10.5826/dpc.1301a4
Introduction: Dermoscopy aids in identifying histopathological subtypes and the presence of clinically undetectable pigmentation in basal cell carcinoma (BCC).
Objectives: To investigate the dermoscopic features of BCC subtypes and better understand non-classical dermoscopic patterns.
Methods: Clinical and histopathological findings were recorded by a dermatologist who was blinded to the dermoscopic images. Dermoscopic images were interpreted by two independent dermatologists blinded to the patients’ clinical and histopathologic diagnosis. Agreement between the two evaluators and with histopathological findings was evaluated using Cohen’s kappa coefficient analysis.
Results: The study included a total of 96 BBC patients with 6 histopathologic variants: nodular (n=48, 50%), infiltrative (n=14, 14.6%), mixed (n=11, 11.5%), superficial (n=10, 10.4%), basosquamous (n=10, 10.4%), and micronodular (n=3, 3.1%). Clinical and dermoscopic diagnosis of pigmented BCC showed high agreement with histopathological diagnosis. The most common dermoscopic findings according to subtype were as follows: nodular BCC: shiny white-red structureless background (85.4%), white structureless areas (75%), and arborizing vessels (70.7%); infiltrative BCC: shiny white-red structureless background (92.9%), white structureless areas (78.6%), arborizing vessels (71.4%); mixed BCC: shiny white-red structureless background (72.7%), white structureless areas (54.4%), and short fine telangiectasias (54.4%); superficial BCC: shiny white-red structureless background (100%), short fine telangiectasias (70%); basosquamous BCC: shiny white-red structureless background (100%), white structureless areas (80%), keratin masses (80%); micronodular BCC: short fine telangiectasias (100%).
Conclusions: In this study, arborizing vessels were the most common classical dermoscopic feature of BCC, while shiny white-red structureless background and white structureless areas were the most frequent non-classical dermoscopic features.
text/xml
2160-9381
2197
en
Nuray Can
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
pigmentation
Clinical, Dermoscopic and Histopathological Evaluation of Basal Cell Carcinoma Subtypes
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2021-11-24
2023-01-31
2023-03-10
e2023004
Dermatol Pract Concept
Introduction: Dermoscopy aids in identifying histopathological subtypes and the presence of clinically undetectable pigmentation in basal cell carcinoma (BCC).
Objectives: To investigate the dermoscopic features of BCC subtypes and better understand non-classical dermoscopic patterns.
Methods: Clinical and histopathological findings were recorded by a dermatologist who was blinded to the dermoscopic images. Dermoscopic images were interpreted by two independent dermatologists blinded to the patients’ clinical and histopathologic diagnosis. Agreement between the two evaluators and with histopathological findings was evaluated using Cohen’s kappa coefficient analysis.
Results: The study included a total of 96 BBC patients with 6 histopathologic variants: nodular (n=48, 50%), infiltrative (n=14, 14.6%), mixed (n=11, 11.5%), superficial (n=10, 10.4%), basosquamous (n=10, 10.4%), and micronodular (n=3, 3.1%). Clinical and dermoscopic diagnosis of pigmented BCC showed high agreement with histopathological diagnosis. The most common dermoscopic findings according to subtype were as follows: nodular BCC: shiny white-red structureless background (85.4%), white structureless areas (75%), and arborizing vessels (70.7%); infiltrative BCC: shiny white-red structureless background (92.9%), white structureless areas (78.6%), arborizing vessels (71.4%); mixed BCC: shiny white-red structureless background (72.7%), white structureless areas (54.4%), and short fine telangiectasias (54.4%); superficial BCC: shiny white-red structureless background (100%), short fine telangiectasias (70%); basosquamous BCC: shiny white-red structureless background (100%), white structureless areas (80%), keratin masses (80%); micronodular BCC: short fine telangiectasias (100%).
Conclusions: In this study, arborizing vessels were the most common classical dermoscopic feature of BCC, while shiny white-red structureless background and white structureless areas were the most frequent non-classical dermoscopic features.
Nuray Can
2023/01/31
10.5826/dpc.1301a4
e2023004
Departments of Pathology, Faculty of Medicine, Trakya University, Edirne, Turkey
2160-9381
pigmentation
en
e2023004
Akay BN, Saral S, Heper AO, Erdem C, Rosendahl C. Basosquamous carcinoma: Dermoscopic clues to diagnosis. J Dermatol. 2017;44(2):127-34. DOI: 10.1111/1346-8138.13563.
Clinical, Dermoscopic and Histopathological Evaluation of Basal Cell Carcinoma Subtypes
https://dpcj.org/index.php/dpc/article/download/2197/1946
          Clinical, Dermoscopic and Histopathological
               Evaluation of Basal Cell Carcinoma
                   Yıldız Gürsel Ürün1, Sezin Fiçicioğlu1, Mustafa Ürün1, Nuray Can2


1 Departments of Dermatology and Venereology, Trakya University, Edirne, Turkey
2 Departments of Pathology, Faculty of Medicine, Trakya University, Edirne, Turkey



Key words: basal cell carcinoma, dermoscopy, dermatoscopy, subtype, pigmentation
Citation: Gürsel Ürün Y, Fiçicioğlu S, Can N. Clinical, Dermoscopic and Histopathological Evaluation of Basal Cell Carcinoma.
Dermatol Pract Concept. 2023;13(1):e202304. DOI: https://doi.org/10.5826/dpc.1301a4
Accepted: September 9, 2022; Published: January 2023
Copyright: ©2023 Gürsel Ürün 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: Yıldız Gürsel Ürün, Department of Dermatology and Venereology, Faculty of Medicine, Trakya University, Edirne/
Turkey. tel: +90 284 235 7641 / +90 505 537 30 63 E-mail: yildizgurselurun@trakya.edu.tr




  ABSTRACT             Introduction: Dermoscopy aids in identifying histopathological subtypes and the presence of c­ linically
                       undetectable pigmentation in basal cell carcinoma (BCC).
                       Objectives: To investigate the dermoscopic features of BCC subtypes and better understand non-­
                       classical dermoscopic patterns.
                       Methods: Clinical and histopathological findings were recorded by a dermatologist who was blinded
                       to the dermoscopic images. Dermoscopic images were interpreted by two independent dermatologists
                       blinded to the patients’ clinical and histopathologic diagnosis. Agreement between the two evaluators
                       and with histopathological findings was evaluated using Cohen’s kappa coefficient analysis.
                       Results: The study included a total of 96 BBC patients with 6 histopathologic variants: nodular (n=48,
                       50%), infiltrative (n=14, 14.6%), mixed (n=11, 11.5%), superficial (n=10, 10.4%), basosquamous
                       (n=10, 10.4%), and micronodular (n=3, 3.1%). Clinical and dermoscopic diagnosis of pigmented
                       BCC showed high agreement with histopathological diagnosis. The most common dermoscopic find-
                       ings a­ ccording to subtype were as follows: nodular BCC: shiny white-red structureless background
                       (85.4%), white structureless areas (75%), and arborizing vessels (70.7%); infiltrative BCC: shiny
                       white-red structureless background (92.9%), white structureless areas (78.6%), arborizing vessels
                       (71.4%); mixed BCC: shiny white-red structureless background (72.7%), white structureless areas
                       (54.4%), and short fine telangiectasias (54.4%); superficial BCC: shiny white-red structureless back-
                       ground (100%), short fine telangiectasias (70%); basosquamous BCC: shiny white-red structureless
                       background (100%), white structureless areas (80%), keratin masses (80%); micronodular BCC:
                       short fine telangiectasias (100%).




Original Article | Dermatol Pract Concept. 2023;13(1):e202304                                                                         1
                      Conclusions: In this study, arborizing vessels were the most common classical dermoscopic feature
                      of BCC, while shiny white-red structureless background and white structureless areas were the most
                      frequent non-classical dermoscopic features.




Introduction                                                      Faculty of Medicine Ethics Committee (approval number:
                                                                  10/18, date: 26.04.2021).
Basal cell carcinoma (BCC) is the most common skin can-              The main demographic features (age, sex, previous his-
cer, and its incidence has doubled in the last 25 years [1, 2].   tory of BCC, Fitzpatrick skin type, lesion location and
Although it rarely metastasizes, it is an important cause of      whether it is in a sun-exposed or sun-protected area), clinical
morbidity in untreated patients [3]. BCC has diverse clin-        features (lesion palpability, ulceration, presence of pigmenta-
icopathological manifestations, including nodular, superfi-       tion) were recorded for each patient by an independent der-
cial, morpheaform, and pigmented variants [4]. BCCs are           matologist. The same dermatologist examined the patients’
pigmented in more than 50% of dark-skinned people and             clinical images and histopathologic data. Histopathologic as-
less than 10% of light-skinned people [5, 6]. Knowledge of        sessment of pigmentation was based on the presence of pig-
the histopathologic subtypes of BCC is important both for         mented basaloid sockets in the dermis or melanin deposits at
estimating the potential risk of recurrence and for choosing      the dermo-epidermal junction. The clinical diagnosis of hy-
the type of treatment [7].                                        perpigmentation was made by evaluating macro photographs
    Dermoscopy is a noninvasive technique commonly used           and the retrospective history of the patients. Based on these
in the diagnosis of skin tumors [8]. This is an in vivo tech-     findings, the patients were divided into two subgroups, clin-
nique with 89-91.2% sensitivity and 95% specificity. BCC’s        ically and histopathologically pigmented and nonpigmented
dermoscopy includes features that vary with age, sex, race,       BCC, and six subgroups based on histopathologic type.
histopathologic subtype, tumor location, and presence or ab-         Dermoscopic images were obtained with FotoFinder
sence of pigmentation [9]. When the dermoscopic features          platform-based dermoscopy system (FotoFinder Systems
defined for superficial BCC are correctly determined, the         GmbH, Germany) using 20X lenses. For each lesion, ­images
rate of correct diagnosis increases to 99% [10]. There are no     were obtained in polarized mode using both contact and
clear criteria for dermoscopic evaluation of rarer, aggressive    noncontact techniques. Minimal pressure was applied and
histopathologic subtypes [6, 11, 12].                             ultrasound gel was used to preserve vessel morphology
    In this study, we aimed to establish a relationship between   and ensure optimal visualization.
BCC histopathologic subtypes and the clinical and dermo-             Dermoscopic images were interpreted on a computer
scopic features of BCC, to describe the dermoscopic features      display by two independent dermatologists who were both
of the rarer aggressive subtypes of BCC, to better understand     blinded to the patients’ clinical and histopathologic diagnosis.
the dermatoscopic patterns of nonvascular/­
                                          nonpigmented               BCC and its subtypes were defined according to the crite-
structures to diagnose early BCC lesions before the classical     ria compiled by Reiter et al. [3]. Accordingly, structures were
pattern features are observed. Furthermore, our secondary         divided into three categories:
purpose was to compare the frequency of clinical and der-
moscopic pigmentation in patients with a histopathologic          1. Pigmented structures: multiple blue-grey dots and
diagnosis of pigmented BCC.                                          globules, large blue-grey ovoid nests, leaflike areas,
                                                                     spoke-wheel areas, and concentric structures
                                                                  2. Vascular structures: arborizing vessels, short fine telan-
Materials and Methods
                                                                     giectasias, polymorphous vessels (more than one vessel
This retrospective study was conducted in patients who pre-          pattern), and others (dotted, coiled [glomerular], looped
sented to the dermatology and venereal diseases department           [hairpin], and helical [corkscrew] vessels)
of Trakya University between December 2017 and April              3. Nonvascular/nonpigmented         structures:    shiny   white
2021. The records of 96 patients with BCC who presented              structures (shiny white streaks, shiny white blotches and
to the outpatient clinic between these dates were screened.          strands, rosettes) surface changes (multiple small erosions,
Patients who had clinical and dermoscopic images on record,          ulceration), shiny white-red structureless background.
whose BCC subtype was determined histopathologically, and
who had a histopathological diagnosis of total excision were         In addition, the article by Kittler et al. [13] was used to
included. The study was approved by the Trakya University         standardize the naming of dermoscopic terms. The “rosettes”


2                                                                      Original Article | Dermatol Pract Concept. 2023;13(1):e202304
structure that Kittler et al. evaluated within the structure of            Table 1. Demographics, clinical and
shiny white structures was also examined in this subtitle. The          histopathological evaluation of basal cell
dermoscopic diagnosis of basosquamous BCC was based on                             carcinoma patients.
the study by Giacomel et al. [14]. In addition, some of the
                                                                                                                          N= 96
dermoscopic patterns indicating melanocytic lesions (brown
                                                                    Age
to black dots/globules, blue/white veil, pigmented network,           Mean± SD                                        67.13±12.58
pseudopods, radial flowing, or a polymorphous vascular                Range                                            32.0-87.0
pattern) used by Altamura et al. were included in the evalu-        Sex [n (%)]
ation [4].                                                            Male                                              69 (71.9)
    In the dermoscopic evaluation, two dermatologists                 Female                                            27 (28.1)
grouped the lesions as pigmented and non-pigmented ac-              Past history of BCC [n (%)]
cording to the presence of at least one pigmentation-related          Negative                                          79 (82.3)
                                                                      Positive                                          17 (17.7)
dermoscopic criterion. These data were then compared with
clinical and histopathologic grouping.                              Skin phototypes [n (%)]
                                                                      I                                                  3 (3.1)
                                                                      II                                                41 (42.7)
Statistics                                                            III                                               41 (42.7)
Statistical analysis of the data was performed using IBM              IV                                                10 (10.4)
SPSS Statistics version 22 software. As the ages of the               V                                                  1(1.0)
male and ­
         female patients were not normally distributed,             Location [n (%)]
Mann-Whitney U test was used to compare age between the               Head and neck                                     87 (90.6)
                                                                      Upper limbs                                        3 (3.1)
groups. Cohen’s kappa coefficient was used to analyze agree-
                                                                      Lower limbs                                        1 (1.0)
ment between the two evaluators and with histopathological
                                                                      Trunk                                              5 (5.2)
findings. P values < 0.05 were considered statistically signifi-
                                                                    Site of the lesion [n (%)]
cant. Findings of milia-like cysts by the two independent der-         Sun exposed                                      78 (81.3)
matologists did not show statistically significant agreement           Sun protected                                    18 (18.8)
with dermoscopic findings (p > 0.05). These dermoscopic             Palpability [n (%)]
features were excluded from the evaluation.                           Flat                                              35 (36.5)
                                                                      Elevated                                          32 (33.3)
                                                                      Nodular                                           29 (30.2)
Results                                                             Ulcer [n (%)]
                                                                      Negative                                          75 (78.1)
The sociodemographic and clinical characteristics and der-
                                                                      Positive                                          21 (21.9)
moscopic images of a total of 96 patients with BCC were ex-
                                                                    Clinical pigmentation [n (%)]
amined. The patients ranged in age from 32 to 87 years, with
                                                                      Non-pigmented                                     74 (77.1)
a mean age of 67.13 ± 12.58. Sixty-nine patients (71.9%)              Pigmented                                         22 (22.9)
were men and 27 (28.1%) were women. Seventeen patients              Histopathological pigmentation [n (%)]*
(17.7%) had a past history of BCC. The most common                    Non-pigmented                                     66 (68.8)
­Fitzpatrick skin phototypes were II (42.7%) and III (42.7%).         Pigmented                                         30 (31.3)
    Most tumors were located in the head and neck region            Histopathological subtypes [n (%)]
(n = 87; 90.6%) and in sun-exposed areas (n = 78, 81.3%).             Superficial                                       10 (10.4)
On clinical evaluation, 35 (36.5%) of the lesions were flat, 32       Nodular                                            48 (50)
                                                                      Micronodular                                       3 (3.1)
(33.3%) were elevated, and 29 (30.2%) were nodular. Clini-
                                                                      Infiltrative                                      14 (14.6)
cally visible ulceration and pigmentation were observed in 21
                                                                      Mixed                                             11 (11.5)
(21.9%) and 22 (22.9%) of the lesions, respectively (Table 1).        Basosquamous                                      10 (10.4)
    The following BCC histopathologic variants were ob-
served: nodular (n = 48, 50%), infiltrative (n = 14, 14.6%);       BCC = Basal Cell Carcinoma.
                                                                   * Histopathological pigmentation corresponds to pigmented basa-
mixed (n = 11, 11.5%); superficial (n = 10, 10.4%); ba-            loid nests in the dermis or melanin deposition at the dermo-­epidermal
sosquamous (n = 10, 10.4%); and micronodular (n = 3.1%)            junction.
(Table 1). The clinical images of the histopathologically con-
firmed BCC subtypes are shown in Figure 1.                         elevated for infiltrative BCC (n=9, 64.3%), and flat for su-
    The clinical characteristics of the histopathologic sub-       perficial BCC (n=10, 100%).
types are compared in Table 2. The most common clinical                The lesions’ pigmentation characteristics and their clin-
appearance was nodular for nodular BCC (n = 20, 41.7%),            ical, dermoscopic, and histopathologic correlations were


Original Article | Dermatol Pract Concept. 2023;13(1):e202304                                                                          3
        Figure 1. The clinical aspect of basal cell carcinoma. (A) Pigmented, (B) Superficial, (C) Nodular, (D) Infiltrative, (E) Mixed, (F)
        Basosquamous.



                             Table 2. Clinical assessment of basal cell carcinoma subtypes.
                      Nodular           Infiltrative         Mixed          Superficial           Basosquamous               Micronodular
                      (n = 48)            (n = 14)          (n = 11)         (n = 10)                (n = 10)                   (n = 3)
 Flat                  12 (25)            3 (21.4)          6 (54.5)          10 (100)                2 (20.0)                   2 (66.7)
 Elevated             16 (33.3)           9 (64.3)          2 (18.2)              0                   4 (40.0)                   1 (33.3)
 Nodular              20 (41.7)           2 (14.3)          3 (27.3)              0                   4 (40.0)                       0

Numbers in parentheses represent percentages.



    Table 3. Comparison of the presence of histopathologic pigmentation with the presence of clinical
                       and dermoscopic pigmentation in basal cell carcinoma.
                                                                           Presence of histopathologic pigmentation
                                                              Negative                 Positive                Total
                                                              n         %             n        %           n           %         κ             p
 Presence of clinical pigmentation Negative                  64        97.0           10      33.3        74        77.1      0,686      0,000
                                   Positive                   2         3.0           20      66.7        22        22.9
 Presence of dermoscopic                   Negative          63        95.5            -       -          63        65.6      0,929      0,000
 pigmentation                              Positive           3         4.5           30     100.0        33        34.4
 N = 96                                                      66        68.8           30      31.3        96           100

Cohen’s kappa concordance test (κ)



compared. According to this table, clinical and dermoscopic                 Dermoscopic Characteristics of BCC
features were consistent with histopathological features in                 Histopathologic Subtypes
the diagnosis of pigmented BCC (Table 3).                                   Nodular BCC presented most commonly with shiny
     The frequency of different dermoscopic features in BCC                 white-red structureless background (n = 41, 85.4%), shiny
and its subtypes is detailed in Table 4.                                    white blotches and strands (n = 36, 75%), arborizing vessels



4                                                                                 Original Article | Dermatol Pract Concept. 2023;13(1):e202304
Table 4. Distribution of dermatoscopic patterns according to different types of basal cell carcinoma.
                                                  Nodular       Infiltrative      Mixed      SF        BS         MN         BCC
                                                   n (%)           n (%)          n (%)     n (%)     n (%)      n (%)      n (%)
 Vascular      Arborizing vessels                34 (70.7)      10 (71.4)        5 (45.5)   2 (20)    7 (70)    1 (33.3)   59 (61.4)
 structures    Short fine telangiectasias        17 (35.4)       8 (57.1)        6 (54.5)   7 (70)    5 (50)    3 (100)    46 (47.8)
               Polymorphous vessels              19 (39.6)       4 (28.6)        4 (36.4)   3 (30)    6 (60)       -       36 (37.5)
               Others [dotted, coiled              2 (4.2)        1 (7.1)            -      1 (10)    2 (20)       -        6 (6.3)
               ­(glomerular), looped
                ­(hairpin), helical
                 (corkscrew) vessels]
 Pigmented Multiple blue-grey dots                 1 (2.1)           -            1 (9.1)   1 (10)        -        -        3 (3.1)
 structures Multiple blue-grey globules            3 (6.3)        1 (7.1)         1 (9.1)     -       1 (10)       -        6 (6.3)
               Large blue-grey ovoid nests       13 (27.1)           -            1 (9.1)     -       1 (10)    1 (33.3)   16 (16.6)
               Brown dots                         6 (12.5)           -            1 (9.1)   4 (40)    1 (10)    2 (66.7)   14 (14.6)
               Brown globules                     9 (18.8)           -           2 (18.2)   4 (40)    1 (10)    3 (100)    19(19.8)
               Brown nets                         6 (12.5)        1 (7.1)         1 (9.1)   2 (20)        -     2 (66.7)   12 (12.5)
               Concentric structures              5 (10.4)       2 (14.3)        2 (18.2)   2 (20)        -     2 (66.7)   13 (13.5)
               Leaflike areas                      2 (4.2)           -            1 (9.1)   3 (30)        -     2 (66.7)    8 (8.3)
 Shiny         Shiny white streaks               21 (43.8)       6 (42.9)        5 (45.5)   2 (20)    2 (20)       -       36 (37.5)
 white         Shiny white blotches and           36 (75)       11 (78.6)        6 (54.5)   6 (60)    8 (80)    2 (66.7)   69 (71.9)
 structures    strands
               Rosettes                           5 (10.4)       3 (21.4)        2 (18.2)   1 (10)    2 (20)       -       13 (13.5)
 Others        Multiple small erosions           21 (43,8)       6 (42,9)        3 (27,3)   6 (60)    2 (20)       -       38 (39,6)
               Ulceration                        28 (58.3)      10 (71.4)        5 (45.5)   3 (30)    6 (60)       -       52 (54.2)
               Shiny white-red structureless 41 (85.4)          13 (92.9)        8 (72.7)     10     10 (100)   2 (66.7)   84 (87.5)
               background                                                                   (100)
               Blue whitish veil                   3 (6.3)       2 (14.3)            -        -           -     1 (33.3)    6 (6.3)
               Keratin masses                         -              -           3 (27.3)     -       8 (80)       -       11 (11.4)

SF = Superficial; BS = Basosquamous; MN = Micronodular; BCC = Basal Cell Carcinoma.



(n = 34, 70.7%), and ulceration (n = 28, 58.3%). When                    keratin masses (n= 8, 80%), arborizing vessels (n = 7, 70%),
pigmentation was present, the most common structure was                  and polymorphous vessels (n = 6, 60%).
large blue-grey ovoid nests (n = 13, 27.1%).                                   In micronodular BCC, short fine telangiectasias were
    The most common dermoscopic findings in infiltra-                    observed on dermoscopy (n=3, 100%). In the presence of
tive BCC were shiny white-red structureless background                   pigmentation, the most common dermoscopic finding was
(n = 13, 92.9%), shiny white blotches and strands (n = 11,               brown globules (n = 3, 100%).
78.6%), arborizing vessels (n=10, 71.4%), ulceration (n=10,                    Various dermoscopic images of basal cell carcinomas
71.4%), and short fine telangiectasias (n = 8, 57.1%).                   with vascular structures, pigmented structures, shiny white
    In mixed BCC, the most common dermoscopic find-                      structures, surface changes, shiny white-red structureless
ings were shiny white-red structureless background (n = 8,               background, blue-whitish veil, and keratin masses were
72.7%), shiny white blotches and strands (n = 6, 54.4%),                 shown in detail in Figure 2-5.
and short fine telangiectasias (n = 6, 54.4%).
    The most common dermoscopic findings in superficial
                                                                         Discussion
BCC were shiny white-red structureless background (n = 10,
100%), short fine telangiectasias (n = 7, 70%), shiny white              In this study, patients with clinical and dermoscopic
blotches and strands (n = 6, 60%), and multiple small ero-               ­pigmented/unpigmented BCC were evaluated using polar-
sions (n = 6, 60%).                                                      ized dermoscopy to assist in the diagnosis of BCC subtypes.
    Basosquamous BCC presented with dermoscopic find-                          The sociodemographic characteristics of the patients
ings of shiny white-red structureless background (n = 10,                in our study were found to be consistent with previous
100%), shiny white blotches and strands (n = 8, 80%),                    studies [11, 15]. In various publications, nodular BCC has



Original Article | Dermatol Pract Concept. 2023;13(1):e202304                                                                         5
               Figure 2. Dermoscopic features of (A) Arborizing vessels, (B) Short fine telangiectasias, (C) Polymorphous
               vessels, (D) Looped (hairpin) vessels.



consistently been reported as the most common subtype                 study [3]. In studies conducted in 2005 and 2008, the term
(57.6-78.7%), followed by superficial BCC (14.8-17.5%)                “shiny white-red structureless” was used, and these struc-
and infiltrative BCC (6.2-26.2%) [16,17]. Arits et al. re-            tures were observed in all superficial BCCs [21, 22]. Trigoni
ported total rates for superficial and infiltrative BCC of            et al. included shiny white-red structureless background
23.8% and 27.6%, respectively [18]. In our study, infiltra-           features observed within lesions under a general description
tive BCC was more frequent than superficial BCC.                      of white-red structureless areas [23]. Emiroglu et al., on the
    When BCC subtypes were clinically evaluated, our re-              other hand, referred to these structures as “milky-pink to red
sults were similar to those of Lallas et al. [19]. A notable          background” and emphasized that they are also seen in other
feature of both studies was the absence of nodular lesions            BCC subtypes that are mostly superficial [24]. A 2021 publi-
among superficial BCCs. Superficial BCCs classically pres-            cation used this term as “red-white homogenous areas” and
ent as a well-circumscribed and erythematous thin plaque or           noted that they are present in superficial and nodular BCC
patch with scale [20]. Both Lallas et al. and our studies sup-        subtypes [25]. We evaluated the lesions similar to the state-
port this clinical appearance. Micronodular BCC is difficult          ment by Trigoni et al. Accordingly, in our study, the shiny
to distinguish clinically from superficial and nodular BCC            white-red structureless background was found in all super-
and can present as erythematous macules or thin ­papules/             ficial BCC cases as well as in other BCC subtypes. Since this
plaques [20]. The clinically rare nodule appearance of micro-         is a nonvascular/nonpigmented structure, a dermoscopic fea-
nodular BCC was observed both in our study and by Lallas              ture in BCC diagnosis, it was not considered in some studies
et al. [19].                                                          [26, 27]. The main problem is that the studies did not use a
    In the review by Reiter et al., shiny white structures            standardized term. We believe that standardization is needed
and shiny white-red structureless background structures               in defining nonvascular/nonpigmented structures.
were evaluated in nonvascular/nonpigmented structures. It                 There are few studies in the literature comparing the in-
has been emphasized that different terms were used in each            cidence of shiny white structures in BCC subtypes [24, 26].



6                                                                           Original Article | Dermatol Pract Concept. 2023;13(1):e202304
                Figure 3. The different dermoscopic pigmentation patterns of basal cell carcinoma. (A) Multiple blue-grey
                dots, (B-C) Multiple blue-grey globules, Large blue-grey ovoid nests, (D) Brown dots, (E) Brown globules,
                (F) Brown nets, (G) Concentric structures, (H) Leaflike areas.



When these studies and our study are examined, shiny white            the difference was not statistically significant [28]. This may
structures are most common in the nodular BCC subtype.                be due to the small sample size.
When the incidence of rosette structures in BCC subtypes                  Pigmented BCC is considered a low-risk variant in some
is examined, they were most commonly seen in superficial              publications [29]. However, Xavier-Júnior et al. described
BCCs in the study by Suppa et al. [26], whereas they were             pigmented BCCs with higher risk morphology, including
most commonly seen in nodular BCCs in our study. A better             sclerosing and micronodular subtypes [30]. Lallas et al. em-
understanding of these structures will facilitate the diagnosis       phasized that pigmentation can occur in all subtypes [28].
of BCC subtypes.                                                      We also observed dermoscopic pigmentation findings in all
    Lallas et al. reported that pigmentation could be de-             subtypes, most commonly in nodular BCC.
tected in 30% of clinically nonpigmented BCCs using der-                  Altamura et al. reported that 40.6% of BCCs had der-
moscopy and emphasized that dermoscopy has the potential              moscopic findings suggestive of the features of melanocytic
to reveal clinically undetectable pigmentation [28]. In our           lesions [4]. In our study, polymorphous vascular pattern was
study, there was consistency among clinical (22.9%), dermo-           observed in 36 patients (37.5%), brown globules in 18 pa-
scopic (34.4%), and histopathological (31.3%) features in             tients (18.8%), dots in 13 patients (13.5%), and blue-whitish
­diagnosing pigmented BCC. As in the study of Lallas et al.,          veil in 6 patients (6.3%). Altamura et al. emphasized that
the frequency of clinically pigmented BCC was lower than              these dermoscopic features may make it difficult to distin-
the rate of dermoscopic and histopathological diagnosis, but          guish pigmented (especially heavily pigmented) BCCs from



Original Article | Dermatol Pract Concept. 2023;13(1):e202304                                                                      7
Figure 4. Dermoscopic features of (A) Shiny white streaks, (B) Shiny white blotches and strands, (C) Rosettes.




Figure 5. Other dermoscopic features of basal cell carcinoma. (A) Multiple small erosions, (B) Ulceration, (C) Shiny white-red structureless
background, (D) Blue-whitish veil, (E) Keratin masses.



melanocytic nevi and melanomas [4]. Clinician caution is                fine telangiectasias (40%) [3, 31]. The dermoscopy study
advised in this respect.                                                conducted by Popadić included three infiltrative BCCs and
    Infiltrative BCC was reported to present with arboriz-              white shiny areas were detected in all of these patients [32].
ing vessels (76%), followed by ulceration (44%) and short               Information about the subgroups of white shiny areas was



8                                                                             Original Article | Dermatol Pract Concept. 2023;13(1):e202304
not given in this study. Pampena et al. evaluated 71 infiltra-    findings are consistent with the study by Verduzco-Martínez
tive BCC patients and reported the most common dermo-             et al. [36]. However, the insufficient number of patients in all
scopic findings to be short white streaks (77.5%), arborizing     studies makes it difficult to comment on the specific findings
vessels (71.8%), and shiny red-white structureless areas          of micronodular BCC.
(69.0%) [33]. Of the white shiny areas in our study, the most        In patients with basosquamous BCC, Giacomel et al.
common were shiny white blotches and strands (78.6%) and          observed dermoscopic features of unfocused (peripheral)
shiny white streaks (42.9%). In infiltrative BCCs, knowl-         arborizing vessels (73%), keratin masses (73%), shiny
edge of the subgroups of shiny white structures will help in      white blotches and strands (73%), ulceration or blood
diagnosis.                                                        crusts (68%), polymorphous vessels (50%) [14]. Akay et
    Pampena et al. determined that short fine telangiectasias     al. reported dermoscopic features of keratin mass (91.7%),
are common on dermoscopy of infiltrative BCC and con-             ulceration (69.4%), shiny white blotches and strands
cluded that arborizing vessels and short fine telangiectasias     (69.4%), and polymorphous vessels (61.1%) in basosqua-
can be seen in the same lesion [33]. Similarly, we observed       mous BCC [38]. When the results of these two studies
both arborizing vessels (71.4%) and short fine telangiecta-       and our own are evaluated, keratin masses, shiny white
sias (57.1%) in our infiltrative BCC patients. When the same      blotches and strands, ulceration, and polymorphous ves-
authors evaluated the degree of dermoscopic pigmentation          sels are among the most common dermoscopic findings.
in infiltrative BCC, they found that these lesions were more      Dermoscopy of basosquamous BCC shows features of ke-
amelanotic and less pigmented than nodular BCC [33]. In           ratinization with vascular patterns suggestive of BCC [38].
our study, the frequency of pigmentation seen in infiltrative     The greatest limitation of our study was that arborizing
BCC (6.1%) and mixed BCC (6.1%) patients was lower                vessel structures were not grouped as focused or unfocused
than in other BCC subtypes.                                       when evaluating basosquamous BCC. Therefore, we are
    Reiter et al. in their review reported that the most com-     unable to evaluate the appearance of arborizing vessels in
mon dermoscopic findings seen in superficial BCC were             this group.
short-fine telangiectasia (60%), multiple small erosions             This study has several limitations. Firstly, it was retro-
(43%), and shiny white structures (43%). Furthermore,             spective and conducted in a small patient population. In
79% of lesions were observed to have a white-red structured       addition, the population living in the Trakya area is predom-
background. They emphasized that shiny white-red struc-           inantly Fitzpatrick skin type II-III. Another limitation is that
tureless background is a unique dermoscopic finding for           histopathologic examinations were conducted by a single
superficial BCC [3]. Papageorgiou et al. emphasize that the       pathologist who was not blinded. Finally, the absence of a
white shiny blotches/strands structure is a predictor of super-   control group (dermoscopic images including benign and
ficial BCC in anatomic sites other than the lower extremities     malignant lesions) was another limitation.
[34]. In our study, shiny white-red structureless background
and shiny white blotches and strands structures are the most
                                                                  Conclusion
common nonvascular/nonpigmented structures in superficial
BCC, which is consistent with previous literature. Zalaudek       In this study, the most common finding among the classical
et al. accepted blue-gray ovoid nests as a negative predic-       dermoscopic features of BCC was arborizing vessels, while
tor of superficial BCC [35]. Similarly, blue-gray ovoid nests     shiny white-red structureless background and shiny white
were not detected in any of the superficial BCCs in our study.    blotches and strands were the most frequent n
                                                                                                              ­ onvascular/
Considering that brown structures are associated with mela-       nonpigmented structures dermoscopic features. The der-
nin, accumulation is observed in the dermo-epidermal junc-        moscopic features observed in the BCC histopathologic
tion on dermoscopy and constitutes a feature of superficial       subtypes were consistent with the literature. However, a
BCC [28]. In light of available data, brown dots and globular     specific/dermoscopic structure belonging to BCC subtypes
structures were mostly seen in superficial and micronodular       could not be detected. Of the less common subtypes, the
BCC in our study.                                                 frequency of short fine telangiectasias was 100% in micro-
    Verduzco-Martínez et al. evaluated the dermoscopic            nodular BCC, whereas shiny white-red structureless back-
findings of a patient with micronodular BCC and observed          ground was detected in 100%, shiny white blotches and
truncated vessels and globules [36]. In their study evaluating    strands in 80%, and keratin mass in 80% of basosquamous
the dermoscopic properties of aggressive BCC types includ-        BCCs. The small number of these subtypes in our popula-
ing micronodular BCC, Kim et al. reported that the appear-        tion and the absence of the morpheaform type precludes a
ance of multiple blue-gray globules was more common [37].         comprehensive interpretation of dermoscopic presentations
El-Sayeda et al. observed arborizing vessels and blue-gray        in all BCC subtypes. Further studies are needed for this
globules in a patient with micronodular BCC [11]. Our             purpose.



Original Article | Dermatol Pract Concept. 2023;13(1):e202304                                                                   9
References                                                                      16. de Vries E, Louwman M, Bastiaens M, de Gruijl F, Coebergh
                                                                                    JW. Rapid and continuous increases in incidence rates of
 1. Navarrete-Dechent C, Liopyris K, Rishpon A, et al. Associ-                      basal cell carcinoma in the southeast Netherlands since 1973.
    ation of Multiple Aggregated Yellow-White Globules With                         J Invest Dermatol. 2004;123(4):634-8. DOI: 10.1111/j.0022
    Nonpigmented Basal Cell Carcinoma. JAMA Dermatol.                               -202X.2004.23306.x.
    2020;156(8):882-90. DOI: 10.1001/jamadermatol.2020.1450.                    17. Scrivener Y, Grosshans E, Cribier B. Variations of basal cell
 2. Lallas A, Argenziano G, Zendri E, et al. Update on non-melanoma                 carcinomas according to gender, age, location and histo-
    skin cancer and the value of dermoscopy in its diagnosis and                    pathological subtype. Br J Dermatol. 2002;147(1):41-7. DOI:
    treatment monitoring. Expert Rev Anticancer Ther. 2013;13(5):                   10.1046/j.1365-2133.2002.04804.x.
    541-58. DOI: 10.1586/era.13.38.                                             18. Arits AH, Schlangen MH, Nelemans PJ, Kelleners-Smeets NW.
 3. Reiter O, Mimouni I, Dusza S, Halpern AC, Leshem YA,                            Trends in the incidence of basal cell carcinoma by histopatholog-
    ­Marghoob AA. Dermoscopic features of basal cell carcinoma                      ical subtype. J Eur Acad Dermatol Venereol. 2011;25(5):565-9.
     and its subtypes: A systematic review. J Am Acad Dermatol.                     DOI: 10.1111/j.1468-3083.2010.03839.x.
     2021;85(3):653-64. DOI: 10.1016/j.jaad.2019.11.008.                        19. Lallas A, Tzellos T, Kyrgidis A, et al. Accuracy of dermoscopic
 4. Altamura D, Menzies SW, Argenziano G, et al. Dermatoscopy                       criteria for discriminating superficial from other subtypes of
     of basal cell carcinoma: morphologic variability of global and                 basal cell carcinoma. J Am Acad Dermatol. 2014;70(2):303-11.
     local features and accuracy of diagnosis. J Am Acad Dermatol.                  DOI: 10.1016/j.jaad.2013.10.003.
     2010;62(1):67-75. DOI: 10.1016/j.jaad.2009.05.035.                         20. Cameron MC, Lee E, Hibler BP, et al. Basal cell carcinoma: Epide-
 5. Betti R, Gualandri L, Cerri A, Inselvini E, Crosti C. Clinical f­ eatures       miology; pathophysiology; clinical and histological subtypes; and
     and histologic pattern analysis of pigmented basal cell carcino-               disease associations. J Am Acad Dermatol. 2019;80(2):303-17.
     mas in an Italian population. J Dermatol. 1998;25(10):691-4.                   DOI: 10.1016/j.jaad.2018.03.060.
     DOI: 10.1111/j.1346-8138.1998.tb02484.x.                                   21. Giacomel J, Zalaudek I. Dermoscopy of superficial basal cell
 6. Lallas A, Apalla Z, Argenziano G, et al. The dermatoscopic                      carcinoma. Dermatol Surg. 2005;31(12):1710-3. DOI: 10.2310
     universe of basal cell carcinoma. Dermatol Pract Concept.                      /6350.2005.31314.
     2014;4(3):11-24. DOI: 10.5826/dpc.0403a02.                                 22. Scalvenzi M, Lembo S, Francia MG, Balato A. Dermoscopic
 7. Bichakjian CK, Olencki T, Aasi SZ, et al. Basal Cell Skin Cancer,               patterns of superficial basal cell carcinoma. Int J Dermatol.
     Version 1.2016, NCCN Clinical Practice Guidelines in Oncology.                 2008;47(10):1015-8. DOI: 10.1111/j.1365-4632.2008.03731.x.
     J Natl Compr Canc Netw. 2016;14(5):574-97. DOI: 10.6004                    23. Trigoni A, Lazaridou E, Apalla Z, et al. Dermoscopic features
     /jnccn.2016.0065.                                                              in the diagnosis of different types of basal cell carcinoma: a
 8. Kato J, Horimoto K, Sato S, Minowa T, Uhara H. Dermoscopy                       ­prospective analysis. Hippokratia. 2012;16(1):29-34.
     of Melanoma and Non-melanoma Skin Cancers. Front Med.                      24. Emiroglu N, Cengiz FP, Kemeriz F. The relation between dermos-
     2019;6:180. DOI: 10.3389/fmed.2019.00180.                                       copy and histopathology of basal cell carcinoma. An Bras Der-
 9. Niculet E, Craescu M, Rebegea L, et al. Basal cell carcinoma:                    matol. 2015;90(3):351-6. DOI: 10.1590/abd1806-4841.2015
     Comprehensive clinical and histopathological aspects, novel                     3446.
     ­imaging tools and therapeutic approaches (Review). Exp Ther               25. Behera B, Kumari R, Thappa DM, Gochhait D, Srinivas BH,
      Med. 2022;23(1):60. DOI: 10.3892/etm.2021.10982.                               Ayyanar P. Dermoscopic features of basal cell carcinoma in skin
10. Pan Y, Chamberlain AJ, Bailey M, Chong AH, Haskett M, Kelly                      of color: A retrospective cross-sectional study from Puducherry,
      JW. Dermatoscopy aids in the diagnosis of the solitary red scaly               South India. Indian J Dermatol Venereol Leprol. 2021;23:1-7.
      patch or plaque-features distinguishing superficial basal cell car-            DOI: 10.25259/ijdvl_420_20.
      cinoma, intraepidermal carcinoma, and psoriasis. J Am Acad Der-           26. Suppa M, Micantonio T, Di Stefani A, et al. Dermoscopic variabil-
      matol. 2008;59(2):268-74. DOI: 10.1016/j.jaad.2008.05.013.                     ity of basal cell carcinoma according to clinical type and anatomic
11. El-Sayed SK, El-Sayed GE-DA, Kamel AM, Al-Tramsy AA,                             location. J Eur Acad Dermatol Venereol. 2015;29(9):1732-41.
      Ateia SY. Efficacy of dermoscopy in the diagnosis of differ-                   DOI: 10.1111/jdv.12980.
      ent basal cell carcinoma subtypes. Egypt J Dermatol Venerol.              27. Navarrete-Dechent C, Bajaj S, Marchetti MA, Rabinovitz H,
      2020;40(1):15-22. DOI: 10.4103/ejdv.ejdv_26_19.                                Dusza SW, Marghoob AA. Association of Shiny White Blotches
12.   Ungureanu L, Cosgarea I, Şenilǎ S, Vasilovici A. Role of Der-                  and Strands With Nonpigmented Basal Cell Carcinoma: Evalua-
      moscopy in the Assessment of Basal Cell Carcinoma. Front Med                   tion of an Additional Dermoscopic Diagnostic Criterion. JAMA
      (Lausanne). 2021;8:718855. DOI: 10.3389/fmed.2021.718855.                      Dermatol. 2016;152(5):546-52. DOI: 10.1001/jamadermatol.
13.   Kittler H, Marghoob AA, Argenziano G, et al. Standardiza-                      2015.5731.
      tion of terminology in dermoscopy/dermatoscopy: Results of                28. Lallas A, Argenziano G, Kyrgidis A, et al. Dermoscopy uncovers
      the third consensus conference of the International Society of                 clinically undetectable pigmentation in basal cell carcinoma. Br J
      ­Dermoscopy. J Am Acad Dermatol. 2016;74(6):1093-106. DOI:                     Dermatol. 2014;170(1):192-5. DOI: 10.1111/bjd.12634.
       10.1016/j.jaad.2015.12.038.                                              29. Elder DE, Massi D, Scolyer RA, Willemze R. WHO Classification
14.    Giacomel J, Lallas A, Argenziano G, et al. Dermoscopy of                      of Skin Tumours. 4th ed. Lyon, France: IARC Press; 2018.
       ­basosquamous carcinoma. Br J Dermatol. 2013;169(2):358-64.              30. Xavier-Júnior JCC, Ocanha-Xavier JP, Camilo-Júnior DJ, Pires
        DOI: 10.1111/bjd.12394.                                                      D’ávilla S CG, Mattar NJ. Is pigmented BCC a unique histo-
15.     Muzic JG, Schmitt AR, Wright AC, et al. Incidence and Trends of              logical variant or is it only a clinical presentation? Australas J
        Basal Cell Carcinoma and Cutaneous Squamous Cell Carcinoma:                  Dermatol. 2020;61(1):80-1. DOI: 10.1111/ajd.13181.
        A Population-Based Study in Olmsted County, ­Minnesota, 2000            31. Álvarez-Salafranca M,Ara M, Zaballos P. Dermoscopy in Basal Cell
        to 2010. Mayo Clin Proc. 2017;92(6):890-8. DOI: 10.1016/j                    Carcinoma: An Updated Review. Actas Dermosifiliogr (Engl Ed).
        .mayocp.2017.02.015.                                                         2021;112(4):330-8. DOI: 10.1016/j.ad.2020.11.011.



10                                                                                    Original Article | Dermatol Pract Concept. 2023;13(1):e202304
32. Popadić M. Dermoscopy of aggressive basal cell carcinomas.              Melanocytic skin tumors. J Am Acad Dermatol. 2010;63(3):361-
    Indian J Dermatol Venereol Leprol. 2015;81(6):608-10. DOI:              74; quiz 375-6. DOI: 10.1016/j.jaad.2009.11.698.
    10.4103/0378-6323.168343.                                           36. Verduzco-Martínez AP, Quiñones-Venegas R, Guevara-­Gutiérrez
33. Pampena R, Parisi G, Benati M, et al. Clinical and Dermoscopic          E, Tlacuilo-Parra A. Correlation of dermoscopic findings with
    Factors for the Identification of Aggressive Histologic Subtypes        histopathologic variants of basal cell carcinoma. Int J Der-
    of Basal Cell Carcinoma. Front Oncol. 2020;10:630458. DOI:              matol. 2013;52(6):718-21. DOI: 10.1111/j.1365-4632.2012.
    10.3389/fonc.2020.630458.                                               05816.x.
34. Papageorgiou C, Apalla Z, Variaah G, et al. Accuracy of dermo-      37. Kim HS, Park JM, Mun JH, et al. Usefulness of Dermatoscopy for
    scopic criteria for the differentiation between superficial basal       the Preoperative Assessment of the Histopathologic Aggressive-
    cell carcinoma and Bowen’s disease. J Eur Acad Dermatol Vene-           ness of Basal Cell Carcinoma. Ann Dermatol. 2015;27(6):682-7.
    reol. 2018;32(11):1914-9. DOI: 10.1111/jdv.14995.                       DOI: 10.5021/ad.2015.27.6.682.
35. Zalaudek I, Kreusch J, Giacomel J, Ferrara G, Catricalà C,          38. Akay BN, Saral S, Heper AO, Erdem C, Rosendahl C. Basosqua-
    Argenziano G. How to diagnose nonpigmented skin tumors:
    ­                                                                       mous carcinoma: Dermoscopic clues to diagnosis. J Dermatol.
    a review of vascular structures seen with dermoscopy: part I.           2017;44(2):127-34. DOI: 10.1111/1346-8138.13563.




Original Article | Dermatol Pract Concept. 2023;13(1):e202304                                                                         11
