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August 5, 2014 / molehunter

Irregular pigmented structures in a BCC

This case makes my point about the use of generic terms for the pigmented structures we see in about a quarter of all basal cell cancers (BCCs).

typical story of a slow growing lesion on elderly sun exposed skin.


Not a brilliantly focused picture, the lesion was about 7/8 mm cross. Dermoscopy is revealing.

case 1A 814 (2)

Lots of pigment to see. At about 3 and 4 o’clock I can see blue grey structures but they aren’t really ‘ovoid’. At about 5 o’clock just round from them clockwise are some irregular dots, or are they globules? Some more further round at 7 o’clock.

At 10 round to 2 o’clock I can see some interesting structures which fit into the ‘cart wheel’ category, especially marked at 11-11.30. The interior of the lesion is mainly pink and perhaps there are some tightly focused vessels.

Diagnosis: pigmented BCC. In fact, histology is awaited (confirmed pigmented BCC-18.8.2014-SH) and the team I work with feel that suspected pigmented BCCs should be fast tracked for excision as sometimes they are confused with melanomas. Will post histology later, but I bet its a pigmented BCC.

Learning point: BCC pigmented structures are described as blue-grey ovoid nests, cart wheels or maple leaves. However I also see dots and globules, and indescribable features. I teach my learners that although these stereotypical text book shapes are seen, in the end its only cancer cells mutating out of control so don;lt be too clever trying to categorise them. ‘irregular pigmented structures’ are good enough for me.

revision : the 4 main dermoscopic features of a BCC are

1) pink background

2) arborising/tightly focused vessels

3) micro ulcers

4) irregular pigmented structures.

Again, you won’t always see all 4 features. 2 is enough if clear.



Leave a Comment
  1. Maryam Sadeghi / Aug 6 2014 1:55 am

    Interesting! It looks like a melanoma, but I agree the maple leaf structure is the dominant feature. Thanks for the post. I’ve been following your blog for a long time and I enjoy learning from your interesting cases!

  2. molehunter / Aug 6 2014 9:07 am

    Thanks Maryam. I haven’t been posting much lately due to business and travel but will try to post at least once a week from now on. I don’t have histology yet (will post when I do) but I am 98% certain this is a BCC.

  3. Dr Fran Sargen / Aug 6 2014 10:28 am

    thanks, great picture, I would be very interested to see histology, I also love seeing these blogs, did the Cardiff course last year and haven’t looked back.

  4. molehunter / Aug 19 2014 10:28 am

    It was confirmed as a pigmented BCC. I would have bet £1,000 on it, but only against a rich person I didn’t like. But I wouldn’t bet the patient’s life on it-heavily pigmented suspected BCCs should be excised fast track because every now and then one will be a melanoma.

  5. Sunburn Relief / Sep 10 2014 11:45 am

    The sun-exposed areas of the head and neck are the most commonly involved sites. Sun exposure in childhood may be especially important. Thank you for sharing! This is very helpful!

  6. new games 2014 / Oct 7 2014 3:44 am

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