
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-171
10.4103/jehp.jehp_83_24
Case Report
Diagnostic dilemma in pigmented basal cell carcinoma: A case report
Dhand Deepshikha 1
Sharma Pooja 2
Bala Neetu 3
Dhawan Vishesh 4
Singh Kuldeep 5
Singh Neha 6
Joshi Ashmita 7
Sachdeva Mandeep 8
Tadia Vijay 9
1 Department of Pathology, Maharishi Markandeshwar University, Ambala, Haryana, India
2 Department of Surgery, Atal Cancer Care Centre, Ambala, Haryana, India
3 Department of Pathology, Atal cancer Care Centre, Ambala, Haryana, India
4 Department of Pathology, Maharishi Markandeshwar University, Ambala, Haryana, India
5 Director Health Services, Haryana, India
6 Department of Pathology, Maharishi Markandeshwar University, Ambala, Haryana, India
7 Department of Pathology, Maharishi Markandeshwar University, Ambala, Haryana, India
8 Registrar, Haryana Medical Council, Haryana, India
9 Department of Hospital Administration, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Address for correspondence: Dr. Neetu Bala, SMO, Atal Cancer Care Centre, Ambala Cantt – 134 003, Haryana, India. E-mail: neetudoctor86@gmail.com
2024
05 7 2024
13 17114 1 2024
12 2 2024
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Basal cell carcinoma (BCC) is the most common malignant skin tumor, constituting 80% of nonmelanocytic skin tumors. Intermittent exposure to ultraviolet radiation is considered a major risk factor for BCC. This study was done in 2023 at a tertiary care cancer centre in North India. Pigmented BCC is a rare entity, a histopathological and clinical variant of BCC. This entity belongs to the category of nonmelanocytic skin tumors but exhibits increased pigmentation. Increased pigmentation also creates suspicion of melanocytic tumors, seborrheic keratosis, and Discoid Lupus Erythematosus DLE. However, this diagnostic dilemma can be elicited with histopathological analysis and clinical correlation. However, to prevent basal cell carcinoma, the best is to avoid direct sunlight; if it cannot be avoided, use sunscreen.

Basal cell carcinoma
biopsy
humans
skin neoplasm
surgical procedure
==== Body
pmcIntroduction

Basal cell carcinoma (BCC) is a form of malignant skin neoplasm known as a non-melanocytic skin tumor.[1] It has low mortality and intensely low metastatic rates (even though, when present, it signifies a poor patient prognosis); it also has an extensive morbidity rate through local devastation and recurrence, specifically when perineural involvement is noticed clinically or histo-pathologically.[2] A main risk factor for this entity is frequent exposure to ultraviolet (UV) radiation. A clinical and pathological variant of BCC is pigmented BCC, which exhibits increased pigmentation. Nonpigmented BCC is the universal type of skin tumor, whereas pigmented BCC is a rare entity. Pigmented BCC is a fairly exceptional variant, even though it accounts for 5% of all BCCs in Hispanics.[3] In the current study, we found one instance of pigmentary BCC with abnormal growth in a geriatric patient.

Case History

An 85-year-old man presented to the surgical OPD of a tertiary care cancer center in North India with a complaint of a pigmented lesion on the left temporal region for approximately two years. It also featured an itching and burning sensation, possibly due to photosensitivity. The lesion gradually developed and deteriorated over a year, finally growing up to the present size of 5 × 6 cm.

On examination, the patient had a single, well-defined, brown- and black-colored pigmented lesion with rolled-up margins measuring 5 × 6 cm over the left lateral area of the forehead [Figure 1]. Initially, the lesion seemed crimson and elevated and had curled-up borders.

Figure 1 Pre-operative picture of the lesion with rolled up margins, brown and black in colour

Telangiectasias and thicker, pigmented papular islands of growth were seen on the surface. No evidence of local lymphadenopathy was present. The systemic evaluation’s findings were within normal limits. After clinical evaluation, the patient underwent radiological investigations regarding the margins and adjacent and distant tissue involvement. Following clinical-radiological correlation, surgical excision was planned [Figure 2].

Figure 2 Post-operative picture revealing scar mark after surgical removal of lesion

Following biopsy and histopathological analysis, the following findings were evident: the tumor contained basaloid cells arranged in nest-like forms, sheets, and clusters [Figure 3].

Figure 3 Tumor arranged in sheets, clusters, and cribriform pattern (100×, H and E Stain)

Distinguishable basaloid cells, retraction clefts, and pigmented patches were visualized [Figure 4].

Figure 4 Basaloid cells, peripheral palisading, and retraction clefting artifacts (400×, H and E stain)

In addition, pigment-loaded macrophages were visualized [Figure 5].

Figure 5 Tumor cells and pigment-laden macrophages (400×, H and E stain)

The histopathological findings indicated pigmented BCC. Tumor cells were not visualized in any of the borders (medial, lateral, superior, inferior, and resection). Melanoma, squamous cell carcinoma, and discoid lupus erythematous were kept as differential diagnoses. Nevertheless, using clinical equating and histological analysis, the differential diagnoses were ignored with the aid of histology. A correlation between clinical and histological findings confirmed the diagnosis of pigmented BCC.

Discussion

BCC growth is a type of skin cancer caused by nonfilament keratinizing cells in the epidermal layer. It has various subclassifications, including pigmented BCC.[4] Less than 5% of all BCCs are pigmented BCCs. They are distinguishable by their brown- or black-pigmented look, a histologically and clinically different feature from BCC.[5] Our case was one of pigmented BCC. Pigmentation is one of the rarest morphological manifestations of basal cell malignancy. Its incidence is higher in people with darker skin tones, including Asian, Black, and Hispanic people. Caucasians experience it less frequently.

The most important variables of etiology are environmental conditions, phenotypes, and genetic predisposition. The development of BCCs can be seriously threatened by short-term exposure to UV radiation.[6] Certain genes, such as the patched (PTCH1) gene for BCC and the p53 gene for squamous cell carcinoma, are altered by UV light within the cells. Many bases will be replaced at pyrimidine sites. This inflammation is caused by activating the cyclooxygenase-2 pathway.[7] Patients with red hair, blue eyes, or a propensity to freckle are more at risk. Other risk factors are ionizing radiation, arsenic exposure, and coal tar derivatives.

Pigmented BCC usually appears on sun-exposed skin, commonly on the head and neck, as a transparent, slowly spreading lesion. It is most common in fair men older than 50 years of age. It has several distinguishing features, such as local virulence, and is below 0.01% of incidences of metastasis.[8] It is common to see nodular, superficial spreading, and penetrating BCCs. Pigmented BCCs are rare and occur in just 5% of all cases.

Basal cells are the most common, and palisading of lesional nuclei on the periphery, customized stroma, and artifacts of clefting between the stroma and the epithelium are also common. The most common species is a nodal variety in which neoplastic aggregation sees basaloid cells spread to the dermis in combination with a particularly narrow and specific tumor stroma. Cells have small cytoplasms and larger, round, or extended nuclei. BCCs may be distinguished from squamous cell carcinomas by peritumoral lacunae or retraction clefts. An increase in melanin pigment, which is produced by benign melanocytes that colonize tumors, is characteristic of the pigmented BCC subtype. The most likely differential diagnoses for this condition are BCC, seborrheic keratosis, pigment naevi, and melanoma.

Management

Excision is the most commonly used treatment option for skin malignancies other than melanoma. The acceptable tumor clearance rate is 84.9%, with a median margin of 3–6 mm for small, well-defined BCCs. The tumor site, such as the mid-face and trunk, is connected to an incomplete excision.[9] Surgery can correct surgical errors using flaws, flaps, grafts, and secondary intent healing. According to the investigations, pigmented BCCs showed only minor clinical invasion compared with unpigmented BCCs.[8] A multidisciplinary tumor board should discuss the management of difficult-to-treat BCCs. Hedgehog inhibitors (HHIs), such as vismodegib or sonidegib, should be offered to patients with locally advanced and metastatic BCC. Immunotherapy with anti-PD1 antibodies (cemiplimab) is a second-line treatment in patients with a progression of disease, contraindication, or intolerance to HHI therapy. Radiotherapy represents other treatment modalities for BCCs, including cryosurgery, laser surgery, radiotherapy, Mohs micrographic surgery (which has the highest cure rates and greater tissue conservation), curettage and electrodesiccation, and photodynamic therapy.[10]

Conclusion

The most prevalent kind of malignant nonmelanoma skin cancer worldwide is BCC. Although pigmented BCC is uncommon, its prevalence is rising among Asian populations. UV exposure is the most significant risk factor that can be reduced. Re-application of sunscreen when there is continuous exposure to the sun and after swimming, etc., is advised to prevent BCC. Try to stay away from direct sun when rays are strongest during the afternoon time; if needed, apply and re-apply sunscreen as per the dermatologist’s suggestions. Try to stay in the shade when possible. The doctor is responsible for informing and reassuring the patient that this malignancy has been identified, necessary precautions are being taken, and a set of efficient treatment modalities is being implemented. Improved education for patients and the introduction of novel treatments are expected to lead to improved survival and more effective results. In our case, the patient lost their follow-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

We are thankful to the whole lab staff and operation theatre ot staff of ACCC.
==== Refs
1 Tanese K Diagnosis and Management of basal cell carcinoma Curr treat options oncol 2019 20 13 doi: 10.1007/s11864-019-0610-0 30741348
2 Niculet E Craescu M Rebegea L Bobeica C Nastase F Lupasteanu G Basal cell carcinoma: Comprehensive clinical and histopathological aspects, novel imaging tools and therapeutic approaches (Review) Exp Ther Med 2022 23 60 doi: 10.3892/etm. 2021.10982 34917186
3 Abudu B Cohen PR Pigmented basal cell carcinoma masquerading as a melanoma cureus 2019 11 e4369 31192074
4 Saizan A Taylor S Elbuluk N Pigmented basal cell carcinoma: An argument for sub-classification J drugs dermatol 2023 22 217 18 doi: 10.36849/JDD.6883 36745362
5 Xavier-Júnior JCC Ocanha-Xavier JP Camilo-Júnior DJ Pires D’ávilla SCG Mattar NJ Is pigmented BCC a unique histological variant or is it only a clinical presentation? Australas J Dermatol 2020 61 80 81 doi: 10.1111/ajd.13181 31625594
6 Brown PJ Milch JM Hivnor CM Pigmented basal cell carcinoma of the nipple: A case report and review of the literature Cutis 2013 92 253 7 24343213
7 Aszterbaum M Beech J Epstein EH Jr Ultraviolet radiation mutagenesis of hedgehog pathway genes in basal cell carcinomas J Investig dermatol symp proc 1999 4 41 5 doi: 10.1038/sj.jidsp.5640179
8 Marzuka AG Book SE Basal cell carcinoma: Pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management Yale J Biol Med 2015 88 167 79 26029015
9 Goh BK Ang P Wu YJ Goh CL Characteristics of basal cell carcinoma amongst asians in singapore and a comparison between completely and incompletely excised tumors Int J Dermatol 2006 45 561 4 doi: 10.1111/j.1365-4632.2004.02515.x 16700792
10 Peris K Fargnoli MC Kaufmann R Arenberger P Bastholt L Seguin NB European consensus-based interdisciplinary guideline for diagnosis and treatment of basal cell carcinoma-update 2023 Eur J Cancer 2023 192 113254 doi: 10.1016/j.ejca.2023.113254 37604067
