Msk Dermatology · Year 2 · from Msk Dermatology

Case 1: Basal Cell Carcinoma

Patient Presentation

Demographics: 68-year-old male

Chief Complaint: Slowly growing "pimple" on nose that won't heal

History of Present Illness: The patient noticed a small bump on his nose 8 months ago. He thought it was a pimple, but it has slowly enlarged. It occasionally bleeds when he washes his face. He has a history of significant sun exposure from working as a construction worker for 40 years.

Past Medical History:

  • No prior skin cancers
  • Fair skin, burns easily (Fitzpatrick type II)
  • Extensive occupational sun exposure

Physical Examination:

  • Nose (right ala):
  • 1.2 cm pearly, translucent papule
  • Rolled, raised borders
  • Central depression/ulceration with crusting
  • Telangiectasias (arborizing vessels) over surface
  • No significant scaling

Workup and Results

Dermoscopy:

  • Arborizing (tree-like) vessels
  • Blue-gray ovoid nests
  • Leaf-like structures
  • No pigment network

Shave Biopsy:

  • Nodular basal cell carcinoma
  • Basaloid nests with peripheral palisading
  • Retraction artifact between tumor and stroma

Clinical Image

Clinical photograph showing nodular basal cell carcinoma on the nose with characteristic pearly, translucent appearance, rolled borders, central ulceration, and visible telangiectasias.

Diagnosis

Nodular Basal Cell Carcinoma - High-Risk Location

Features:

  • Most common skin cancer
  • Most common BCC subtype (nodular)
  • Locally invasive but rarely metastasizes
  • High-risk location (central face/"H-zone")

Discussion

This case illustrates basal cell carcinoma:

  • Most Common Skin Cancer: The lecture identifies BCC as the most common type of skin cancer, arising from basal keratinocytes.
  • Nodular BCC Features: The lecture describes nodular BCC as having pearly/translucent appearance, telangiectasias, and rolled borders. Significant scaling is absent (unlike SCC).
  • Locally Invasive: The lecture emphasizes that BCC rarely metastasizes but is locally invasive, which can cause significant tissue destruction, especially on the face.
  • Arborizing Vessels: The lecture identifies arborizing (tree-like) vessels as a dermoscopic feature of BCC.
  • Mohs Surgery: The lecture notes that Mohs micrographic surgery achieves cure rates exceeding 99% and is preferred for BCC in high-risk areas (face).

Treatment Plan

  1. Mohs Micrographic Surgery (Preferred):
  • Tissue-sparing technique
  • Same-day margin assessment
  • >99% cure rate
  • Indicated for high-risk location (nose)
  1. Alternative Options (if Mohs unavailable):
  • Standard excision with 4mm margins
  • Electrodessication and curettage (not for this location)
  1. Follow-up:
  • Full skin exam every 6-12 months
  • 50% of patients develop another BCC within 5 years
  • Sun protection counseling
  1. Patient Education:
  • Daily sunscreen SPF 30+
  • Protective clothing and hats
  • Avoid peak sun hours
  • Monthly self-skin exams

Teaching Points

  1. BCC is the most common skin cancer; rarely metastasizes but locally invasive
  2. Nodular BCC: Pearly, translucent with telangiectasias and rolled borders
  3. Arborizing vessels on dermoscopy suggest BCC
  4. Mohs surgery preferred for high-risk locations (>99% cure rate)
  5. Morpheaform (sclerosing) BCC is the most aggressive subtype

All cases for this lecture as Markdown