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June 17, 2012 / molehunter

Four nodular ulcerated basal cell cancers

This basal cell cancer had been treated as a benign leg ulcer for months without improvement-observe the marks from bandaging. Regular leg ulcers due to poor circulation are usually lower down, near the ankle, and accompanied by signs of poor circulation. Always think of skin cancer if an ulcer is not typical and/or if it does not improve with correct treatment.

Observe ‘string of pearls’ along upper edge, pink background and ulcerated portion. Also small blue dot on the right, in from about 3 o’clock. These pigmented ‘blue/grey ovoid nests’ are seen better on dermoscopy and are seen in at least a tenth of BCC’s in my experience. Once you start seeing them on dermoscopy you will find they are easier to notice on naked eye inspection, at least the larger examples. This tumour had been incorrectly diagnosed as something harmless by several doctors over many months. Always be suspicious of a solitary growing lesion if you cannot make a positive diagnosis of something harmless. Really, if something like this is not a skin cancer, what is it? It must be something.

The owner of this large ulcerated nodule had been denying it for a long time, perhaps hoping it would go away by itself, perhaps afraid that it might be a cancer but would not actually become a cancer until a doctor said so. How sad.  We are there to help, we often can help, why suffer needlessly? It was a cancer, but a BCC so curable. If it had been a melanoma or squamous cell cancer it might have spread during the period of time before treatment. Also, by not coming forward earlier, the poor patient had a bigger scar and a longer period of anxiety. All of us working in any capacity in this field must get better at helping people come forward and get their skin cancers diagnosed and treated sooner. Looking at this, it is most likely a BCC due to the fine blood vessels we can see, particularly in the edge between 12 and 3 o’clock, but all you can say with certainty is that it needs to be excised and would have been better excised when it was a good deal smaller.

The last of the four cases in this post, a really ‘classic’ BCC with central ulcer crater filled with slough/scab, a rolled pearly edge with telangiectatic blood vessels. Couldn’t be more ‘textbook’ . But seven times beware of thinking that all BCCs look like ‘textbook’ cases. Most do not, especially when they are smaller. I will be posting examples of smaller lesions that are picked up better with dermoscopy. Smaller cancers are much easier and safer to treat. This one was about 12mm diameter.  Dermoscopy was little or no help diagnosing any of these 4 tumours, but they were all readily diagnosable by basic history taking and examination, and above all being willing to reconsider a diagnosis for a lesion that is growing and not responding to conservative treatment, for example the BCC that is mistaken for a  venous leg ulcer or patch of ringworm or eczema.


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