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.
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.