10.5826/dpc.1302a148
text/xml
2160-9381
2906
en
Stanislav Tolkachjov
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
surgical margins
“Stretching Dermoscopy” to Delineate the Margins of Basal Cell Carcinoma on Photodamaged Telangiectatic Skin
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2023-04-29
2022-10-20
2023-04-29
2023-06-05
e2023148
Dermatol Pract Concept
Stanislav Tolkachjov
2023/04/29
10.5826/dpc.1302a148
e2023148
Department of Dermatology, The University of Texas at Southwestern Medical Center, Dallas, Texas, United States.
2160-9381
surgical margins
en
e2023148
Jayasekera PSA, Dodd J, Oliphant T, Langtry JAA, Lawrence CM. Dermoscopy prior to Mohs micrographic surgery does not improve tumour margin assessment and leads to fewer Mohs stages. Br J Dermatol. 2018;178(2):565-566.
“Stretching Dermoscopy” to Delineate the Margins of Basal Cell Carcinoma on Photodamaged Telangiectatic Skin
https://dpcj.org/index.php/dpc/article/download/2906/2085
                 “Stretching Dermoscopy” to Delineate
                  the Margins of Basal Cell Carcinoma
                 on Photodamaged Telangiectatic Skin
            Felipe B. Cerci1-3, Mara Lynda Zehnder4, Aimilios Lallas5, Betina Werner2,6,7,
                                 Stanislav Nickolaevich Tolkachjov8-11


 1 Mohs Curitiba, Clínica Cepelle. Curitiba, Brazil
 2 Post-graduate Program – Internal Medicine and Health Sciences, Universidade Federal do Paraná, Curitiba, Brazil
 3 Dermatology Service, Hospital Universitário Evangélico Mackenzie, Curitiba, Brazil
 4 Department of Dermatology, University Hospital Basel, Basel, Switzerland
 5 First Department of Dermatology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
 6 Dermatology Service, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil
 7 Department of Pathology, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil
 8 Epiphany Dermatology, Dallas, Texas, USA
 9 Texas A&M College of Medicine, Dallas, Texas, USA
10 Department of Dermatology, The University of Texas at Southwestern Medical Center, Dallas, Texas, USA
11 Division of Dermatology, Baylor Scott & White, Dallas, Texas, USA



Key words: dermoscopy, basal cell carcinoma, Mohs micrographic surgery, skin cancer, surgical margins
Citation: Cerci FB, Zehnder ML, Lallas A, Werner B, Tolkachjov SN. “Stretching Dermoscopy” to Delineate the Margins of Basal
Cell Carcinoma on Photodamaged Telangiectatic Skin. Dermatol Pract Concept. 2023;13(2):e2023148. DOI: https://doi.org/10.5826/
dpc.1302a148
Accepted: November 4, 2022; Published: April 2023
Copyright: ©2023 Cerci et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Stanislav N. Tolkachjov, MD, 1640 FM 544. Suite 100 The Colony, TX 75056 Phone: 972-961-7869
E-mail: stan.tolkachjov@gmail.com




Introduction                                                             linear ramified (arborizing) vessels that are usually well-­
                                                                         focused and bright red, and superficial BCC displays thinner
Dermoscopy is widely used in clinical practice for basal cell            and shorter vessels, the so-called superficial fine telangiec-
carcinoma (BCC) diagnosis and has been shown to accurately               tasias [1]. In contrast, telangiectatic vessels from chronic
predict the tumor subtype [1]. Furthermore, dermoscopy                   sun damage are smaller, less focused and dull-red. However,
was shown to enhance the clinical preoperative assessment                when BCC develops on severely sun-damaged skin with nu-
of peripheral margins, especially for pigmented BCCs [2].                merous telangiectasias, it might be challenging to discrimi-
In non-pigmented, the topographic evaluation of the ves-                 nate them from tumoral vessels and delineate the tumor [3].
sels may be an important way to assess the tumor margins.                     Stretching the skin around the tumor has been proposed
­Commonly, dermoscopy of non-superficial BCC reveals large               to improve the assessment of its margins by enhancing the




Research Letter | Dermatol Pract Concept. 2023;13(2):e2023148                                                                        1
macroscopic visualization of the opalescent color that cor-             dermoscopy can also achieve compression of UV-induced
responds to the stromal alterations of BCC (Figure 1) [4].              telangiectasias, but it may also compress the tumoral vessels,
    Although it can be reasonably hypothesized that combin-             which are important for the diagnosis.
ing skin stretching with dermoscopy might offer additional                  Dermoscopy alone has been used for preoperative mar-
information and further improve the assessment of BCC                   gin delineation of BCC during classic surgery and also to
margins, this is not supported by evidence up to date.                  reduce the number of stages in Mohs micrographic surgery
                                                                        (MMS), but data on the latter are controversial {5,6]. Sim-
Case Presentation                                                       ilarly, skin traction by itself has been described as an im-
                                                                        portant preoperative step to maximize the contrast between
We present a case that aims to suggest that combining both              BCC and surrounding normal skin during naked eye exam-
techniques might be superior to using each technique alone              ination [4]. In the present case, the tumor was cleared after
to delineate BCC margins prior to surgical removal in ar-               one stage of MMS.
eas with a telangiectatic background. Figure 1A shows an
ill-defined infiltrative BCC on the upper cutaneous lip of a
63-year-old female patient and Figure 1B depicts the same               Conclusions
lesion after skin stretching.
                                                                        We suggest that combining both techniques might be a
    In the standard non-contact polarized dermoscopic eval-
                                                                        simple and inexpensive way to enhance the preoperative
uation, tumor is evaluated without stretching the surround-
                                                                        examination in classic surgery or the first stage of MMS.
ing skin (Figure 2A). In “stretching dermoscopy,” the skin
                                                                        However, our hypothesis needs to be evaluated by further
adjacent to the tumor is stretched during dermoscopic exam-
                                                                        studies assessing whether stretching dermoscopy allows for
ination (Figure 2B). With this maneuver, the opalescent white
                                                                        less incomplete excisions during classic surgery or reduced
structureless area of the BCC becomes more evident. In ad-
                                                                        number of stages in MMS.
dition, the blood flow of the smaller vessels surrounding the
tumor is reduced without compromising the larger arboriz-
ing vessels of the tumor, enhancing, thus, the discrimination           Acknowledgment: The patient has given written informed
between them (Figure 2). The pressure applied with contact              consent to the publication of her case details.




 Figure 1. Clinical presentation. (A) 63-year-old female patient, presenting with an ill-defined plaque on the upper cutaneous lip and signs
 of photodamaged skin as lentigines and telangiectasias in all sun-exposed areas of the face. (B) View when stretching the surrounding skin.




2                                                                            Research Letter | Dermatol Pract Concept. 2023;13(2):e2023148
 Figure 2. Stretching Dermoscopy. (A) Non-contact polarized dermoscopy of a basal cell carcinoma on the upper cutaneous lip, with a
 telangiectatic background. (B) Dermoscopy after stretching the surrounding tissue. Note how the basal cell carcinoma is better visualized
 contrasting with the surrounding telangiectatic background. (C) The tumor margins as assessed after stretching dermoscopy. (D) Demar-
 cation of the tumor boundary before excision. The excision was performed at the outer margin of the black ink.




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Research Letter | Dermatol Pract Concept. 2023;13(2):e2023148                                                                            3
