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An 80-year-old man is brought in by family for evaluation of a lesion on his nose. It manifested several years ago, at a smaller size, but has recently and abruptly grown. Although asymptomatic, the lesion is disturbing to the patient, who can now see it out of the corner of his eye.
The patient worked all of his adult life in the outdoors, as a farm and ranch hand. He has an extensive history of nonmelanoma skin cancer; several lesions have been removed from his face and arm.
Since the patient lives alone and rarely has visitors, it has been months since anyone has seen him. But as soon as his son-in-law saw the patient, he was sufficiently alarmed by the lesion to insist that care be sought.
EXAMINATION
The patient’s facial skin shows abundant evidence of chronic, severe sun damage: a whitish, spongy look to the skin on his forehead and upper cheeks and a great deal of discoloration and scaling.
The lesion in question is a 3 x 1.5–cm, round, bulbous, smooth mass covering the right alar bulb. The surface is glassy-looking, with multiple telangiectasias. It is very firm but nontender on palpation. Shave biopsy is performed.
What is the diagnosis?
DISCUSSION
The biopsy results confirmed the suspicion of basal cell carcinoma (BCC). BCCs typically grow very slowly, often taking years to become noticeable, although not every BCC follows the rules. Some are more aggressive than others, both in terms of growth and clinical behavior.
It’s quite likely that in this case, the patient’s social isolation created the impression that his lesion grew abruptly and dramatically. (A subsequent eye exam revealed a number of problems, including severe presbyopia and advanced cataracts, so the patient himself might not have noticed the lesion for a while.) However, due to the large size and aggressive nature of the lesion—and the fact that the patient lives more than two hours from the nearest city, rendering his other treatment option, radiation, impractical—he was referred for Mohs surgery.
This process will establish clear surgical margins and provide acceptable closure. The latter may require reconstruction of the nose, depending on the depth of the cancer. Mohs surgeons often co-manage such cases with their counterparts in ENT or plastic surgery.
The differential for this lesion included keratoacanthoma , squamous cell carcinoma, and cyst.
TAKE-HOME LEARNING POINTS
• Basal cell carcinoma (BCC) is typically very slow growing, but there are exceptions.
• Social isolation can allow lesions and conditions to advance before they’re detected.
• Shave biopsy is indicated only for possible nonmelanoma skin cancers. Possible melanomas require excision, multiple punches, or deep shave to establish depth (a key prognostic factor).
• Rapid growth of BCCs suggests more aggressive clinical behavior, which in turn suggests the need for controlled margins to ensure complete removal.
An 80-year-old man is brought in by family for evaluation of a lesion on his nose. It manifested several years ago, at a smaller size, but has recently and abruptly grown. Although asymptomatic, the lesion is disturbing to the patient, who can now see it out of the corner of his eye.
The patient worked all of his adult life in the outdoors, as a farm and ranch hand. He has an extensive history of nonmelanoma skin cancer; several lesions have been removed from his face and arm.
Since the patient lives alone and rarely has visitors, it has been months since anyone has seen him. But as soon as his son-in-law saw the patient, he was sufficiently alarmed by the lesion to insist that care be sought.
EXAMINATION
The patient’s facial skin shows abundant evidence of chronic, severe sun damage: a whitish, spongy look to the skin on his forehead and upper cheeks and a great deal of discoloration and scaling.
The lesion in question is a 3 x 1.5–cm, round, bulbous, smooth mass covering the right alar bulb. The surface is glassy-looking, with multiple telangiectasias. It is very firm but nontender on palpation. Shave biopsy is performed.
What is the diagnosis?
DISCUSSION
The biopsy results confirmed the suspicion of basal cell carcinoma (BCC). BCCs typically grow very slowly, often taking years to become noticeable, although not every BCC follows the rules. Some are more aggressive than others, both in terms of growth and clinical behavior.
It’s quite likely that in this case, the patient’s social isolation created the impression that his lesion grew abruptly and dramatically. (A subsequent eye exam revealed a number of problems, including severe presbyopia and advanced cataracts, so the patient himself might not have noticed the lesion for a while.) However, due to the large size and aggressive nature of the lesion—and the fact that the patient lives more than two hours from the nearest city, rendering his other treatment option, radiation, impractical—he was referred for Mohs surgery.
This process will establish clear surgical margins and provide acceptable closure. The latter may require reconstruction of the nose, depending on the depth of the cancer. Mohs surgeons often co-manage such cases with their counterparts in ENT or plastic surgery.
The differential for this lesion included keratoacanthoma , squamous cell carcinoma, and cyst.
TAKE-HOME LEARNING POINTS
• Basal cell carcinoma (BCC) is typically very slow growing, but there are exceptions.
• Social isolation can allow lesions and conditions to advance before they’re detected.
• Shave biopsy is indicated only for possible nonmelanoma skin cancers. Possible melanomas require excision, multiple punches, or deep shave to establish depth (a key prognostic factor).
• Rapid growth of BCCs suggests more aggressive clinical behavior, which in turn suggests the need for controlled margins to ensure complete removal.
An 80-year-old man is brought in by family for evaluation of a lesion on his nose. It manifested several years ago, at a smaller size, but has recently and abruptly grown. Although asymptomatic, the lesion is disturbing to the patient, who can now see it out of the corner of his eye.
The patient worked all of his adult life in the outdoors, as a farm and ranch hand. He has an extensive history of nonmelanoma skin cancer; several lesions have been removed from his face and arm.
Since the patient lives alone and rarely has visitors, it has been months since anyone has seen him. But as soon as his son-in-law saw the patient, he was sufficiently alarmed by the lesion to insist that care be sought.
EXAMINATION
The patient’s facial skin shows abundant evidence of chronic, severe sun damage: a whitish, spongy look to the skin on his forehead and upper cheeks and a great deal of discoloration and scaling.
The lesion in question is a 3 x 1.5–cm, round, bulbous, smooth mass covering the right alar bulb. The surface is glassy-looking, with multiple telangiectasias. It is very firm but nontender on palpation. Shave biopsy is performed.
What is the diagnosis?
DISCUSSION
The biopsy results confirmed the suspicion of basal cell carcinoma (BCC). BCCs typically grow very slowly, often taking years to become noticeable, although not every BCC follows the rules. Some are more aggressive than others, both in terms of growth and clinical behavior.
It’s quite likely that in this case, the patient’s social isolation created the impression that his lesion grew abruptly and dramatically. (A subsequent eye exam revealed a number of problems, including severe presbyopia and advanced cataracts, so the patient himself might not have noticed the lesion for a while.) However, due to the large size and aggressive nature of the lesion—and the fact that the patient lives more than two hours from the nearest city, rendering his other treatment option, radiation, impractical—he was referred for Mohs surgery.
This process will establish clear surgical margins and provide acceptable closure. The latter may require reconstruction of the nose, depending on the depth of the cancer. Mohs surgeons often co-manage such cases with their counterparts in ENT or plastic surgery.
The differential for this lesion included keratoacanthoma , squamous cell carcinoma, and cyst.
TAKE-HOME LEARNING POINTS
• Basal cell carcinoma (BCC) is typically very slow growing, but there are exceptions.
• Social isolation can allow lesions and conditions to advance before they’re detected.
• Shave biopsy is indicated only for possible nonmelanoma skin cancers. Possible melanomas require excision, multiple punches, or deep shave to establish depth (a key prognostic factor).
• Rapid growth of BCCs suggests more aggressive clinical behavior, which in turn suggests the need for controlled margins to ensure complete removal.
