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Basal cell carcinoma with spontaneous regression: Added value of reflectance confocal microscopy when the dermoscopic diagnosis is uncertain
Basal cell carcinoma with spontaneous regression: Added value of reflectance confocal microscopy when the dermoscopic diagnosis is uncertain Ivette Alarcon, MD,a,b Cristina Carrera, MD, PhD,a,b,c Pilar Turegano, MD,d Josep Malvehy, MD, PhD,a,b,c and Susana Puig, MD, PhDa,b,c,e Barcelona and Tarragona, Spain
CLINICAL PRESENTATION A 76-year-old woman presented with a lesion on her left leg. The physical examination revealed an 18- 3 13-mm erythematous plaque featuring a circular area with black pigmentation (Fig 1).
Fig 1. Basal cell carcinoma with regression. A, Clinical appearance and dermoscopy showing blue-black pigmentation, an erythematous area with irregular vessels (white arrow), and shiny white streaks (black arrow). B, A mosaic of reflectance confocal microscopy showing the 2 well differentiated areas: hyper-reflective structures within the blue square corresponding to the circular area, the highly specific nest (white arrow), and basaloid cords of basal cell carcinoma (black arrow) inside the yellow square.
DERMOSCOPIC APPEARANCE The erythematous area revealed the presence of linear irregular vessels, subtle remnant pigmented pseudonetwork, red-whitish areas, and shiny white streaks. A circular area of blue-black granular pigmentation was observed together with the presence of sparse granular pigmentation (Fig 1).
From the Melanoma Unit,a Dermatology Department, Hospital Clinic of Barcelona; August Pi i Sunyer Biomedical Research Institute,b Barcelona; Centre of Biomedical Research on Rare Diseases,c ISCIII, Barcelona; Dermatology Department,d Hospital Universitari Joan XXIII, Tarragona; and the Department of Medicine,e Universitat de Barcelona. Supported in part by grants from Fondo de Investigaciones Sanitarias P.I. 09/01393 and 12/00840, Spain, and by the CIBER de Enfermedades Raras of the Instituto de Salud Carlos III, Spain.
Conflicts of interest: None declared. Correspondence to: Susana Puig, MD, PhD, Melanoma Unit, Dermatology Department, Hospital Clinic Barcelona, Villarroel 170, 08036, Barcelona, Spain. E-mail: [email protected]. J Am Acad Dermatol 2014;71:e7-9. 0190-9622/$36.00 ª 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.01.877
e7
e8 Alarcon et al
J AM ACAD DERMATOL
JULY 2014
CONFOCAL MICROSCOPY APPEARANCE We were able to recognize a preserved epidermis, and in superficial dermis we noted telangiectasialike vessels and tumor cords with peripheric clefting. We also recognized an area with dense aggregates of melanophages (Figs 1 and 2).
Fig 2. Basal cell carcinoma with regression. A, Mosaic of reflectance confocal microscopy revealing the well circumscribed basaloid cords of hyporeflective, tightly packed cells arranged parallel to each other (ie, palisading) with peripheric clefting ( yellow arrows). The normal organization of the dermoepidermal junction was altered, and we could not distinguish the papillae. B, In the papillary dermis, we noted linear, telangiectasia-like horizontal vessels ( yellow arrows). C, The circular pigmented area corresponded under reflectance confocal microscopy to dense aggregates of pleomorphic hyporeflective cells of poorly defined borders in the dermis or plump cells (blue arrows). D, Histopathology revealing a proliferation of atypical basaloid cells that form an axis parallel to the epidermal surface with a slit-like retraction of the palisaded basal cells from the subjacent stroma (asterisk). E, Melanin pigmentation in the histiocytes of the subjacent stroma (black arrows) and lymphocytes (blue arrows). (Hematoxylineeosin stain; original magnifications: D, 310; E, 320.)
HISTOLOGIC DIAGNOSIS Biopsy specimens were obtained and revealed 2 well differentiated areas, one of them showing a proliferation of atypical basaloid cells forming an axis parallel to the epidermal surface. The other area revealed melanin pigmentation in the histiocytes of the subjacent stroma and an infiltrate of lymphocytes through the dermis (Fig 2).
KEY MESSAGE In the present case, dermoscopic findings did not allow differentiation between malignant melanoma (MM) and basal cell carcinoma (BCC). Linear vessels could be interpreted as the canalicular vessels of BCC or as the irregular vessels of MM. Shiny white streaks were also misleading, because they are commonly observed in both diseases.1 Blue-black granular pigmentation was interpreted as regression, which is generally associated with melanocytic lesions and is often considered as a clue of malignancy.2 Reflectance confocal microscopy accurately differentiated both diagnoses, showing highly specific criteria for BCC. In addition, RCM did not show any specific criteria of a melanocytic lesion and was able to characterize the blue-black pigmentation as melanophagia.
J AM ACAD DERMATOL VOLUME 71, NUMBER 1
Alarcon et al e9
REFERENCES 1. Balagula Y, Braun RP, Rabinovitz HS, Dusza SW, Scope A, Liebman TN, et al. The significance of crystalline/chrysalis structures in the diagnosis of melanocytic and nonmelanocytic lesions. J Am Acad Dermatol 2012;67:194.e1-8. 2. De Giorgi V, Massi D, Salvini C, Sestini S, Carli P. Features of regression in dermoscopic diagnosis: a confounding factor? Two clinical, dermoscopic-pathologic case studies. Dermatol Surg 2006;32:282-6.
CLINICAL PRESENTATION A 76-year-old woman presented with a lesion on her left leg. The physical examination revealed an 18- 3 13-mm erythematous plaque featuring a circular area with black pigmentation (Fig 1).
Fig 1. Basal cell carcinoma with regression. A, Clinical appearance and dermoscopy showing blue-black pigmentation, an erythematous area with irregular vessels (white arrow), and shiny white streaks (black arrow). B, A mosaic of reflectance confocal microscopy showing the 2 well differentiated areas: hyper-reflective structures within the blue square corresponding to the circular area, the highly specific nest (white arrow), and basaloid cords of basal cell carcinoma (black arrow) inside the yellow square.
DERMOSCOPIC APPEARANCE The erythematous area revealed the presence of linear irregular vessels, subtle remnant pigmented pseudonetwork, red-whitish areas, and shiny white streaks. A circular area of blue-black granular pigmentation was observed together with the presence of sparse granular pigmentation (Fig 1).
From the Melanoma Unit,a Dermatology Department, Hospital Clinic of Barcelona; August Pi i Sunyer Biomedical Research Institute,b Barcelona; Centre of Biomedical Research on Rare Diseases,c ISCIII, Barcelona; Dermatology Department,d Hospital Universitari Joan XXIII, Tarragona; and the Department of Medicine,e Universitat de Barcelona. Supported in part by grants from Fondo de Investigaciones Sanitarias P.I. 09/01393 and 12/00840, Spain, and by the CIBER de Enfermedades Raras of the Instituto de Salud Carlos III, Spain.
Conflicts of interest: None declared. Correspondence to: Susana Puig, MD, PhD, Melanoma Unit, Dermatology Department, Hospital Clinic Barcelona, Villarroel 170, 08036, Barcelona, Spain. E-mail: [email protected]. J Am Acad Dermatol 2014;71:e7-9. 0190-9622/$36.00 ª 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.01.877
e7
e8 Alarcon et al
J AM ACAD DERMATOL
JULY 2014
CONFOCAL MICROSCOPY APPEARANCE We were able to recognize a preserved epidermis, and in superficial dermis we noted telangiectasialike vessels and tumor cords with peripheric clefting. We also recognized an area with dense aggregates of melanophages (Figs 1 and 2).
Fig 2. Basal cell carcinoma with regression. A, Mosaic of reflectance confocal microscopy revealing the well circumscribed basaloid cords of hyporeflective, tightly packed cells arranged parallel to each other (ie, palisading) with peripheric clefting ( yellow arrows). The normal organization of the dermoepidermal junction was altered, and we could not distinguish the papillae. B, In the papillary dermis, we noted linear, telangiectasia-like horizontal vessels ( yellow arrows). C, The circular pigmented area corresponded under reflectance confocal microscopy to dense aggregates of pleomorphic hyporeflective cells of poorly defined borders in the dermis or plump cells (blue arrows). D, Histopathology revealing a proliferation of atypical basaloid cells that form an axis parallel to the epidermal surface with a slit-like retraction of the palisaded basal cells from the subjacent stroma (asterisk). E, Melanin pigmentation in the histiocytes of the subjacent stroma (black arrows) and lymphocytes (blue arrows). (Hematoxylineeosin stain; original magnifications: D, 310; E, 320.)
HISTOLOGIC DIAGNOSIS Biopsy specimens were obtained and revealed 2 well differentiated areas, one of them showing a proliferation of atypical basaloid cells forming an axis parallel to the epidermal surface. The other area revealed melanin pigmentation in the histiocytes of the subjacent stroma and an infiltrate of lymphocytes through the dermis (Fig 2).
KEY MESSAGE In the present case, dermoscopic findings did not allow differentiation between malignant melanoma (MM) and basal cell carcinoma (BCC). Linear vessels could be interpreted as the canalicular vessels of BCC or as the irregular vessels of MM. Shiny white streaks were also misleading, because they are commonly observed in both diseases.1 Blue-black granular pigmentation was interpreted as regression, which is generally associated with melanocytic lesions and is often considered as a clue of malignancy.2 Reflectance confocal microscopy accurately differentiated both diagnoses, showing highly specific criteria for BCC. In addition, RCM did not show any specific criteria of a melanocytic lesion and was able to characterize the blue-black pigmentation as melanophagia.
J AM ACAD DERMATOL VOLUME 71, NUMBER 1
Alarcon et al e9
REFERENCES 1. Balagula Y, Braun RP, Rabinovitz HS, Dusza SW, Scope A, Liebman TN, et al. The significance of crystalline/chrysalis structures in the diagnosis of melanocytic and nonmelanocytic lesions. J Am Acad Dermatol 2012;67:194.e1-8. 2. De Giorgi V, Massi D, Salvini C, Sestini S, Carli P. Features of regression in dermoscopic diagnosis: a confounding factor? Two clinical, dermoscopic-pathologic case studies. Dermatol Surg 2006;32:282-6.