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May 11, 2013 / molehunter

Odd partly pigmented lesion

A middle aged white man presented with a lesion on his back. History was unclear.

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There is a nondescript pink lesion below the right scapula. Not much can be said about it on this view, sorry I don’t have a close up. I suggest it could be a dermatofibroma or benign naevus, but its hard to rule anything out except to say that a haemangioma seems very unlikely due to the lack of red or purple colour. Dermoscope time.

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Lots more to see! Beginning with the most obvious and most global feature, it is a mostly pink lesion. There is some red and blue/grey as well. There is no way you can say this is normal, but what is it?

The red areas we can see at 4 o’clock and in from 9 and 11 o’clock correspond to micro ulcers (or erosions). These are classically seen in basal cell cancers. There are also numerous lacunar pigmented structures throughout the lesion, particularly obvious in a cluster in the bottom right quadrant. These are well defined but internally hazy, rather like washed-out greyish watercolour structures. I suggest that these are pseudolacunae, in fact several in my current learning group wondered about the lacunae of haemangioma. This is an understandable mistake, but lacunae in a haemangioma are better defined than this and must not be grey or brown-these colours are not allowed in a haemangioma, only red, blue, mauve/purple and black if thrombosed. They also need to be a global feature, i.e. making up pretty much the whole of the lesion without features of a different kind of lesion.

There are some whitish structures which look a little bit like the whitish stroma we see in haemangiomas. However, taking the pink background, micro ulcers and irregular pigmented structures together, this has to be a BCC. This was confirmed on excision.

LESSON Basal cell cancers (BCCs) have 4 classic dermoscopic features

-pink background

-micro ulcers

-telangiectatic/arborizing vessels

-irregular pigmented structures

this has 3 features out of 4 (in fact there are some fine well focussed vessels but they are not very clear so I will let them pass).  An amelanotic/hypopigmented melanoma was also suggested, but I would not consider this very likely as there are clear features of a BCC. Pseudolacunae are not that common, basically I see them as partly developed blue-grey ovoid structures.

I teach that it is a bit of a mug’s game to try to classify irregular shapes in a developing cancer too precisely, I prefer to use the generic term ‘irregular pigmented structures’ for the pigmented structures we see n BCCs. This term can include your maple leaf structures, spoke wheels, ovoid nests and the rest. Don’t try too hard to impose order on chaos. However, it is reasonable to refer suspected pigmented BCCs for urgent assessment and excision as no 2 tumours are identical and you can’t always tell a pigmented BCC from a hypopigmented melanoma. It is a safe rule for a beginner to assume that a pigmented BCC might be a melanoma.

An interesting case. Some people in the learning group were confused by the dermoscopic appearance but I never had any doubt that this was a BCC. But then I have seen a lot of them and learned under many experienced teachers.

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