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Year : 2022  |  Volume : 67  |  Issue : 4  |  Page : 481
Basal cell carcinoma and intra-dermal nevus: An addition to BCC associated “MUSK IN A NEST”

From the Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Web Publication2-Nov-2022

Correspondence Address:
Vikram Narang
From the Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_677_21

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How to cite this article:
Soni A, Jindal S, Narang V, Garg B, Kaur H. Basal cell carcinoma and intra-dermal nevus: An addition to BCC associated “MUSK IN A NEST”. Indian J Dermatol 2022;67:481

How to cite this URL:
Soni A, Jindal S, Narang V, Garg B, Kaur H. Basal cell carcinoma and intra-dermal nevus: An addition to BCC associated “MUSK IN A NEST”. Indian J Dermatol [serial online] 2022 [cited 2022 Dec 8];67:481. Available from:


A 54-year-old female presented with non-healing, slow-growing, ulcer over left cheek of seven months duration. The ulcer was situated over left cheek measuring 2x1cm with rolled out margins. Clinical possibility of the ulcer being basal cell carcinoma was kept and wide local excision of lesion was carried out. Histopathological examination confirmed basal cell carcinoma (BCC) within the area of ulcer; seen as nests of basaloid cells having peripheral palisading with retraction artifacts and presence of extracellular mucin. Also identified was an intra-dermal nevus present next to BCC; seen as presence of nevus cells within the dermis with no junctional activity. There was a clear-cut demarcation between the two tumours. On immunohistochemistry, the BCC component expressed immunopositivity for Ber-EP4 while the nevus cells were immunopositive for S-100. Thus, a final histopathological diagnosis of basal cell carcinoma with concurrent intradermal nevus was rendered [Figure 1].
Figure 1: Photomicrograph (haematoxylin and eosin stain; ×40) shows BCC with adjacent intra-dermal nevus (panel a); Photomicrograph (haematoxylin and eosin stain; ×100) shows intra-dermal nevus (panel b); Photomicrograph (haematoxylin and eosin stain; ×100) shows BCC (panel c); Intradermal nevus shows immunopositivity (x100) for S-100 (panel d); BCC shows immunopositivity (×100) for Ber-EP4 (panel e)

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A “collision tumor” is described as the occurrence of more than one benign or malignant neoplasm at the same anatomic location.[1] The terminology “collision tumor” indicates that the association between the two skin tumors is accidental which led to the proposal of a few new terminologies like “compound tumors” and “multiple skin neoplasms at one site (MUSK IN A NEST)”[2] by some authors. Cohen et al.[2] proposed the acronym “MUSK IN A NEST” which is composed of letters from descriptive terminology “multiple skin neoplasms at one site.” The authors also proposed dineoplastic, trineoplastic, tetraneoplastic, pentaneoplastic, and hexaneoplastic cutaneous tumors for two to six skin tumors at the same site, respectively. Our case was a dineoplastic skin tumor with a combination of one benign and one malignant neoplasm. Cohen et al. reviewed the literature about BCC-associated “MUSK IN A NEST” and found out that the associated second neoplasm belonged to one of the various categories such as adnexal tumors, fibrous tumors, hamartomas, keratinous tumors, melanocytic and pigmented tumors, neural tumors, vascular and lymphatic tumors. Yet, the combination of BCC and melanocytic nevus was uncommonly found and only a few cases of this association have been reported in the literature to date.[1],[3]

Various theories have been postulated to explain the occurrence of MUSK IN A NEST. The first theory states that this coexistence is merely accidental. The second theory proposed that the occurrence of a second tumor is due to epithelial and/or stromal changes induced by the first tumor.[1] The third theory is related to the field cancerization phenomenon which states that the coexistence of MUSK IN A NEST is linked to common etiological factors such as ultraviolet radiation or other environmental carcinogens.[4] The fourth theory is related to stem cell cancerization which states that a common progenitor cell or stem cell is responsible for the development of biphasic neoplasm.[5] It is important to be aware of the possibility of the occurrence of MUSK IN A NEST. Yet, histopathological examination is mandatory to document the types of various coexisting cutaneous neoplasms to determine the treatment plan and prognosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Boyd AS, Rapini RP. Cutaneous collision tumors. An analysis of 69 cases and review of the literature. Am J Dermatopathol 1994;16:253-7.  Back to cited text no. 1
Cohen PR, Calame A. Multiple skin neoplasms at one site (MUSK IN A NEST): A comprehensive review of basal cell carcinoma and benign or malignant “collision” tumors at the same cutaneous location. Clin Cosmet Investig Dermatol 2020;13:731-41.  Back to cited text no. 2
Moscarella E, Rabinovitz H, Oliviero MC, Brown L, Longo C, Zalaudek I, et al. The role of reflectance confocal microscopy as an aid in the diagnosis of collision tumors. Dermatology 2013;227:109-17.  Back to cited text no. 3
Pierard GE, Fazaa B, Henry F, Kamoun MR, Pierard-Franchimont C. Collision of primary malignant neoplasms on the skin: The connection between malignant melanoma and basal cell carcinoma. Dermatology 1997;194:378-9.  Back to cited text no. 4
Cornejo KM, Deng AC. Malignant melanoma within squamous cell carcinoma and basal cell carcinoma: Is it a combined or collision tumor?–A case report and review of the literature. Am J Dermatopathol 2013;35:226-34.  Back to cited text no. 5


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