|Year : 2019 | Volume
| Issue : 2 | Page : 130-135
Retrospective analysis of demographic, clinical, and histopathological parameters in patients with basal cell carcinoma
Aparna Palit1, P Ram Sushruth2, Keshavmurthy A Adya2, Ajit B Janagond2, Niranjan S Deshmukh2, Arun C Inamadar2
1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Dermatology, Venereology and Leprosy, Shri B. M. Patil Medical College, Hospital and Research Center, BLDE (Deemed to be University), Vijayapur, Karnataka, India
|Date of Web Publication||15-Jul-2019|
Arun C Inamadar
Department of Dermatology, Venereology and Leprosy, Shri B. M. Patil Medical College, Hospital and Research Center, BLDE (Deemed to be University), Vijayapur - 586 103, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Basal cell carcinoma (BCC) is a common malignancy among light-skin races. Chronic solar exposure is the most important precipitating factor. In India, BCC is the second in order among the nonmelanoma skin cancers, the first being squamous cell carcinoma. Actual incidence and prevalence of this tumor in various geographical regions of India remain undefined. Aim: The aim is to study the demographic, clinical, and histopathological parameters of the patients suffering from BCC residing in a rural area of northern Karnataka. Materials and Methods: Retrospective data analysis of the patients suffering from BCC was performed from the records of dermatology outpatients' department of a tertiary healthcare center in north Karnataka. Results: A total of 41 cases of BCC were examined during 12 years. The duration of the lesions varied from 6 months to 20 years. Female patients outnumbered males in a ratio of 3.36:1. Majority of the patients were homemakers and agricultural workers. Nodular, noduloulcerative, and pigmented BCC were the most common clinical pattern and 9 (28.1%) cases of morpheaform BCC were recorded. Four patients had genodermatoses; three were xeroderma pigmentosum and one case of nevoid BCC syndrome. These patients had multiple lesions of BCC. Classical histopathological features were recorded in all cases. One specimen showed evidence of metatypical epithelioma. Conclusion: Most of the patients in this series belonged to the rural part of North Karnataka, predominantly homemakers and agricultural workers. Females were more commonly affected, attributable to the intermittent type of solar exposure. Morpheaform BCC accounted for less than a quarter of cases, and multiple BCCs associated with genodermatoses were seen in four cases.
Keywords: Basal cell carcinoma, nevoid basal cell carcinoma syndrome, nonmelanoma skin cancer, xeroderma pigmentosum
|How to cite this article:|
Palit A, Sushruth P R, Adya KA, Janagond AB, Deshmukh NS, Inamadar AC. Retrospective analysis of demographic, clinical, and histopathological parameters in patients with basal cell carcinoma. Clin Dermatol Rev 2019;3:130-5
|How to cite this URL:|
Palit A, Sushruth P R, Adya KA, Janagond AB, Deshmukh NS, Inamadar AC. Retrospective analysis of demographic, clinical, and histopathological parameters in patients with basal cell carcinoma. Clin Dermatol Rev [serial online] 2019 [cited 2020 May 30];3:130-5. Available from: http://www.cdriadvlkn.org/text.asp?2019/3/2/130/262777
| Introduction|| |
Basal cell carcinoma (BCC) is the most common nonmelanoma skin cancer (NMSC) worldwide. It is common among the Caucasian and other light-skinned races. Exposure to ultraviolet (UV) light is the most important precipitating factor in the pathogenesis of BCC. Intermittent and intense sunlight exposure since childhood and through adolescence may determine the adult risk of BCC. However, such exposure is common among light-skinned individuals residing in temperate climate where recreational sunexposure in summer season is common. In tropical countries like India sunexposure is more or less continuous throughout the year which may be occupational or related to daily activities as well.
In recent years, the incidence of BCC has been increasing worldwide; Europe, United States of America, and the highest in Australia. Currently, even an increasing trend has been observed in Asian countries.
Classical skin lesion of BCC is an asymptomatic papule or nodule with pearly, rolled border, located over the head and face [Figure 1]. Various morphological patterns have been described, of which the nodular type is the most common (50%–80%), followed by superficial type (15%)., Recently, newer clinical variants such as “red dot BCC” and “candle wax BCC” have been described., Although photo-exposed body parts are the most common sites of involvement, covered body parts (thigh, leg, and female genitalia), and oral mucosa are known to get involved.
|Figure 1: A classical skin lesion of basal cell carcinoma characterized by a nodule with pearly, rolled border|
Click here to view
Among NMSC squamous cell carcinoma (SCC) is more common in India, followed by BCC. Primary cutaneous malignant melanoma is rare occurrence in Indian skin. Few series of patients with BCC have been reported from various parts of India.,,,,, We, hereby, present the demographic, clinical, and histopathological data of 41 Indian patients with Fitzpatrick IV and V skin types, suffering from BCC.
| Materials and Methods|| |
Retrospective data were analyzed from the records of the patients with BCC examined in the dermatology outpatient department of a tertiary healthcare center located in Karnataka, India. The data included for the analysis was recorded over 12 years (2006–2017).
The institution is located in a district town of northern Karnataka. The region is arid and sunny with usual day time temperature varying from 30°C to 45°C throughout the seasons. The population catered by the institution is mostly from the agricultural background who works in the field throughout the year. The females in this region are mostly involved in household works but often involved in agricultural work as well.
Demographic parameters of each patient, duration of disease, any precipitating factor, and details of the tumor were recorded. Skin biopsy was done in all the patients for confirmation of clinical diagnosis. Dermoscopy was performed in 10 patients. All patients were managed surgically.
| Results|| |
Forty one patients with BCC were examined during 12 years. Among them, 4 patients had genodermatoses; two girls and one young adult male had xerodema pigmentosum (XP) [Figure 2], one adult male presented with nevoid BCC syndrome [Figure 3]. Females were more common sufferers than males (female: male = 3.36:1). Various demographic details of the patients are presented in [Table 1]. The most frequent affected age group was 61–70 years (n = 11), followed by 51–60 years (n = 10). Four patients were in the age group of 21–30 years of whom two cases were non-syndromic BCC. One patient was >80 years of age. Two girls with XP were <10 years. The duration of skin lesions varied between 6 months and 20 years at presentation. Only two college students presented to the hospital within 6 months of the occurrence of the lesion on the face. No year-wise rising trend in the occurrence of BCC was observed over 12 years.
|Figure 2: Multiple basal cell carcinomas in a patient with xeroderma pigmentosum nodulo-ulcerative lesion and morpheaform lesion|
Click here to view
|Figure 3: Multiple basal cell carcinoma of pigmented and nodulo-ulcerative type in a patient with nevoid basal cell carcinoma syndrome|
Click here to view
Face was the most common site involved (n = 35). Thirty seven patients had single lesion and multiple lesions were present in the four cases of genodermatoses. The most common clinical diagnosis was nodular BCC. All nodular BCC had a pigmented appearance; some were ulcerated at presentation or developed ulceration subsequently. Large morpheaform lesions were found in 9 cases (21.9%), all of which showed raised, pigmented border, indistinct at some areas. Some of these lesions showed surface ulceration and crusting. One giant morpheaform lesion had involvement of inner canthus of the eye. Central atrophy and depigmentation were seen in two cases. Giant BCC (lesion >5 cm) were seen in five cases. Clinical characteristics of the patients are described in [Table 2] and [Table 3]. Various morphological patterns of BCC are presented in [Figure 4] and [Figure 5].
|Figure 4: Various morphological patterns of basal cell carcinoma. (a) Nodulo-ulcerative lesion on ala of nose; note the evidence of chronic solar damage on facial skin. (b) Pigmented basal cell carcinoma, note the pigmented, thread-like, raised border|
Click here to view
|Figure 5: Morpheaform basal cell carcinoma; (a) Hyperpigmented, thread-like incomplete border with central atrophy, cribriform surface and crusting. (b) Giant lesion causing destruction of inner canthus of right eye. (c) Surface atrophy, depigmentation and ulceration. (d) Postoperative view|
Click here to view
Histopathologically, nests and cords of basaloid cells with peripheral palisading was the consistent feature. Retraction artifacts were present in 25 and melanin deposit (within nests and stroma) was present in 20 specimens. Strands of basaloid cells extending to the dense fibrous stroma were seen in 10 cases, nine of which were from clinically morpheaform lesions. Stromal lymho-monocytic infiltrates were seen in 18 cases. Two of the specimens showed mitotic figures. Keratin pearls were seen in five cases. One specimen showed dysplastic cells around the nests of basal cells and was diagnosed with metatypical epithelioma. Various histopathological features of BCC are presented in [Figure 6]. Dermoscopic features of few cases of BCC are presented in [Figure 7], [Figure 8], [Figure 9].
|Figure 6: Histopathological features of basal cell carcinoma. (a) Solid islands of basaloid cells in nodular basal cell carcinoma (H and E, ×100). (b) Buds of basaloid cells extending from epidermis with retraction artifacts (black arrows) (H and E, ×100). (c) Palisading arrangement of basaloid cells at the periphery of cell nests (H and E, ×100). (d) Micronodular basal cell carcinoma showing multiple nodules of basaloid cells in the upper dermis (H and E, ×40). (e) Pigmented basal cell carcinoma showing solid islands of basaloid cells (black arrow) with melanin in the papillary and reticular dermis (H and E, ×40)|
Click here to view
|Figure 7: Dermoscopy of superficial basal cell carcinoma showing 'Maple leaf' structures (yellow arrows) at the margins with hemorrhage (yellow star) and superficial white scaling (black star). Arborizing (black arrow) and dotted (black square) patterns of blood vessels are seen in the center of the lesion (×10)|
Click here to view
|Figure 8: Dermoscopy of pigmented basal cell carcinoma showing blue-gray ovoid globules (yellow stars) along with bluish-gray (yellow squares) and bluish-black (yellow circles) structure-less areas; focal hemorrhage (white star) and superficial white scales (black star). The bluish-gray and bluish-black colors correspond to melanin in the papillary and reticular dermis respectively (dermoscopy, ×10; H and E, ×10)|
Click here to view
|Figure 9: Dermoscopy of noduloulcerative basal cell carcinoma showing maple leaf' structures (yellow stars) and blue-gray ovoid globules (yellow circle) at the margin and central white structure-less areas (red stars) indicative of scarring (×10)|
Click here to view
| Discussion|| |
The data presented here is from the dermatology outpatient department of a single center in north Karnataka. Over a span of 12 years, 37 non-syndromic cases of BCC with solitary lesions and 4 syndromic cases with multiple lesions were recorded. A series of BCC patients have been reported from Mangaluru (south Karnataka); it was a retrospective clinico-pathological analysis of 100 cases of BCC (2006–2014). The total number of cases reported over 9 years was 2.5 times higher than this series. Probably, the specimen collections in this report were cumulative from both dermatology and other surgical departments of the institution, as the authors were pathologists. Another series of 60 patents with all cutaneous malignancies (Davangere, Central Karnataka) reported by pathologists (2005–2009) had recorded five cases of BCC.
In a series of 85 patients with eyelid malignancies, taken up for reconstructive surgery by plastic surgeons in Maharashtra, central India (1996–2009), BCC was the most commonly recorded eyelid malignancy (n = 41, 48.2%). Kumar et al. have reported a series of patients with BCC from the department of Dermatology of a tertiary care center in Punjab, north India (2011–2013). There were 36 confirmed cases of BCC during the study period of 3 years. A year-wise rising trend in the occurrence of BCC was observed. Female preponderance was recorded among the patients with BCC, as in the present series. On comparison with our data, the occurrence of BCC was higher in this study. Similar was the finding in the study by Malhotra et al. from New Delhi, North India, who documented 34 cases of BCC (2007–2009) during 3 years. This may presumably be at least partially attributable to the higher altitude resulting in more intense UV rays exposure in north Indian population. In a study conducted by the otorhinolaryngologists, among the Sikkimese population with NMSC (n = 37) in the head-and-neck region, SCC was the most common malignancy encountered, followed by BCC (n = 13, 35.1%).
BCC is locally invasive and distant metastasis is rare (<0.5%)., However, there are reports of metastatic BCC in Indian literature. People with BCC are at risk of other primary cutaneous malignancies, such as SCC and melanoma. Moore and Bennett have found that the Asian population tend to develop fewer BCCs during their lifetime as compared to the Caucasians even with comparable sunexposure. They also found a higher age of onset and no gender predilection among Asian patients with BCC. Although Caucasians are at risk of developing more than one subsequent BCCs within 1 year, such risks were not found among Asians.
Dermoscopy is a modern tool which can be used for pre-biopsy evaluation of BCC. Although there are certain dermoscopic findings suggestive of the diagnosis of BCC, it must always be confirmed by histopathological examination. Presurgical assessment of histopathological aggressiveness of BCC lesions can also be estimated by dermoscopy. Kim et al. have demonstrated that histopathological aggressiveness of BCCs may be indicated by the dermoscopic findings of multiple blue-gray globules, arborizing vessels, and concentric structures, whereas the frequent presence of large blue-gray ovoid nests indicates nonaggressive nature of the tumor. Dermoscopy is also useful to detect the extension of the tumor beyond clinically visible margin, helping in wide excision during surgery. Dermoscopic findings of all the 41 patients were not available in this series of patients because of nonavailability of the facility before the year 2017.
Here, a series of rural south Indian patients with BCC has been reported. Female patients, mostly homemakers, were the common sufferers of BCC. This supports the role of intermittent solar UV rays exposure in the pathogenesis of BCC in Indians. Nodular, nodulo-ulcerative, and pigmented lesions were the most common variants. Morpheaform BCCs were seen in nine cases and five cases had giant lesions. Multiple lesions of BCCs were seen in four patients with genodermatoses. Very long duration of up to 20 years was observed before the patients sought for medical help, even though face is the most important body part of cosmetic concern. This may be attributed to the asymptomatic nature of the BCC lesions during the initial phase. Illiteracy, ignorance about health related issues, and other pressing factors in daily lives prohibiting the rural population to seek prompt health care may also be the responsible factors, at least partially. In general, south Indian population has a darker skin shade as compared to north Indians, but two cases of early-onset nonsyndromic BCC were recorded in this series, indicating that skin color may not be a protective factor always. Although the incidence of BCC is on the rise worldwide, we did not observe this trend over 12 years. Retrospective data collection is the limitation of this study. However, it is a single centre dermatologists' experience on dark complexioned rural Indian patients suffering from BCC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Verkouteren JAC, Ramdas KHR, Wakkee M, Nijsten T. Epidemiology of basal cell carcinoma: Scholarly review. Br J Dermatol 2017;177:359-72.
Feller L, Khammissa RAG, Kramer B, Altini M, Lemmer J. Basal cell carcinoma, squamous cell carcinoma and melanoma of the head and face. Head Face Med 2016;12:11.
Marzuka AG, Book SE. Basal cell carcinoma: Pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management. Yale J Biol Med 2015;88:167-79.
Dourmishev LA, Rusinova D, Botev I. Clinical variants, stages, and management of basal cell carcinoma. Indian Dermatol Online J 2013;4:12-7.
] [Full text]
Cohen PR. Red dot basal cell carcinoma. J Clin Aesthet Dermatol 2017;10:56-8.
O'Donnell BP, Duarte CW. A prospective evaluation of the candle wax sign: A visual clue to diagnose aggressive basal cell carcinoma. J Am Acad Dermatol 2017;77:163-4.
Woods TR, Cohen DM, Islam MN, Kratochvil FJ, Stewart JC, Reeder SL, et al.
Intraoral basal cell carcinoma, a rare neoplasm: Report of three new cases with literature review. Head Neck Pathol 2014;8:339-48.
Sreeram S, Lobo FD, Naik R, Khadilkar UN, Kini H, Kini UA. Morphological spectrum of basal cell carcinoma in Southern Karnataka. J Clin Diagn Res 2016;10:EC04-7.
Adinarayan M, Krishnamurthy SP. Clinicopathological evaluation of nonmelanoma skin cancer. Indian J Dermatol 2011;56:670-2.
] [Full text]
Kale SM, Patil SB, Khare N, Math M, Jain A, Jaiswal S. Clinicopathological analysis of eyelid malignancies – A review of 85 cases. Indian J Plast Surg 2012;45:22-8.
] [Full text]
Kumar S, Mahajan BB, Kaur S, Yadav A, Singh N, Singh A. A study of basal cell carcinoma in South Asians for risk factors and characterization: A hospital based study. J Skin Cancer 2014;2014:173582.
Malhotra P, Singh A, Ramesh V. Basal cell carcinoma in the North Indian population: Clinicopathologic review and immunohistochemical analysis. Indian J Dermatol Venereol Leprol 2011;77:328-30.
] [Full text]
Baruah B, Sengupta S, Kesari SP, Ilapakurty B. Pattern of nonmelanoma skin cancers in Sikkim, India: A 3-year clinicopathological review. Indian J Otolaryngol Head Neck Surg 2013;65:160-2.
Tengli MB, Roohi S, Yelawanti GK, Chimkod R, Pattankar VL. Giant pigmented basal cell carcinoma: A case report. J Med Res Prac 2014;3:8-10.
Shrivastava R, Singh KK, Shrivastava M. Soft tissue metastasis in basal cell carcinoma. Indian J Dermatol 2007;52:206-8. [Full text]
Moore MG, Bennett RG. Basal cell carcinoma in Asians: A retrospective analysis of ten patients. J Skin Cancer 2012;2012:741397.
Kim HS, Park JM, Mun JH, Song M, Ko HC, Kim BS. Usefulness of dermatoscopy for the preoperative assessment of the histopathologic aggressiveness of basal cell carcinoma. Ann Dermatol 2015;27:682-7.
Lallas A, Apalla Z, Argenziano G, Longo C, Moscarella E, Specchio F, et al.
The dermatoscopic universe of basal cell carcinoma. Dermatol Pract Concept 2014;4:11-24.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3]