Year : 2005 | Volume
: 50 | Issue : 3 | Page : 161--163
Unusual presentation of basal cell carcinoma on face
B Jeevankumar, Devinder Mohan Thappa
Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605 006, India
Devinder Mohan Thappa
Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605 006
A 63-year-old woman presented with an asymptomatic slowly growing lesion on the nose of 5 years duration. On cutaneous examination, the nose and adjacent left cheek showed a single, large, ill-defined, indurated annular plaque with distinct margin. Close examination of the edges of the plaque revealed thread like raised border. A biopsy from the edge of the plaque showed buds and irregular proliferations of tumor tissue attached to the undersurface of the epidermis and masses of epitheliometous basal cells in the dermis surrounded by clear-cut spaces and dermal fibrotic changes. The peripheral cell layer of the tumor formations showed palisading. These histologic features were consistent with basal cell carcinoma. We, herewith report this case of overlap of superficial spreading BCC with morphea-like basal cell carcinoma for its rarity and unique features.
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Jeevankumar B, Thappa DM. Unusual presentation of basal cell carcinoma on face.Indian J Dermatol 2005;50:161-163
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Jeevankumar B, Thappa DM. Unusual presentation of basal cell carcinoma on face. Indian J Dermatol [serial online] 2005 [cited 2021 Feb 28 ];50:161-163
Available from: https://www.e-ijd.org/text.asp?2005/50/3/161/18933
Basal cell carcinoma (BCC) is a malignant skin tumor arising from basal cells of the surface epidermis or external root sheath of the hair follicle. Many clinical variants have been described. These include: (1) noduloulcerative type (2) the superficial spreading type (3) pigmented (4) Pinkus tumor (5) morphea-like and (6) the cystic type. We herewith report a case of overlap of superficial spreading BCC with morphea-like basal cell carcinoma in a 63 year-old woman for its rarity and unique features.
A 63-year-old woman presented with an asymptomatic slowly growing lesion on the nose of 5 years duration. It started as a small reddish spot over the nose, which gradually increased in size over the last 5 years to attain the present size, covering nearly the whole of the nose extending on to the left cheek. There was no history of radiation therapy or trauma preceding the development of this growth. She had no constitutional symptoms or medical problems.
On cutaneous examination, the nose and adjacent left cheek showed a single, large, indurated annular plaque with distinct margin [Figure 1]. The surface of the plaque was smooth and shiny. Close examination of the edges of the plaque revealed thread like raised border. The patient's general condition was good and regional lymph nodes were not enlarged.
Laboratory data, including blood counts, liver and renal function tests were all normal. X-ray of the nose showed no bone destruction or calcification. A biopsy from the edge of the plaque showed buds and irregular proliferations of tumor tissue attached to the undersurface of the epidermis and masses of basal cell epithelioma cells in the dermis surrounded by clear-cut spaces and dermal fibrotic changes. The peripheral cell layer of the tumor formations showed palisading [Figure 2]. These histologic features were consistent with basal cell carcinoma. The patient was sent to Plastic Surgery department for wide excision and grafting.
Morphea-like basal cell carcinoma is an uncommon form of basal cell carcinoma. This type form 2% of all basal cell carcinomas. They have also been referred to as fibrosing, scirrhous, desmoplastic and morpheic forms. The morphea-like BCC is well described by Howell and Caro as follows: (1) the clinical appearance not generally suggestive of a neoplasm (2) wax-like white or yellowish white color (3) localization to the head and neck (4) obscure margin of the lesion and conspicuous absence of a rolled edge or thread like elevated pearly border, a feature differentiates morphea-like BCC from superficial cicatrizing epithelioma (5) the sclerosus consistency of the lesion which suggests a piece of leather let into the skin (6) absence of ulceration or crusting of surface unless secondary to trauma or treatment (7) a smooth shiny surface occasionally covered by an almost imperceptible scale, while older lesions may have a depressed or delled center (8) telangiectatic surface (9) failure to respond to conventional therapy. The lesion generally is single. The shape of this tumor is variable and the size varies from a few mm in diameter to an area as large as one-half of the forehead. The tumor is not common in association with farmers and sailor's skin, xeroderma pigmentosum, or chronic roentgen dermatitis and apparently it does not develop from the precancerous dermatoses.
Morphea-like BCC has characteristic histologic features which include the strands of basal cells interspersed amid dense fibrous stroma. Most of the strands are narrow often only one cell thick. However on careful searching, one may find a few large aggregates and branching tumor cells. The strands of tumor cells often extend deep into the dermis. Often the degree of infiltration far exceeds what is clinically apparent. If the stroma has dense eosinophilic areas resembling a keloid, the term 'morpheic' has traditionally been used. Genetic studies have found the enhanced procollagen gene expression in this variant. Also large defects have been found in the basal lamina that surrounds the tumor nests. Smooth muscle alpha-actin and myosin are often present in stroma. Histologically this tumor has to be differentiated from desmoplastic trichoepithelioma which shows considerable number of horn cysts besides having in common a thin strand of small basaloid cells embedded in a dense fibrous stroma.
The close clinical differential diagnosis of morphea-like BCC is superficial cicatrizing basal cell carcinoma, which resembles localized scleroderma only in its central, partially healed portion. They occur exclusively on the cheeks. The tumor manifests as cicatricial surface with nests of active lesions that are usually ulcerated. A fine waxy border or a thread like raised edge as well as telangiectasia is present.,  Our case showed overlapping features. Though morphology of the plaque suggested morphea-like BCC, outer edge of the lesion suggested superficial spreading BCC.
The natural course of the tumor varies from that of a very slowly growing lesion in most cases to an invasive, destructive and very dangerous cancer in others. Morphea-like BCC occurring on the 'H-zone' that is on the nose, forehead and temple have higher risk of recurrence after therapy than other regions of the face. Especially troublesome areas are the embryonic fusion planes such as nasolabial fold, medial canthus and the area behind the ears. BCCs in these regions can grow as 'icebergs' with only the top of the tumor visible. Aggressive tumor like morphea-like BCC creates treatment dilemmas. They do not respond well to superficial or ablative procedures such as curettage, electrodessication, cryotherapy or shave excision. Since they have a higher risk of recurrence, treatment is generally surgical. Mohs micrographic surgery has been advocated since this technique offers the best possible evaluation of the excision margins., 
In conclusion, morphea-like BCC is one of the rare morphological variant of BCC. However, the occurrence of bizarre clinical presentations over typical sites often leads to misdiagnosis and inappropriate treatments causing significant morbidity. This case report highlights an unusual case of morphea-like BCC with overlapping features of superficial spreading type BCC occurring on the nose of a woman having remarkable resemblence to lupus vulgaris. The diagnosis in our case was confirmed by histopathology. This type of BCC deserves well-planned therapy because of its destructive potential.
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