Unknown Lesions Found on a 51-Year-Old Man With Eyelid Cyst

Robert S. Bader, MD

Disclosures

February 03, 2020

Discussion

Basal cell carcinoma is the most common form of skin cancer in the United States, Australia, and many other countries with a large white population. Persons of color can develop basal cell carcinoma, especially lighter-skinned individuals with a history of repeated, prolonged, recreational or occupational sun exposure.[1]

Risk factors include fair complexion, red hair, blue eyes, history of intermittent intense sun exposure, history of blistering sunburns as a child, radiation therapy, family history of basal cell carcinoma, and immunosuppression.[2] Once an individual has had a basal cell carcinoma, the risk of developing a subsequent basal cell carcinoma is about 50% within 5 years.[3]

Basal cell carcinoma presents with several different clinical morphologies, which can widely vary.[4] The clinician must be aware of these different clinical presentations. In addition, these clinical types may have different histologic features, which greatly influence the form of therapy that one would choose (see Figure 2).

The most common type of basal cell carcinoma is nodular. It usually presents as a round, pearly, or flesh-colored papule with telangiectasia. Central ulceration is common, especially with larger tumors. Bleeding with the slightest trauma is common. These tumors are found most commonly on the face, head, and neck, especially the nose.[5] The forehead, ears (especially in men), cheeks, and periocular skin are commonly affected, although any part of the body may be involved.

Micronodular tumors do not have a classic appearance; the growth pattern of small collections of tumor cells make treatment with curettage less successful. Cystic basal cell carcinomas present as a blue-grey, dome-shaped, cystic papule or nodule. Clinically, they often resemble eccrine or apocrine hidrocystomas. Pigmented variants comprise 6% of all basal cell carcinomas. They have all of the features of a nodular basal cell carcinoma, but with brown or black pigment in some or most areas of the tumor. Treatment with ionizing radiation will not resolve the pigmentation at the site of the tumor.

Superficial basal cell carcinoma is an extremely common type that is also termed superficial multicentric basal cell carcinoma. This type accounts for about 15% of all basal cell carcinomas. They are seen mostly on the upper trunk (45%), shoulders, or distal extremities (15%), appearing as an erythematous, well-circumscribed macule, patch, or plaque, often with fine scale.[5] Close examination may show telangiectasia or a pearly translucence, especially at the border. Occasionally, the tumors heal in one area, leaving a white, slightly atrophic scar as the tumor spreads to neighboring skin. The lesions enlarge slowly and are easily misdiagnosed as psoriasis or eczema. This tumor is the most common type seen in patients with HIV infection.

The infiltrative subtype is aggressive and is characterized microscopically by tumor cells infiltrating into the dermis as strands between the collagen fibers. It does not have the scarlike appearance of the morpheaform type of basal cell carcinoma. This type of growth pattern makes them less amenable to curettage.

The morpheaform, sclerotic, or cicatricial variant accounts for less than 6% of all basal cell carcinomas and often presents as a yellow-waxy or white scarlike patch or plaque that rarely ulcerates, with 95% presenting on the head or neck. These tumors are usually flat or slightly depressed, fibrotic, and firm, lacking the typical findings of a superficial or nodular basal cell carcinoma. Histologically, tumor cells grow as strands amid a densely packed hypocellular connective tissue.

When a basal cell carcinoma is neglected, a large ulceration may form. A pearly border may or may not be present. This rodent ulcer variant is easily misdiagnosed as a venous stasis ulcer when on the lower extremity. Solitary basal cell carcinomas in young persons are typically located in the region of embryonic clefts on the face. Because they are often deeply invasive, complete surgical removal is recommended; this technique is superior to curettage. Teenagers and children can be affected, and the condition may be associated with basal cell nevus syndrome or nevus sebaceus.

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