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CASE REPORTS

Year : 2020  |  Volume : 3 |  Issue : 2 |  Page : 28-31 |  DOI : https://DOI-10.46319/RJMAHS.2020.v03i02.008

 

Pigmented Basal Cell Carcinoma  - An atypical clinical and histopathological variant

Madhumitha S1, Ravishankara S2, Kavitha Y3

1 Postgraduate, 2 Professor & Head, 3 Associate Professor, Department of ENT, KVG Medical College, Court Road, Kurunjibhag, Sullia, Karnataka, India

DOI-10.46319/RJMAHS.2020.v03i02.008
Abstract
Basal cell carcinoma is the most common skin tumour, comprising 80% of skin cancers. Pigmented basal cell carcinoma is an atypical clinical and histopathological variant. We report a case of pigmented basal cell carcinoma in a 72 year old lady with complaints of multiple skin lesions over the face. Fine needle aspiration cytology from the lesion reported as basal cell carcinoma. A wide local excision with rotational flap reconstruction was performed under local anaesthesia.
Keywords: Basal cell carcinoma (BCC), Pigmented basal cell carcinoma, Rotational flap.

Introduction
Basal cell carcinoma (BCC) constitutes approximately 75% of nonmelanoma skin cancers.[1] It is usually observed in  patients aged above 60 years. Pigmented BCC is a rare variant described in literature and clinically resemble as malignant melanoma. We present a case report of an elderly patient whose pigmented basal cell carcinoma masqueraded as malignant melanoma.
Case report
A 72 years old lady came to our out patient department with complaints of multiple skin lesions over the dorsum of nose for eight years which increased in size since last two years and itching since last six months. Sudden increase in size noticed since two months. She was also a known case of Type II Diabetes Mellitus, systemic hypertension and lichen planus on treatment. On examination, two lesions were found. The first lesion was measuring about 1x1.5 cms, nodulo-ulcerative found on the right ala of the nose (Fig 1). The second lesion measuring about 0.5 x 0.5 cm over the left side of the dorsum of the nose along with two hyperpigmented (black) satellite lesions measuring about 0.1cm each. There was no regional lymphadenopathy. General physical examination revealed multiple, hyperpigmented scaly plaques over the extensor surface of both lower limbs. The provisional diagnosis was made as malignant melanoma.
1 2
Figure 1: Pigmented ulcerated lesion
Fine Needle Aspiration Cytology (FNAC) was reported as basal cell carcinoma. Following all necessary investigations, a wide local excision with rotational flap on right side and bilobed flap on left for reconstruction under local anesthesia was performed (Fig 2 & 3). Frozen sections of the specimen margins were free of tumour involvement. Post-operative period was uneventful. Wound healed with good cosmetic appearance (Fig 4 & 5). There was no recurrence following six months follow up.
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Figure 2 &3: Excision and flap reconstruction
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Figure 4 & 5: Immediate post-operative and post- operative day 10
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Figure 6 & 7: Microscopic picture showing pigment laden basal carcinoma cells

Discussion
BCC is derived from non keratinizing cells that originate from the basal layer of the epidermis in sun exposed area of body.[2] The most common clinical variant is nodular basal cell carcinoma comprising about 60 - 80% of the cases. Other types are Cystic BCC, Sclerodermiform (Morpheiform) BCC, Infiltrated basal cell carcinoma, Micronodular basal cell carcinoma, Superficial basal cell carcinoma, Pigment basal cell carcinoma, Fibroepithelioma of Pinkus.[3] Pigmented BCC comprises only 6% of the total BCC. [2] Pigmented BCC and malignant melanoma have to be differentiated as the later needs aggressive treatment.[3] BCC may be treated by surgery, cryotherapy, radiotherapy, curettage and electrodessication, chemotherapy.[5] In this case we used bilobed flap which is the most useful flap particularly for the repair of nasolabial region defects. It provides an excellent colour match and is relatively free from distortion. The contour deformities are rare.[4] Recurrence rate for a completely excised (3mm margin) pigmented BCC is less than 5 %. [6] This is a rare clinical case which needed a meticulous flap reconstruction as there were multiple lesions. This case clinically resembled malignant melanoma but histopathology clinched the final diagnosis of pigmented basal cell carcinoma.
Conclusion
Pigmented BCC is a rare condition. As local recurrence is the main concern for an excised BCC, complete resection with clear margins is the gold standard for pigmented BCC treatment.
Financial support and sponsorship: Nil
Conflict of interest: Nil
References
1.     Scott- Brown's Textbook of Otorhinolaryngology, Head and Neck Surgery, 8th  vol-3. UK, CRC Press ,2018: p 1321. 
2.     Deepadarshan et al. “Pigmented Basal cell carcinoma: A clinical variant, report of two cases.” JCDR. 2013; 7(12): 3010-11. doi:10.7860/JCDR/2013/7568.3831
3.     Dourmishev LA, Rusinova D, Botev I. Clinical variants, stages, and management of basal cell carcinoma. Indian dermatology online journal. 2013;4(1):12.
4.     McGregor JC, Soutar DS. A critical assessment of the bilobed flap. British journal of plastic surgery. 1981;34(2):197-205.
5.     Masahiro N, Keiji T, Yasuhiro N, Akira H. Basal Cell Carcinoma of the Head and Neck. Journal of Skin Cancer. 2010 ;15:2011
6.     Lin SH, Cheng YW, Yang YC, Ho JC, Lee CH. Treatment of pigmented basal cell carcinoma with 3 mm surgical margin in Asians. BioMed research international. 2016;1-6.
7.     Maloney ME, Jones DB, Sexton FM. Pigmented basal cell carcinoma: investigation of 70 cases. Journal of the American Academy of Dermatology. 1992;27(1):74-8.
Address for Correspondence: Dr. Madhumitha S., Postgraduate, Dept. of ENT,  KVG Medical College, Kurunjibhag, Sullia, Karnataka, India. Email: honeymads@gmail.com


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