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06-16-2012, 07:56 PM
Basal Cell Carcinoma, Morpheaform subtype:

78 year-old male with complaints of enlarging Left Lower Lid lesion

Andrew Doan, MD, PhD, Thomas Oetting, MD
February 21, 2005
Chief Complaint:. 78 year-old male with complaints of enlarging LLL lesion.
History of Present Illness: Patient complained of a painless, red lesion noticed on the left lower lid (LLL) for 4-6 months. He was not sure if the lesion had grown in size, but wanted an evaluation because the lesion has not resolved.
PMH: Hypertension, mild coronary artery disease, and mild cataracts.
Exam:

Best corrected visual acuities: 20/25 OU.
Pupils: equal, no RAPD.
EOM: full OU
VF: normal
DFE: retina exam notable for normal macula, vessels, and periphery OU.
SLE: notable for the lesion shown below LLL. Mild cataracts OU.
Photo of LLL lesion.
http://webeye.ophth.uiowa.edu/eyeforum/cases-i/cases/eyelid_03102004.jpg
SLE Photo of the LLL lesion (higher magnification). Note the loss of eye lashes (madarosis) and irregular lid margin.
http://webeye.ophth.uiowa.edu/eyeforum/cases-i/cases/eyelid2_03102004.jpg
SLE Photo of the LLL lesion, lid margin & palpebral conjunctivae. Note the telangiectasia of the lesion, disruption of the lid margin, and hyperemia. Borders of this lesion are indistinct. http://webeye.ophth.uiowa.edu/eyeforum/cases-i/cases/eyelid3_03102004.jpg
Discussion

Morpheaform Basal Cell Carcinoma

This patient was diagnosed initially with a chalazion. When warm compresses and lid hygiene failed to resolve the LLL lesion, a full-thickness wedge biopsy was performed. We should be concerned about sebaceous cell carcinoma (SCC) and masquerade syndrome because SCC can be difficult to diagnose and detect. If one is concerned about SCC, the ocular pathologist should be informed so that oil red-O stain will be used to detect presence of lipid. Because SCC can be missed on frozen section, half of the specimen was sent for frozen section evaluation and the other half of the specimen was sent for histopathology.
The pathology report was consistent with morpheaform basal cell carcinoma (BCC). In morpheaform BCC, instead of bulky tumor nodules, there are slender strands of tumor cells. Morpheaform BCC is the most aggressive of all the BCC types: nodulo-ulcerative (most common), pigmented, morpheaform, and superficial.
Diagnosis: Morpheaform Basal Cell Carcinoma

EPIDEMIOLOGY


Incidence: 300-600 cases per 100,000
30% lifetime risk
Age: adults and elderly
Male:Female ratio 3:2
Low mortality, but high morbidity due to disfigurement.
Most common skin cancer.
SIGNS


Nodulo-ulcerative: waxy papules with central depression, ulceration, bleeding, crusting, rolled border, translucency, and telangiectases over lesion.
Pigmented: areas of brown and black pigment seen in lesion along with the signs similar to nodulo-ulcerative.
Morpheaform: sclerotic plaques or papules, border not defined, and bleeding/ucleration/crusting are not common.
Superficial: scaly patches or papules, threadlike border, and can mimic psoriasis or eczema.
Madarosis (loss of lashes)
Disruption of lid margin and architecture
SYMPTOMS


Non-healing sore which may bleed of varying duration on face, ears, lids, neck, and skin.
Bleeding with minor trauma
Ulceration
Sun exposure
Radiation exposure
Arsenic exposure
h/o Xeroderma pigmentosum
TREATMENT


Take wedge biopsy to rule-out sebaceous cell carcinoma.
Mohs' micrographic surgery or excision with frozen-section control.
Close follow-up for recurrence.

Differential Diagnoses:


Actinic Keratosis
Bowen Disease
Keratoacanthoma
Sebaceous Hyperplasia
Seborrheic Keratosis
Squamous Cell Carcinoma
Trichoepithelioma
References


Lear JT, Smith AG. Basal cell carcinoma. Postgrad Med J. 1997 Sep;73(863):538-42.
Michael L Ramsey, MD. Basal Cell Carcinoma. www.emedicine.com
Nerad JA, Whitaker DC. Am J Ophthalmol. 1988 Dec 15;106(6):723-9. Periocular basal cell carcinoma in adults 35 years of age and younger.