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Six years ago, a lesion appeared on this now 39-year-old woman’s forehead. It grew steadily to its current size, impinging on her brow line. Although it has been asymptomatic, the patient is concerned about malignancy, since she has a significant personal and family history of skin cancer. She has had several lesions removed from her face and back over the years.
EXAMINATION
There is a 2.2-cm, roughly round, white, cicatricial, concave lesion on the patient’s lower right forehead, extending into the brow line. Around the periphery are several 2- to 5-mm eroded papules. There are no palpable nodes on the head or neck.
Several scars are seen elsewhere on the patient’s face and back, consistent with her history. Her type II/VI skin is quite fair and sun-damaged.
A 6-mm deep punch biopsy of the lesion is obtained.
What is the diagnosis?
Biopsy reveals a morpheaform basal cell carcinoma (BCC; also known as cicatricial BCC) with perineural involvement that extends to the margin of the sample. While BCCs are almost never fatal, if ignored, their relentless growth can be problematic. This case illustrates that, along with the wide variety of morphologic presentations.
Of the different types of BCC, the most common are nodular. These present as pearly (ie, translucent) papules or nodules, with or without focal erosion or frank ulceration; they often have prominent telangiectasias coursing over their surfaces. BCCs can also appear as rashes (superficial BCC) that may not attract attention.
This patient’s lesion is one of the least common variations: It combines features of a morpheaform (scarlike) BCC with focal noduloulcerative papular lesions studding its periphery. The concavity of the scarlike portion, along with its prolonged presence, predicted deep involvement of adjacent tissue—confirmed by the biopsy results.
At a minimum, this patient will need Mohs micrographic surgical removal, with closure by skin graft or secondary intention. Given the deep perineural involvement, surgery alone may not clear the cancer; radiation therapy may be necessary.
TAKE-HOME LEARNING POINTS
- Morpheaform basal cell carcinoma (BCC), also known as cicatricial BCC, can present as a white, scarlike patch, often with an atrophic surface.
- This type of BCC is more aggressive than most, often requiring Mohs surgery.
- There are at least three other types of BCC, most of which involve nonhealing ulcerative papules or nodules.
- This patient’s history of sun-caused skin cancers makes recurrence likely.
Six years ago, a lesion appeared on this now 39-year-old woman’s forehead. It grew steadily to its current size, impinging on her brow line. Although it has been asymptomatic, the patient is concerned about malignancy, since she has a significant personal and family history of skin cancer. She has had several lesions removed from her face and back over the years.
EXAMINATION
There is a 2.2-cm, roughly round, white, cicatricial, concave lesion on the patient’s lower right forehead, extending into the brow line. Around the periphery are several 2- to 5-mm eroded papules. There are no palpable nodes on the head or neck.
Several scars are seen elsewhere on the patient’s face and back, consistent with her history. Her type II/VI skin is quite fair and sun-damaged.
A 6-mm deep punch biopsy of the lesion is obtained.
What is the diagnosis?
Biopsy reveals a morpheaform basal cell carcinoma (BCC; also known as cicatricial BCC) with perineural involvement that extends to the margin of the sample. While BCCs are almost never fatal, if ignored, their relentless growth can be problematic. This case illustrates that, along with the wide variety of morphologic presentations.
Of the different types of BCC, the most common are nodular. These present as pearly (ie, translucent) papules or nodules, with or without focal erosion or frank ulceration; they often have prominent telangiectasias coursing over their surfaces. BCCs can also appear as rashes (superficial BCC) that may not attract attention.
This patient’s lesion is one of the least common variations: It combines features of a morpheaform (scarlike) BCC with focal noduloulcerative papular lesions studding its periphery. The concavity of the scarlike portion, along with its prolonged presence, predicted deep involvement of adjacent tissue—confirmed by the biopsy results.
At a minimum, this patient will need Mohs micrographic surgical removal, with closure by skin graft or secondary intention. Given the deep perineural involvement, surgery alone may not clear the cancer; radiation therapy may be necessary.
TAKE-HOME LEARNING POINTS
- Morpheaform basal cell carcinoma (BCC), also known as cicatricial BCC, can present as a white, scarlike patch, often with an atrophic surface.
- This type of BCC is more aggressive than most, often requiring Mohs surgery.
- There are at least three other types of BCC, most of which involve nonhealing ulcerative papules or nodules.
- This patient’s history of sun-caused skin cancers makes recurrence likely.
Six years ago, a lesion appeared on this now 39-year-old woman’s forehead. It grew steadily to its current size, impinging on her brow line. Although it has been asymptomatic, the patient is concerned about malignancy, since she has a significant personal and family history of skin cancer. She has had several lesions removed from her face and back over the years.
EXAMINATION
There is a 2.2-cm, roughly round, white, cicatricial, concave lesion on the patient’s lower right forehead, extending into the brow line. Around the periphery are several 2- to 5-mm eroded papules. There are no palpable nodes on the head or neck.
Several scars are seen elsewhere on the patient’s face and back, consistent with her history. Her type II/VI skin is quite fair and sun-damaged.
A 6-mm deep punch biopsy of the lesion is obtained.
What is the diagnosis?
Biopsy reveals a morpheaform basal cell carcinoma (BCC; also known as cicatricial BCC) with perineural involvement that extends to the margin of the sample. While BCCs are almost never fatal, if ignored, their relentless growth can be problematic. This case illustrates that, along with the wide variety of morphologic presentations.
Of the different types of BCC, the most common are nodular. These present as pearly (ie, translucent) papules or nodules, with or without focal erosion or frank ulceration; they often have prominent telangiectasias coursing over their surfaces. BCCs can also appear as rashes (superficial BCC) that may not attract attention.
This patient’s lesion is one of the least common variations: It combines features of a morpheaform (scarlike) BCC with focal noduloulcerative papular lesions studding its periphery. The concavity of the scarlike portion, along with its prolonged presence, predicted deep involvement of adjacent tissue—confirmed by the biopsy results.
At a minimum, this patient will need Mohs micrographic surgical removal, with closure by skin graft or secondary intention. Given the deep perineural involvement, surgery alone may not clear the cancer; radiation therapy may be necessary.
TAKE-HOME LEARNING POINTS
- Morpheaform basal cell carcinoma (BCC), also known as cicatricial BCC, can present as a white, scarlike patch, often with an atrophic surface.
- This type of BCC is more aggressive than most, often requiring Mohs surgery.
- There are at least three other types of BCC, most of which involve nonhealing ulcerative papules or nodules.
- This patient’s history of sun-caused skin cancers makes recurrence likely.