Case for Diagnosis
Basal Cell Carcinoma on an Atypical Location
Carcinoma basocelular en localización atípica
B. Pimentel
, A. Palmeiro, A. Miroux-Catarino
Corresponding author
Serviço de Dermatologia do Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
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"apellidos" => "Pimentel" "email" => array:1 [ 0 => "pimentel233@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Palmeiro" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Miroux-Catarino" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Dermatologia do Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Carcinoma basocelular en localización atípica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 371 "Ancho" => 755 "Tamanyo" => 79708 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical history and physical examination</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 79-year-old man, with a past medical history of arterial hypertension and dyslipidemia, consulted for a rapidly growing 6-month history lesion on his right inguinocrural region. Physical examination revealed the presence of a well-demarcated erythematous patch of >5<span class="elsevierStyleHsp" style=""></span>cm in diameter, with ulcerated bleeding nodules in the middle, which were painful and friable to the touch (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Dermoscopy confirmed the presence of well-demarcated bright red structureless areas surrounded by orange-hue homogeneous areas covered with scattered brown scales (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Histopathology</span><p id="par0010" class="elsevierStylePara elsevierViewall">The full-thickness skin biopsy of a nodule revealed the presence of cell clumps resembling epidermal basal cells (round nuclei, dense chromatin, and scarce basophilic cytoplasm), with solid centers (totally filled with cells) and peripheral layers with perpendicularly arranged nuclei – palisading nuclei. BerEP4 immunohistochemistry was strongly positive, with intense antibody staining by the cell clumps (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">What is your diagnosis?</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Basal cell carcinoma.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Course of the disease and treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">Due to the extent of the lesion, the patient was first treated with neoadjuvant topical imiquimod 12.5<span class="elsevierStyleHsp" style=""></span>mg/250<span class="elsevierStyleHsp" style=""></span>mg ointment once daily for 5 consecutive days each week for 6 weeks with this treatment alone. Excellent functional and cosmetical outcomes were reported, and since the follow-up biopsy turned out negative for tumor cells after this period, we decided to keep the patient under close observation sparing surgery.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Comment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Non-melanoma skin cancer represents about 1/3 of all malignancies diagnosed worldwide each year. In particular, basal cell carcinoma, is the most common human cancer of all.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Age is an independent risk factor (as the incidence rate doubles from the 4th to the 7th decades of life) and is more prevalent in men, with a 1.5–2 to 1 men-to-women ratio. Because its incidence is on the rise (which will probably continue to rise given the aging population with past and current UV exposure), so are the associated burden and costs, which is a public health problem.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand, basal cell carcinoma mainly affects photo-exposed areas (mostly head, cheeks, and nose, less commonly the trunks and limbs).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Only 1% of the lesions appear on the genitals and perineal area.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> As such, this diagnosis might be overlooked when approaching lesions in these areas. The fact that it is a paucisymptomatic entity (with the patients exhibiting minimal pruritus or occasional bleeding) contributes to delaying its diagnosis. Some factors that have been involved in the development of non-photo exposed areas basal cell carcinoma include chronic maceration, trauma, immunosuppression, arsenic exposure, and ionizing radiation.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Other diagnoses were first considered, such as angiosarcoma, cutaneous lymphoma, squamous cell carcinoma and skin metastasis from an unknown primary tumor. Skin biopsy and immunohistochemistry further allowed definitive diagnosis of basal cell carcinoma.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This case stresses the importance of considering basal cell carcinoma in older patients with lesions of atypical presentations. Although rarely fatal—since systemic disease and metastasis are uncommon—if left untreated it can invade deep into the skin and underlying soft tissues, being highly destructive and disfiguring,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> thus contributing to poor functionality, disability, and disease burden. Proper diagnosis and treatment are crucial to avoid such poor outcomes.</p></span></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical history and physical examination" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Histopathology" ] 2 => array:3 [ "identificador" => "sec0015" "titulo" => "Diagnosis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Course of the disease and treatment" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Comment" ] ] ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1006 "Ancho" => 755 "Tamanyo" => 89238 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 930 "Ancho" => 755 "Tamanyo" => 102164 ] ] ] 2 => array:6 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 371 "Ancho" => 755 "Tamanyo" => 79708 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Changing trends in the disease burden of non-melanoma skin cancer globally from 1990 to 2019 and its predicted level in 25 years" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "W. Hu" 1 => "L. Fang" 2 => "R. Ni" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12885-022-09940-3" "Revista" => array:5 [ "tituloSerie" => "BMC Cancer" "fecha" => "2022" "volumen" => "22" "paginaInicial" => "836" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/35907848" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Basal cell carcinoma: epidemiology; pathophysiology; clinical and histological subtypes; and disease associations" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.C. Cameron" 1 => "E. Lee" 2 => "B.P. Hibler" 3 => "C.A. Barker" 4 => "S. Mori" 5 => "M. Cordova" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2018.03.060" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2019" "volumen" => "80" "paginaInicial" => "303" "paginaFinal" => "317" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29782900" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Distribution of basal cell carcinoma and squamous cell carcinoma by facial esthetic unit" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.H. Choi" 1 => "Y.J. Kim" 2 => "H. Kim" 3 => "S.H. Nam" 4 => "Y.W. Choi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Arch Plastic Surg" "fecha" => "2013" "volumen" => "40" "paginaInicial" => "387" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Basal cell carcinoma of the axilla: review of the World literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P.R. Cohen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s40257-014-0066-8" "Revista" => array:6 [ "tituloSerie" => "Am J Clin Dermatol" "fecha" => "2014" "volumen" => "15" "paginaInicial" => "95" "paginaFinal" => "100" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24567258" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Basal cell carcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. McDaniel" 1 => "T. Badri" 2 => "R.B. Steele" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "titulo" => "StatPearls [Internet]" "fecha" => "2022" "editorial" => "StatPearls Publishing" "editorialLocalizacion" => "Treasure Island (FL)" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00017310/unassign/S0001731024001832/v1_202404150410/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/00017310/unassign/S0001731024001832/v1_202404150410/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731024001832?idApp=UINPBA000044" ]
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