnosed BCC in these two cases as atypical melanocytic lesion and melanoma, respectively. In both cases, we were misled by the presence of melanocytic features, notably brown dots/globules, which are rarely seen in BCC.1Menzies S.W. Westerhoff K. Rabinovitz H. Kopf A.W. McCarthy W.H. Katz B. Surface microscopy of pigmented basal cell carcinoma.Arch Dermatol. 2000; 136: 1012-1016Crossref PubMed Scopus (292) Google Scholar, 2Pehamberger H. Steiner A. Wolff K. In vivo epiluminescence microscopy of pigmented skin lesions, I: pattern analysis of pigmented skin lesions.J Am Acad Dermatol. 1987; 17: 571-573Abstract Full Text PDF PubMed Scopus (544) Google ScholarThe first case was unusual not only for the occurrence of BCC in a young woman but also for displaying peripheral, elongated gray-brown structures that were interpreted as streaks, leaflike areas, or large blue-gray ovoid nests. In the second case, the irregular distribution of blue-gray dots/globules and blue-gray areas did not allow us to rule out a diagnosis of melanoma.2Pehamberger H. Steiner A. Wolff K. In vivo epiluminescence microscopy of pigmented skin lesions, I: pattern analysis of pigmented skin lesions.J Am Acad Dermatol. 1987; 17: 571-573Abstract Full Text PDF PubMed Scopus (544) Google Scholar, 3Argenziano G. Fabbrocini G. Carli P. De Giorgi V. Delfino M. Epiluminescence microscopy: criteria of cutaneous melanoma progression.J Am Acad Dermatol. 1997; 37: 68-74Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar The blue-gray areas and the blue-gray dots/globules could be interpreted as large blue-gray ovoid nests and multiple blue-gray globules, respectively.4Peris K. Altobelli E. Ferrari A. Fargnoli M.C. Piccolo D. Esposito M. et al.Interobserver agreement on dermoscopic features of pigmented basal cell carcinoma.Derm Surg. 2002; 28: 643-645Crossref PubMed Scopus (48) Google ScholarIn conclusion, the global pattern of a lesion should always be considered in the dermoscopic evaluation of melanocytic lesions, and pigmented BCC should be included in the differential diagnosis. To the Editor: Characteristic dermoscopic features of pigmented basal cell carcinoma (BCC) are brownish-gray to gray-black leaflike areas, large blue-gray ovoid nests, multiple blue-gray globules, and spoke-wheel areas.1Menzies S.W. Westerhoff K. Rabinovitz H. Kopf A.W. McCarthy W.H. Katz B. Surface microscopy of pigmented basal cell carcinoma.Arch Dermatol. 2000; 136: 1012-1016Crossref PubMed Scopus (292) Google Scholar However, rare cases have been described in which pigmented BCC displayed features normally found in melanocytic lesions such as blue-whitish veil, multiple brown dots, pseudopods, and pigment network.1Menzies S.W. Westerhoff K. Rabinovitz H. Kopf A.W. McCarthy W.H. Katz B. Surface microscopy of pigmented basal cell carcinoma.Arch Dermatol. 2000; 136: 1012-1016Crossref PubMed Scopus (292) Google Scholar We report two cases of pigmented BCC characterized by equivocal clinical aspects and dermoscopic features typical of melanocytic lesions. Case 1A 16-year-old girl was referred to our clinic for an asymptomatic, firm, 7.4-mm, blue-brown nodule with well-defined and regular border, located on the right side of her neck (Fig 1, A, insert). The lesion, which had been present for 18 months, had slowly enlarged and undergone a change in color during the last 8 months. The patient had no family history of BCC or melanoma.The clinical diagnosis of the lesion was dermal nevus. Dermoscopic analysis showed numerous brown to blue-gray dots/globules, an irregular blue-gray area, and gray-brown elongated structures irregularly distributed at the periphery of the lesion, which were reminiscent of streaks, leaflike areas, or large blue-gray ovoid nests (Fig 1, A). Although the presence of brown dots/globules was highly suggestive of a melanocytic lesion, the equivocal peripheral elongated structures made the diagnosis uncertain.Histopathologic examination showed typical features of pigmented BCC (Fig 1, B). A 16-year-old girl was referred to our clinic for an asymptomatic, firm, 7.4-mm, blue-brown nodule with well-defined and regular border, located on the right side of her neck (Fig 1, A, insert). The lesion, which had been present for 18 months, had slowly enlarged and undergone a change in color during the last 8 months. The patient had no family history of BCC or melanoma. The clinical diagnosis of the lesion was dermal nevus. Dermoscopic analysis showed numerous brown to blue-gray dots/globules, an irregular blue-gray area, and gray-brown elongated structures irregularly distributed at the periphery of the lesion, which were reminiscent of streaks, leaflike areas, or large blue-gray ovoid nests (Fig 1, A). Although the presence of brown dots/globules was highly suggestive of a melanocytic lesion, the equivocal peripheral elongated structures made the diagnosis uncertain. Histopathologic examination showed typical features of pigmented BCC (Fig 1, B). Case 2A 44-year-old woman presented with an asymptomatic, 2.6-cm, well-defined brown to black plaque with irregular border, located on the left parietal region (Fig 2, A, insert). The patient had noticed the lesion 2 months earlier but she was unable to give more information about its duration and/or changes. The patient had no personal or family history of BCC or melanoma. The clinical differential diagnoses were atypical Clark nevus and melanoma.Dermoscopic analysis showed a diffuse light-to-dark brown pigmentation overlaid with brown to blue-gray dots/globules and blue-gray areas irregularly distributed within the lesion (Fig 2, A). The dermoscopic diagnosis was melanoma, although the lesion lacked other features highly suggestive of melanoma such as atypical pigment network, blue-whitish veil, and atypical vascular pattern. Histopathologic examination was suggestive of pigmented BCC (Fig 2, B).Based on clinical and dermoscopic appearances, we misdiagnosed BCC in these two cases as atypical melanocytic lesion and melanoma, respectively. In both cases, we were misled by the presence of melanocytic features, notably brown dots/globules, which are rarely seen in BCC.1Menzies S.W. Westerhoff K. Rabinovitz H. Kopf A.W. McCarthy W.H. Katz B. Surface microscopy of pigmented basal cell carcinoma.Arch Dermatol. 2000; 136: 1012-1016Crossref PubMed Scopus (292) Google Scholar, 2Pehamberger H. Steiner A. Wolff K. In vivo epiluminescence microscopy of pigmented skin lesions, I: pattern analysis of pigmented skin lesions.J Am Acad Dermatol. 1987; 17: 571-573Abstract Full Text PDF PubMed Scopus (544) Google ScholarThe first case was unusual not only for the occurrence of BCC in a young woman but also for displaying peripheral, elongated gray-brown structures that were interpreted as streaks, leaflike areas, or large blue-gray ovoid nests. In the second case, the irregular distribution of blue-gray dots/globules and blue-gray areas did not allow us to rule out a diagnosis of melanoma.2Pehamberger H. Steiner A. Wolff K. In vivo epiluminescence microscopy of pigmented skin lesions, I: pattern analysis of pigmented skin lesions.J Am Acad Dermatol. 1987; 17: 571-573Abstract Full Text PDF PubMed Scopus (544) Google Scholar, 3Argenziano G. Fabbrocini G. Carli P. De Giorgi V. Delfino M. Epiluminescence microscopy: criteria of cutaneous melanoma progression.J Am Acad Dermatol. 1997; 37: 68-74Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar The blue-gray areas and the blue-gray dots/globules could be interpreted as large blue-gray ovoid nests and multiple blue-gray globules, respectively.4Peris K. Altobelli E. Ferrari A. Fargnoli M.C. Piccolo D. Esposito M. et al.Interobserver agreement on dermoscopic features of pigmented basal cell carcinoma.Derm Surg. 2002; 28: 643-645Crossref PubMed Scopus (48) Google ScholarIn conclusion, the global pattern of a lesion should always be considered in the dermoscopic evaluation of melanocytic lesions, and pigmented BCC should be included in the differential diagnosis. A 44-year-old woman presented with an asymptomatic, 2.6-cm, well-defined brown to black plaque with irregular border, located on the left parietal region (Fig 2, A, insert). The patient had noticed the lesion 2 months earlier but she was unable to give more information about its duration and/or changes. The patient had no personal or family history of BCC or melanoma. The clinical differential diagnoses were atypical Clark nevus and melanoma. Dermoscopic analysis showed a diffuse light-to-dark brown pigmentation overlaid with brown to blue-gray dots/globules and blue-gray areas irregularly distributed within the lesion (Fig 2, A). The dermoscopic diagnosis was melanoma, although the lesion lacked other features highly suggestive of melanoma such as atypical pigment network, blue-whitish veil, and atypical vascular pattern. Histopathologic examination was suggestive of pigmented BCC (Fig 2, B). Based on clinical and dermoscopic appearances, we misdiagnosed BCC in these two cases as atypical melanocytic lesion and melanoma, respectively. In both cases, we were misled by the presence of melanocytic features, notably brown dots/globules, which are rarely seen in BCC.1Menzies S.W. Westerhoff K. Rabinovitz H. Kopf A.W. McCarthy W.H. Katz B. Surface microscopy of pigmented basal cell carcinoma.Arch Dermatol. 2000; 136: 1012-1016Crossref PubMed Scopus (292) Google Scholar, 2Pehamberger H. Steiner A. Wolff K. In vivo epiluminescence microscopy of pigmented skin lesions, I: pattern analysis of pigmented skin lesions.J Am Acad Dermatol. 1987; 17: 571-573Abstract Full Text PDF PubMed Scopus (544) Google Scholar The first case was unusual not only for the occurrence of BCC in a young woman but also for displaying peripheral, elongated gray-brown structures that were interpreted as streaks, leaflike areas, or large blue-gray ovoid nests. In the second case, the irregular distribution of blue-gray dots/globules and blue-gray areas did not allow us to rule out a diagnosis of melanoma.2Pehamberger H. Steiner A. Wolff K. In vivo epiluminescence microscopy of pigmented skin lesions, I: pattern analysis of pigmented skin lesions.J Am Acad Dermatol. 1987; 17: 571-573Abstract Full Text PDF PubMed Scopus (544) Google Scholar, 3Argenziano G. Fabbrocini G. Carli P. De Giorgi V. Delfino M. Epiluminescence microscopy: criteria of cutaneous melanoma progression.J Am Acad Dermatol. 1997; 37: 68-74Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar The blue-gray areas and the blue-gray dots/globules could be interpreted as large blue-gray ovoid nests and multiple blue-gray globules, respectively.4Peris K. Altobelli E. Ferrari A. Fargnoli M.C. Piccolo D. Esposito M. et al.Interobserver agreement on dermoscopic features of pigmented basal cell carcinoma.Derm Surg. 2002; 28: 643-645Crossref PubMed Scopus (48) Google Scholar In conclusion, the global pattern of a lesion should always be considered in the dermoscopic evaluation of melanocytic lesions, and pigmented BCC should be included in the differential diagnosis.