10.5826/dpc.1303a125
Introduction: Basal cell carcinoma (BCC) localized in the H-zone, the region of fusion of embryonic masses, has been associated with a higher risk of deeper invasion and more frequent recurrence.
Objectives: The aim of the study was to compare dermoscopic features of BCC in H and non-H zone that may most appropriately characterize those two locations.
Methods: Dermoscopy images of histopathologically confirmed BCCs from 120 patients
were retrospectively analyzed. Dermoscopy features of BCC in H- and non-H zone were described and a comparative study of the dermoscopic pattern of BCC between the two locations was performed.
Results: Of 120 BCC cases included in this study, 41 (34.2%) were located in the H-zone. The most frequent histological type was nodular (51.3% in H- zone and 61.6 % in non-H-zone) followed by superficial (5.1% and 19.8 % in H and non-H-zone respectively).
In dermoscopy, there was a higher prevalence of ulceration (73.2% versus 43.6%, P &lt; 0.001) in H-zone and a lower prevalence of brown globules (26.8% versus 53.2%; P = 0.01), when compared with the non-H-zone.
Conclusions: Our results show that dermoscopic features of BCC on the face fulfill a typical pattern regardless of the region, except for the prevalence of the ulceration which is significantly more frequent in H-zone and the brown globules present significantly more often in the non-H-zone It can be hypothesized that H-zone might predispose to more aggressive course of BCC complicated by ulceration and consequently deeper tissue destruction.
text/xml
2160-9381
2829
en
Beata Bergler-Czop
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
skin cancer
Dermoscopic Pattern of Basal Cell Carcinoma in H- and Non-H-Zones
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2022-09-08
2023-07-31
2023-08-24
e2023125
Dermatol Pract Concept
Introduction: Basal cell carcinoma (BCC) localized in the H-zone, the region of fusion of embryonic masses, has been associated with a higher risk of deeper invasion and more frequent recurrence.
Objectives: The aim of the study was to compare dermoscopic features of BCC in H and non-H zone that may most appropriately characterize those two locations.
Methods: Dermoscopy images of histopathologically confirmed BCCs from 120 patients
were retrospectively analyzed. Dermoscopy features of BCC in H- and non-H zone were described and a comparative study of the dermoscopic pattern of BCC between the two locations was performed.
Results: Of 120 BCC cases included in this study, 41 (34.2%) were located in the H-zone. The most frequent histological type was nodular (51.3% in H- zone and 61.6 % in non-H-zone) followed by superficial (5.1% and 19.8 % in H and non-H-zone respectively).
In dermoscopy, there was a higher prevalence of ulceration (73.2% versus 43.6%, P &lt; 0.001) in H-zone and a lower prevalence of brown globules (26.8% versus 53.2%; P = 0.01), when compared with the non-H-zone.
Conclusions: Our results show that dermoscopic features of BCC on the face fulfill a typical pattern regardless of the region, except for the prevalence of the ulceration which is significantly more frequent in H-zone and the brown globules present significantly more often in the non-H-zone It can be hypothesized that H-zone might predispose to more aggressive course of BCC complicated by ulceration and consequently deeper tissue destruction.
Beata Bergler-Czop
2023/07/31
10.5826/dpc.1303a125
e2023125
Department of Dermatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
2160-9381
skin cancer
en
e2023125
Pogorzelska-Dyrbuś J, Szepietowski JC. Optical super-high magnification dermoscopy of pigmented and nonpigmented nodular basal cell carcinoma. J Cosmet Dermatol. 2022;21(11):6458-6460. DOI: 10.1111/jocd.15082. PMID: 35567508.
Dermoscopic Pattern of Basal Cell Carcinoma in H- and Non-H-Zones
https://dpcj.org/index.php/dpc/article/download/2829/2220
         Dermoscopic Pattern of Basal Cell Carcinoma
                  in H- and Non-H-zones
                 Joanna Pogorzelska-Dyrbuś1, Natalia Salwowska2, Beata Bergler-Czop2


1 Estevita” Specialist Medical Practice, Tychy, Poland
2 Department of Dermatology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland



Key words: dermoscopy, H-zone, basal cell carcinoma, ulceration, skin cancer
Citation: Pogorzelska-Dyrbuś J, Salwowska N, Bergler-Czop B. Dermoscopic Pattern of Basal Cell Carcinoma in H- and Non-H-zones.
Dermatol Pract Concept. 2023;13(3):e2023125. DOI: https://doi.org/10.5826/dpc.1303a125
Accepted: December 12, 2022; Published: July 2023
Copyright: ©2023 Pogorzelska-Dyrbuś 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: Joanna Pogorzelska-Dyrbuś, MD PhD “Estevita” Specialist Medical Practice, 43-100 Tychy, Silesia, Poland,
Phone: +48 32 227 96 30 E-mail: jpogorzelskadyrbus@gmail.com




  ABSTRACT             Introduction: Basal cell carcinoma (BCC) localized in the H-zone, the region of fusion of embryonic
                       masses, has been associated with a higher risk of deeper invasion and more frequent recurrence.
                       Objectives: The aim of the study was to compare dermoscopic features of BCC in H and non-H zone
                       that may most appropriately characterize those two locations.
                       Methods: Dermoscopy images of histopathologically confirmed BCCs from 120 patients were retro-
                       spectively analyzed. Dermoscopy features of BCC in H- and non-H zone were described and a compar-
                       ative study of the dermoscopic pattern of BCC between the two locations was performed.
                       Results: Of 120 BCC cases included in this study, 41 (34.2%) were located in the H-zone. The most
                       frequent histological type was nodular (51.3% in H- zone and 61.6 % in non-H-zone) followed by
                       superficial (5.1% and 19.8 % in H and non-H-zone respectively).
                       In dermoscopy, there was a higher prevalence of ulceration (73.2% versus 43.6%, P < 0.001) in H-zone
                       and a lower prevalence of brown globules (26.8% versus 53.2%; P = 0.01), when compared with the
                       non-H-zone.
                       Conclusions: Our results show that dermoscopic features of BCC on the face fulfill a typical pattern
                       regardless of the region, except for the prevalence of the ulceration which is significantly more fre-
                       quent in H-zone and the brown globules present significantly more often in the non-H-zone It can be
                       hypothesized that H-zone might predispose to more aggressive course of BCC complicated by ulcer-
                       ation and consequently deeper tissue destruction.




Original Article | Dermatol Pract Concept. 2023;13(3):e2023125                                                                    1
Introduction                                                        ulceration and less specific features like milia cysts, brown
                                                                    globules and short fine telangiectasias (SFT) and shiny white
Basal cell carcinoma (BCC) is the most often diagnosed can-         areas were assessed by two independent authors.
cer in the fair-skinned population and its prevalence has in-          All features were classified as present or absent and then
creased dramatically over the last years [1]. Although BCC          comparison between H and non-H zone was made. Dermo-
has generally a good prognosis, due to its high prevalence, it      scopic evaluation with light pressure and solely with ultra-
generates significant medical and economic problems world-          sound gel was performed with Medicam 1000 FotoFinder
wide. The most important risk factor of BCC is exposure to          Systems GmbH camera by 3 experienced observers.
ultraviolet radiation, which is why it arises most frequently
de novo on the face [1,2]. BCC has a generally slow-growing         Statistical Analysis
pattern, however, lesions located on the face appear to be          The categorical variables were presented in both absolute
more aggressive [3,4].                                              numbers and percentages, while the due to non-normal
    The facial area called the H-zone, consisting of the nose,      distribution of the continuous variables, their results were
eye and ear region correspond to the locations of fusion of         summarized using the median with a quartile 1 and 3. Nor-
embryonic masses of mesoderm and the ectoderm. This zone            mality of distribution was tested using the Shapiro-Wilk test.
is related to the higher risk of occurrence of BCC and its          Between-group comparisons of continuous variables were
more aggressive expansion [5-7].                                    conducted using the Mann–Whitney U test, while Pearson
    Clinically, the accuracy of BCC diagnosis is approxi-           chi-squared test was used to evaluate the categorical vari-
mately 60%, while dermoscopy, as an easily available and            ables. The interval of two-sided P < 0.05 was considered
noninvasive diagnostic technique, can increase this quotient        statistically significant. STATISTICA 10 (StarSoft Inc.) was
to over 90% [8,9]. The dermoscopy pattern of BCC has been           used for all calculations. The approval of the bioethics com-
extensively studied, including the differences depending on         mittee was not required, based on the PCN/0022/KB/34/21
the anatomical location, however, the diagnostic criteria are       decision of the Bioethics Committee of the Medical Univer-
continuously updated [10,11].                                       sity of Silesia in Katowice. All patients gave an informed
                                                                    written consent to participate in the study.

Objectives
                                                                    Results
Taking into consideration the reported differences in the
clinical course of the BCCs located in the H-zone, the aim          Of 120 BCC cases included in this study, 41 (34.2%) were lo-
of the study was to compare dermoscopic features of BCC             cated in the H-zone as presented in Table 1 and the Figure 1.
in the H-zone and non-H-zone that may most appropriately            The most frequent histological type was nodular (51.3% in
characterize those two locations.                                   the high-risk zone and 61.6 % in the non-H-zone) followed
                                                                    by the superficial (5.1% and 19.8% in H- and non-H-zone
                                                                    respectively) as demonstrated in Table 2.
Methods
                                                                       Arborizing telangiectasias and short fine telangiectasias
Dermoscopy images of 120 BCCs of patients with skin pho-            were the most frequently seen dermoscopy features in both
totype II recruited from the Department of Dermatology,             face regions, with similar prevalence in the H and non-H
Medical University of Silesia in Katowice, and “Estevita”           zone. Arborizing telangiectasias were present in 78.0% and
Specialist Medical Practice between 2017 and 2020, were             77.2 % and short fine telangiectasias in 78.0% and 84.8 %
analyzed. The location and histological type of the lesion,         in H-zone and non-H-zone respectively. The features of pig-
age and gender of each patient, were analyzed. Patients with        mentation such as leaf-like structures, blue-gray ovoid nests
genetic disorders predisposing to BCC were excluded from            blue-gray globules were present in comparable incidence in
the analysis. The anatomic location of tumors was classified        both groups, with exception of brown globules, which were
as H-zone (nose, ear, eye) and non-H-zone (forehead, cheek,         present significantly more often in the non-H- zone (53.2%
chin and the rest of the face and neck) based on the decision       versus 26.8%, P = 0.01). Moreover, there was a significantly
of two separate authors. If the lesion had been located in the      higher prevalence of ulceration in the H-zone than in the
border zone between the aforementioned anatomical loca-             non-H-zone (73.2% versus 43.6 %, P < 0.001).
tions or there was a discordance in the authors decision, its
eventual classification was based on the discussion of all three    Conclusions
authors. Classical dermoscopic features of BCC like arboriz-
ing telangiectasias, leaf-like structures, blue-gray ovoid nests,   BCC develops mainly as a result of interactions between en-
blue-gray non-aggregated globules, spoke-wheel structures,          vironmental and genetic factors. However, disorders during



2                                                                       Original Article | Dermatol Pract Concept. 2023;13(3):e2023125
                     Table 1. Comparison of dermoscopic features in H- and non-H-zones*.
      Analysed Dermoscopic Features                        H-zone (N=41)                    Non-H-zone (N=79)                  P
 Arborizing teleangiectasias, N (%)                                                                                          0.91
               Absent                                             9 (22.0%)                     18 (22.8%)
               Present                                           32 (78.0%)                     61 (77.2%)
 Leaf-like structures, N (%)                                                                                                 0.14
               Absent                                            33 (80.5%)                     52 (65.8%)
               Present                                            8 (19.5%)                     27 (34.2%)
 Blue-gray ovoid nests, N (%)                                                                                                0.22
               Absent                                            28 (68.3%)                     45 (57.0%)
               Present                                           13 (31.7%)                     34 (43.0%)
 Blue-gray non-aggregated globules, N (%)                                                                                    0.055
               Absent                                            29 (70.7%)                     40 (50.6%)
               Present                                           12 (29.3%)                     39 (49.4%)
 Spoke-wheel structures, N (%)                                                                                               0.13
               Absent                                            39 (95.1%)                     67 (84.8%)
               Present                                             2 (4.9%)                     12 (15.2%)
 Milia cysts                                                                                                                 0.16
               Absent                                            21 (51.2%)                     51 (64.6%)
               Present                                           20 (48.8%)                     28 (35.4%)
 Short fine teleangiectasias, N (%)                                                                                          0.45
               Absent                                             9 (22.0%)                     12 (15.2%)
               Present                                           32 (78.0%)                     67 (84.8%)
 Brown globules, N (%)                                                                                                       0.010
               Absent                                            30 (73.2%)                     37 (46.8%)
               Present                                           11 (26.8%)                     42 (53.2%)
 Ulceration, N (%)                                                                                                          <0.001
               Absent                                            11 (26.8%)                     44 (56.4%)
               Present                                           30 (73.2%)                     35 (43.6%)
 Shiny white areas, N (%)                                                                                                    0.37
               Absent                                            12 (29.3%)                     29 (36.7%)
               Present                                           29 (70.7%)                     50 (63.3%)



the process of embryogenesis and their consequences on the              development in the H-zone and non-H-zone 2) The preva-
clinical course of BCC still remain incompletely examined.              lence of ulceration in the H-zone is significantly higher than
H-zone, the region corresponding to places of fusion of em-             in the non-H zone 3) The BCCs located in the non-H-zone
bryonic masses, is considered a region of higher occurrence             tend to present brown globules in a significantly higher per-
and recurrence of BCC, although it is uncertain, whether the            centage than BCCs from the H-zone.
location of the tumor plays a similar role in the development                 According to the literature, ulceration is a characteristic
and prognosis of BCC as other, already established risk fac-            feature associated with worse clinical behavior, typically in
tors such as histologic subtype, the diameter of the lesion,            nodular BCC [10,13,14]. In our study, it was nodular BCC
and the patient health condition [7,12].                                that dominated the analyzed tumors, as it constituted 61.6%
    Dermoscopic criteria of BCC, which include arborizing               of tumors in the non-H-zone and 51.3% of tumors in the
telangiectasias, large blue/gray ovoid nests, multiple blue/            H-zone. These facts may indicate that a higher incidence of
gray globules, short fine telangiectasia, leaflike areas, mul-          ulceration in the H-zone in our study does not solely reflect
tiple in-focus blue/gray dots, ulceration were proposed by              the histological subtypes of the tumors. On the basis of our
Menzies et al [9].                                                      results, one could hypothesize that tissue interference during
    The main results of our analysis are: 1) The dermo-                 mesenchymal fusion in embryogenesis might predispose to
scopic image of the BCC cases differs depending on their                a more aggressive course of BCC complicated by ulceration



Original Article | Dermatol Pract Concept. 2023;13(3):e2023125                                                                         3
Figure 1. Comparison of the dermoscopic features in H-zone and non-H-zone. In the lesions located in the H-zone, there is a higher preva-
lence of ulceration, and brown globules are more frequently observed in the non-H-zone.




                     Table 2. Comparison of histological subtypes in H- and non-H-zones.
    Histological Subtype, N (%)                    H-zone (N=39)                           Non-H-zone (N=73)                      P
 Nodular                                              20 (51.3%)                                45 (61.6%)                      0.03
 Superficial                                            2 (5.1%)                                14 (19.8%)
 Infiltrative                                           3 (7.7%)                                   1 (1.4%)
 Micronodular                                           0 (0.0%)                                   2 (2.7%)
 Morpheiform                                            2 (5.1%)                                   0 (0.0%)
 Pigmented                                              3 (7.7%)                                   2 (2.7%)
 Multifocal                                            7 (18.0%)                                   7 (9.6%)
 Other                                                  2 (5.1%)                                   2 (2.7%)



in the H-zones. It has been proved that BCC located in fu-            cases [11]. Moreover, the cited manuscript did not divide the
sion planes may demonstrate a deeper tissue invasion, due to          BCCs on the basis of embryological origin, as has been done
the perpendicular arrangement of fibrous connective tissue            in our manuscript.
favorable to infiltration [15-16].                                        Although in some studies, a significant increase in the
    The influence of the location of BCC on the prognosis,            recurrence rate of BCCs located in the H-zone was demon-
including the recurrence rate is still debated. Even though a         strated, no such results were confirmed in the other analyses
recent, thorough analysis of 291 cases of BCC by Conforti             including the study of Yalcin, or Armstrong et al, who did
et al evaluated their dermoscopy patterns with reference to           not find any association between BCC location and the risk
the anatomical location, the authors included tumors located          of invasion, ulceration and recurrence rate [15-17].
on the whole-body surface, thus the cancers located on the                We found a significantly higher frequency of brown glob-
head/neck constituted approximately 47% of all analyzed               ules, not reported before in the literature. It should be noted




4                                                                          Original Article | Dermatol Pract Concept. 2023;13(3):e2023125
that these structures were more often visible in the non-H-            3. Ramachandran S, Fryer AA, Smith A, et al. Cutaneous basal cell car-
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6                                                                           Original Article | Dermatol Pract Concept. 2023;13(3):e2023125
