Superficial Basal Cell Carcinoma on the Face is a Diagnostic Challenge.

Basal cell carcinoma (BCC) is the most common non-melanoma skin cancer. The incidence of BCC is rising. The nodular, superficial spreading, and infiltrating variants are the three most commonly encountered types of BCC in descending order of prevalence. Superficial spreading basal cell carcinoma (SSBCC) accounts for 15-26% of all cases of BCC. It usually occurs on the trunk and upper extremities, but may be seen on the face. Surgical excision is the most commonly used treatment for BCC. Topical chemotherapy agents such as imiquimod or 5-fluorouracil (5-FU) may be various alternatives or adjuvants in the treatment of SSBCC. characteristically shows areas of uninvolved skin between tumor nests.[7].

What was known?

SSBCC is generally a low-grade neoplasm but it can cause significant destruction

It has highest recurrence rate

Appropriate diagnosis and therapy is essential.

Introduction

A 50-year-old woman with no significant medical history presented at the outpatient department (OPD) with a red, slightly scaly, and well demarcated patch [Figure 1]. A punch biopsy was performed and the histopathology slide showed multiple nests of tumor cells with palisading basaloid cells from the dermo-epidermal junction [Figures 2 and 3]. The cells had darker nuclei. However, cleft-like retraction spaces were not seen between the tumor nests and mucinous stroma. Such cleft-like spaces, although characteristic of basal cell carcinoma (BCC), are often not seen in superficial spreading basal cell carcinoma (SSBCC). Histology images suggested SSBCC in this patient and the diagnosis was made.

Figure 1

Lesion present on left temple

Figure 2

SSBCC. Nests of tumor cells at the dermo-epidermal junction (H and E, original magnification ×10)

Figure 3

SSBCC. A cluster of basaloid tumor cells budding downward from the basal cell layer, limited to the dermo-epidermal junction, is visible here. It is flanked on both sides by tumor-free tissue. (H and E, original magnification ×40)

The patient was given topical 5-fluorouracil (5-FU) 5% cream. After washing the entire affected area with soap she used a match stick to apply the medicine. She applied enough medicine each time to cover the area with a thin layer.

She used the 5% cream on the affected areas of 3 × per week (alternate days) [Figure 4].

Figure 4

Lesion 1 month after treatment with topical 5-FU

Discussion

BCC is generally a low-grade neoplasm. Although it can be locally invasive and destructive, it rarely metastasizes and is readily amenable to excisional management. However, facial BCC is particularly of concern because it is considered malignant. It can cause significant destruction and disfigurement by invading surrounding tissues. It also has one of the highest recurrence rates of any BCC. Therefore, appropriate diagnosis and therapy are essential.

SSBCC appears as a scaly and well-defined area. It can resemble a patch of dermatitis and can be confused with eczema, psoriasis, lichen planus, or Bowen's disease.[38]

Thus, the clinical features alone may not point to the appropriate diagnosis. Histopathology is the most reliable diagnostic modality for SSBCC.

Conclusion

A cluster of basaloid cells palisading at the border, budding downward from the basal layer within the dermo-epidermal junction, is the hallmark of SSBCC.

What is new?

Topical 5-fluorouracil (5-FU) 5% cream is effective and safe in treatment of SSBCC.