For several years, a 60-year-old woman has had a nonhealing, asymptomatic “sore” on her upper right cheek. The lesion causes no pain or discomfort; it bothers her simply because it will not go away. It does occasionally bleed.
Several attempts at treatment—including antibiotic ointment, peroxide, and topical alcohol— have failed. A dermatologist once treated the lesion with cryotherapy; this initially reduced its size, but the effect didn’t last.
The patient admits to “worshipping the sun” as a youngster, tanning at every opportunity. Several family members, including her sister and mother, have had skin cancer.
EXAMINATION
A 6.5-mm, round, red nodule is located on the mid-upper right cheek, below the eye. On closer inspection, it appears glassy and translucent, with several obvious telangiectasias. It is surprisingly firm on palpation, though not at all tender to touch.
Elsewhere, the patient’s fair skin has abundant evidence of sun damage, including wrinkles, discoloration, and focal telangiectasias. No other lesions are seen. No nodes are palpable in her head or neck.
With the patient’s permission, and after discussion of the indications, procedure, alternatives, and risks, the lesion is removed by curettement. It is quite friable and shallow, allowing complete removal. The area is left to heal by secondary intention, and the specimen is submitted to pathology.
What is the diagnosis?
DISCUSSION
The pathology report confirmed the suspected diagnosis: noduloulcerative basal cell carcinoma (BCC). By far the most common type of skin cancer in the world, noduloulcerative BCCs are caused by overexposure to the sun.
As obvious as this diagnosis seemed to be, biopsy was warranted to confirm it and to rule out several other items in the differential. The latter include squamous cell carcinoma (which has far more harmful potential than BCC), sebaceous carcinoma, Merkel cell carcinoma, and melanoma.
Not all BCCs are created equal—certain clinical and histologic characteristics predict a more aggressive course. While most BCCs require surgical excision, other treatment options do exist. In this patient’s case, the size and location of the lesion lent it to curettement and healing by secondary intention. Other methods could have included immunotherapy with imiquimod, antitumor creams (eg, 5-fluorouracil), or even radiation therapy. Her lesion was small and well-defined enough that Mohs surgery was not indicated—though some might disagree with that assessment.
TAKE-HOME LEARNING POINTS
- Like all basal cell carcinomas (BCCs), ulcerative BCC—the most common type—is caused by overexposure to the sun.
- BCCs are often mistaken for infection or other sore, which delays the diagnosis.
- Nonhealing lesions should be considered cancerous until proven otherwise.
- Though this diagnosis was fairly obvious, biopsy is necessary to rule out other items in the differential—some of which (ie, Merkel cell carcinoma, melanoma) are potentially fatal.