Dermoscopy and reflectance confocal microscopy in pedunculated basal cell carcinoma.

There have been limited cases of pedunculated basal cell carcinoma (BCC) reported in the literature. The dermoscopic features were described in only one of them. However, not one of them described the confocal microscopy features. In this report we presented a case of pedunculated basal cell carcinoma (BCC) with dermoscopic and reflectance confocal microscopy features.

Introduction

Pedunculated basal cell carcinoma (BCC) is a rare BCC variant. There have been limited cases reported in the PubMed database [1-6]. Dermoscopic features were reported in only one of them [6] and not one described reflectance confocal microscopy (RCM) features.

Case

A 7 × 5 mm slight brown-gray pigmented pedunculated lesion was detected on the right post-auricular region on the routine skin examination of a 60-year-old woman. She had a history of multiple BCCs due to radiotherapy for the treatment of lymphoma in childhood. The lesion displayed arborizing vessels, multiple blue-gray globules and ovoid nests on dermoscopy (Figure 1).

Figure 1

(a, b) Slight brown-gray pigmented pedunculated lesion. (c, d) Arborizing vessels, multiple blue-gray globules and ovoid nests on dermoscopy. [Copyright: ©2017 Seda et al.]

On RCM, at the epidermal layer, polarization (streaming) and some dendritic cells and at the dermoepidermal junctional level, and multiple tumor islands with different sizes were observed. In addition, there were many canalicular vessels all throughout the lesion (Vivascope 3000 Handheld, Mavig GmbH, Munich, Germany). A pedunculated nodular BCC was diagnosed with the large basaloid tumor islands with peripheral palisading and retraction artifact and dilated vascular spaces on histopathology (Figure 2).

Figure 2

(a) Bright tumor island (red arrows). (b) Epidermal polarization. (c) Tumor island and canalicular vessels. (d) Atrophic epidermis, large basaloid tumor islands and melanophages (H&Ex40) (Inset: Pedunculated nodular BCC [H&Ex20]). [Copyright: ©2017 Seda et al.]

The differential diagnosis of pigmented pedunculated lesion may sometimes be challenging and include an acrochordon, seborrheic keratosis, condyloma, dermal nevus, BCC, eccrine poroma or trichoblastoma. Moreover, a pedunculated melanoma should also be excluded. Thus, in vivo diagnostic techniques such as dermoscopy and RCM may play a crucial role in the differential diagnosis.

There have been rare cases of pedunculated BCC reported in the literature. Dermoscopic features were mentioned in only one report describing multiple acrochordon-like BCCs in a patient with Gorlin-Goltz syndrome [6]. In that case, the dermoscopic features observed were multiple or isolated gray-blue globules and/or telangiectases of different caliber and number of branches. Other dermoscopic features of BCC, such as ulceration, maple leaf-like areas, or spoke-wheel areas, were not detected. The dermoscopic features observed in the present case were similar to those findings. On the other hand, RCM findings were not described in any of the cases in the literature. In the present case, observing the typical RCM criteria for BCC helped in making a more confident preoperative diagnosis. To our knowledge, this is the first RCM description of a pedunculated BCC.