10.5826/dpc.1204a195
Introduction: Among the various widely recognized basal cell carcinoma (BCC) clinical patterns, linear basal cell carcinoma (LBCC) is an uncommon morphologic variant of BCC.
Objective: Describe the clinical and dermoscopic characteristics of LBCC.
Methods: Retrospective study including LBCC cases from 5 dermatology centers in North and South America. Biopsy-proven primary BCCs, that presented with at least 3:1 length:width ratio on physical examination, irrespective of tumor subtype or location, were included. Clinical and dermoscopic analysis were performed by 2 experts in dermoscopy.
Results: Eighteen cases of LBCC met our inclusion criteria and were included in the study. Median age at diagnosis was 86.0 years, 10 patients (58.8%) were males. Regarding anatomic location, 11/18 (61.1%) were located on the head and neck, 5/18 (27.7%) cases were found on the trunk, and 2 on lower extremities (11.1%). Under dermoscopy, 15/18 (83.3%) of LBCC were pigmented. All tumors displayed at least one of the BCC-specific dermoscopic criteria the most common being blue-grey globules (72.2%).
Conclusions: Dermoscopy might be useful in the differentiation of LBCC from other diagnoses presenting as linear lesions such as scars, scratches/erosions, and tattoos, among others. Some of these lesions might be confused by naked eye examination alone.
text/xml
2160-9381
2269
en
Alvaro Abarzua-Araya
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermatoscopy
Dermoscopy of linear basal cell carcinomas, a potential mimicker of linear lesions: a descriptive case series
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2021-12-21
2022-10-31
2022-12-02
e2022195
Dermatol Pract Concept
Introduction: Among the various widely recognized basal cell carcinoma (BCC) clinical patterns, linear basal cell carcinoma (LBCC) is an uncommon morphologic variant of BCC.
Objective: Describe the clinical and dermoscopic characteristics of LBCC.
Methods: Retrospective study including LBCC cases from 5 dermatology centers in North and South America. Biopsy-proven primary BCCs, that presented with at least 3:1 length:width ratio on physical examination, irrespective of tumor subtype or location, were included. Clinical and dermoscopic analysis were performed by 2 experts in dermoscopy.
Results: Eighteen cases of LBCC met our inclusion criteria and were included in the study. Median age at diagnosis was 86.0 years, 10 patients (58.8%) were males. Regarding anatomic location, 11/18 (61.1%) were located on the head and neck, 5/18 (27.7%) cases were found on the trunk, and 2 on lower extremities (11.1%). Under dermoscopy, 15/18 (83.3%) of LBCC were pigmented. All tumors displayed at least one of the BCC-specific dermoscopic criteria the most common being blue-grey globules (72.2%).
Conclusions: Dermoscopy might be useful in the differentiation of LBCC from other diagnoses presenting as linear lesions such as scars, scratches/erosions, and tattoos, among others. Some of these lesions might be confused by naked eye examination alone.
Alvaro Abarzua-Araya
2022/10/31
10.5826/dpc.1204a195
e2022195
Melanoma and Skin Cancer Unit, Department of Dermatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Dermatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
2160-9381
dermatoscopy
en
e2022195
Navarrete-Dechent C, Cordova M, Sahu A, Liopyris K, Rishpon A, Chen C, Rajadhyaksha M, Busam KJ, Marghoob AA, Chen CJ. Optical imaging guided- 'precision' biopsy of skin tumors: a novel approach for targeted sampling and histopathologic correlation. Arch Dermatol Res. 2021; 313: 517-29.
Dermoscopy of linear basal cell carcinomas, a potential mimicker of linear lesions: a descriptive case series
https://dpcj.org/index.php/dpc/article/download/2269/1761
         Dermoscopy of Linear Basal Cell Carcinomas,
           a Potential Mimicker of Linear Lesions:
                 a Descriptive Case-series
   Cristian Navarrete-Dechent1,2,3, Michael Armando Marchetti3, Pablo Uribe1,2, Rodrigo J.
        Schwartz4,8, Konstantinos Liopyris3, Nadeem G. Marghoob5, Lucas Galimany 2,
        Juan C. Castro1,2, Natalia Jaimes6, Harold S. Rabinovitz7, Ana Flavia Moraes8,
                       Ashfaq A. Marghoob3, Alvaro Abarzua-Araya1,2


1 Melanoma and Skin Cancer Unit, Department of Dermatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
2 Department of Dermatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
3 Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
4 Dermatology Department, Faculty of Medicine, University of Chile, Santiago, Chile.
5 New York Institute of Technology College of Osteopathic Medicine, OMSIII, Old Westbury, New York, NY, USA.
6 Department of Dermatology, University of Miami-Miller School of Medicine, Miami, FL.
7 Department of Dermatology, Medical College of Georgia, Augusta, GA, USA.
8 Department of Dermatology, AC Camargo Cancer Center: São Paulo, São Paulo, BR
9 Melanoma Institute Australia, Sydney, Australia



Key words: dermoscopy, dermatoscopy, basal cell carcinoma, skin cancer, linear
Citation: Navarrete-Dechent C, Marchetti MA, Uribe P, et al. Dermoscopy of linear basal cell carcinomas, a potential mimicker of linear
lesions: a descriptive case-series. Dermatol Pract Concept. 2022;12(4):e2022195. DOI: https://doi.org/10.5826/dpc.1204a195
Accepted: February 10, 2022; Published: October 2022
Copyright: ©2022 Navarrete-Dechent 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: Cristian Navarrete-Dechent, MD, Department of Dermatology, Escuela de Medicina, Pontificia Universidad
Catolica de Chile, Santiago, Chile, Diagonal Paraguay 362, 6th floor, Santiago, Chile 8330077, Phone: +56-2-2435 3574,
E-mail: ctnavarr@gmail.com




  ABSTRACT             Introduction: Among the various widely recognized basal cell carcinoma (BCC) clinical patterns,
                       linear basal cell carcinoma (LBCC) is an uncommon morphologic variant of BCC.
                       Objectives: Describe the clinical and dermoscopic characteristics of LBCC.
                       Methods: Retrospective study including LBCC cases from 5 dermatology centers in North and South
                       America. Biopsy-proven primary BCCs, that presented with at least 3:1 length:width ratio on p
                                                                                                                   ­ hysical
                       examination, irrespective of tumor subtype or location, were included. Clinical and dermoscopic
                       ­analysis were performed by 2 experts in dermoscopy.
                       Results: Eighteen cases of LBCC met our inclusion criteria and were included in the study. Median
                       age at diagnosis was 86.0 years, 10 patients (58.8%) were males. Regarding anatomic location, 11/18




Original Article | Dermatol Pract Concept. 2022;12(4):e2022195                                                                            1
                      (61.1%) were located on the head and neck, 5/18 (27.7%) cases were found on the trunk, and 2 on
                      lower extremities (11.1%). Under dermoscopy, 15/18 (83.3%) of LBCC were pigmented. All tumors
                      displayed at least one of the BCC-specific dermoscopic criteria the most common being blue-grey
                      globules (72.2%).
                      Conclusions: Dermoscopy might be useful in the differentiation of LBCC from other diagnoses pre-
                      senting as linear lesions such as scars, scratches/erosions, and tattoos, among others. Some of these
                      lesions might be confused by naked eye examination alone.




Introduction                                                         coupled with a digital dermatoscope (VEOS DS3, Canfield
                                                                     INC) and/or a Samsung Galaxy S5 coupled with a Dermlite
Basal cell carcinoma (BCC) is the most common skin cancer            DL3 dermatoscope (3Gen). Clinical images evaluated pig-
worldwide [1]. Several BCC classifications have been pro-            mentation status (yes/no) and whether tumors followed skin
posed based on its clinical and histopathological character-         tension lines according to Newell et al [10]. Dermoscopic
istics [2]. Among the various widely recognized BCC clinical         analyses were performed by 2 investigators (C.N-D. and
patterns, linear basal cell carcinoma (LBCC) is an uncommon          A.A-A) based on the latest dermoscopic consensus by Kittler
morphologic variant of BCC which was described by Lewis              et al [11]. and the most updated BCC criteria [12]. Images
et al [3]. It was defined as ‘a lesion that extends preferentially   were evaluated in both polarized and non-polarized mode.
in one direction, resulting in a tumor or plaque with a length       When there was disagreement in dermoscopic interpretation,
much greater than its width greater than 3:1 ratio’ [3-5]. Due       a third investigator served as a referee (M.A.M.).
to this linear morphology, LBCC can clinically mimic scars,
scratches, striae, or tattoos, among other diagnoses. Although       Statistical Analysis
there is an extended literature with regards to the dermoscopic      Data was analyzed using SPSS 23.0 (SPSS, Armonk). Measures
findings of BCC in general [6-9], little is known regarding the      of central tendency were calculated. Unless otherwise noted,
structures and patterns seen in LBCC under dermoscopy. Ad-           all values are expressed as mean and standard deviation (SD).
ditionally, LBCC clinical features have been scarcely described.

                                                                     Results
Objectives
                                                                     Eighteen cases of LBCC on 17 patients met our inclusion
We sought to evaluate and describe the dermoscopic appear-           criteria and were included in the study; 1 patient contributed
ance and clinical characteristics of LBCC.                           with 2 lesions. Median age at diagnosis was 86.0 years (SD
                                                                     7.6; range 67 – 91 years), 10 patients (58.8%) were males;
                                                                     72.2% (N = 13) were Hispanic/Latino and 27.8% (N = 5)
Methods                                                              were Caucasians.
This retrospective observational study was approved                     In all, 11/18 (61.1%) cases were nodular, 5/18 (27.7%)
by the IRB of Pontificia Universidad Católica de Chile               cases were superficial, 1 case was morphea-form (5.5%), one
(#201127004). We examined all cases of LBCCs between                 case was infiltrative (5.5%). Regarding anatomical location,
January 2016 to January 2021 from 6 dermatologic centers             11/18 (61.1%) were located on the head and neck, 5/18
in 3 countries (Santiago, Chile; Sao Paulo, Brazil; M
                                                    ­ iami,          (27.7%) cases were found on the trunk, and 2 on lower ex-
FL, and New York, NY). A search was performed using                  tremities (11.1%). When evaluating skin tension lines, 15/18
clinical images of diagnosed BCCs. Eligibility criteria were         (83.3%) followed these lines. All tumors were submitted to
based on clinical (not histopathological) features of BCC.           pathological analysis with the clinical/dermoscopic diagnosis
Biopsy-proven primary BCCs, that presented with at least             of BCC. Regarding treatment, 10/18 (55.5%) were treated
3:1 length:width ratio on physical examination, irrespective         with simple excision, 6/18 cases (33.3%) with Mohs micro-
of tumor subtype or location, were included. Recurrent BCCs          graphic surgery, and 1 case (5.5%) with electrodessication
were excluded, as they may present with a ‘false-­positive’          and curettage. One case was lost to follow-up.
­linear appearance due to the nature of linear closures.
    Patients demographics (age, gender) and subsequent               Dermoscopic Analysis
treatment were recorded and maintained in a deidentified da-         Under dermoscopy, 15/18 (83.3%) of LBCC were dermo-
tabase. Clinical and dermoscopic images were obtained with           scopically pigmented and all had absence of reticular net-
2 different devices depending on the center: A digital camera        work. All tumors displayed at least one of the BCC-specific



2                                                                        Original Article | Dermatol Pract Concept. 2022;12(4):e2022195
dermoscopic criteria (Table 1) [12]: blue-gray globules                most frequent anatomic location [13] which was not con-
(72.2%), in-focus dots (66.6%), short-fine telangiectasia              firmed by the present larger, multicentric study including 18
(55.5%), leaf-like areas (61.1%), milky-red background                 cases. Based on our study findings, LBCC can appear in any
(38.8%), ovoid nests (38.8%), ulceration/erosions (44.4%),             anatomical location. To the best of our knowledge, this is the
shiny white blotches and strands (33.3%), arborizing vessels           largest study examining the clinical and dermoscopic presen-
(22.2%), concentric structures (16.6%), and spoke-wheel                tation of LBCCs from diverse clinical settings [5-14].
structures (5.6%) (­Figures 1-4).                                          An interesting finding of our series was that dermoscop-
                                                                       ically pigmented variants comprised >80% of LBCC (Figure

Conclusions
                                                                            Table 1. Dermoscopic features seen in the
In this retrospective study including 18 LBCC, we de-
                                                                              18 cases of linear basal cell carcinoma
scribed the dermoscopic features of LBCC. Dermoscopy
                                                                                     (in alphabetical order).
might be a useful tool for the diagnosis of this uncommon
morphological subtype of BCC, as it presented with clas-                            Dermoscopic feature                        N (%)
sic dermoscopic BCC criteria. No specific or novel dermo-               Absence of pigment network                           18 (100)
scopic findings appear to be associated with LBCC. The                  Arborizing telangiectasia                             4 (22.2)
most common histopathologic subtype corresponded to                     Blue-grey globules                                   13 (72.2)
the nodular subtype. Despite the broad clinical differen-               Concentric structures                                 3 (16.6)
tial diagnosis of linear lesions (i.e. scars, scratches, striae,        In-focus dots                                        12 (66.6)
tattoos, among others), dermoscopy might be of aid in the               Leaf-like structures                                 11 (61.1)
diagnosis of LBCC, as the presence of at least one of the
                                                                        Milky-red background                                  7 (38.8)
BCC-specific features described elsewhere in dermoscopy
                                                                        Ovoid nests                                           7 (38.8)
was seen in all our cases [6,12]. However, additional stud-
                                                                        Shiny white blotches and strands                      6 (33.3)
ies that include other linear lesions as controls are needed
                                                                        Short-fine telangiectasia                            10 (55.5)
to confirm our results.
                                                                        Spoke-wheel like areas                                1 (5.5)
    The most common location in our series was the head
and neck. Some studies have shown the lower eyelid as the               Ulceration/erosion                                    8 (44.4)




Figure 1. Linear Basal Cell Carcinoma, pigmented. (A) Clinical photograph showing a linear pigmented plaque on neck following Langer
lines on the clavicle. (B) Dermoscopic features showing blue-grey globules, ulceration, and leaf-like structures (polarized light, original
magnification 10X). (C) Clinical photograph showing a linear, inconspicuous, pigmented plaque on chest following Langer lines. (D) Dermo-
scopic features showing leaf-like structures and in-focus dots (polarized light, original magnification 10X).



Original Article | Dermatol Pract Concept. 2022;12(4):e2022195                                                                           3
Figure 2. Linear basal cell carcinomas, pigmented. (A) Clinical photograph showing a linear black ulcerated tumor on the lateral neck
following Langer lines. (B) Dermoscopic features blue-grey globules, leaf-like structures, and shiny white blotches and strands (polarized
light, original magnification 10X). (C) Clinical photograph showing a linear pigmented plaque on the anterior leg following Langer lines.
(D) Dermoscopic features showing blue-grey globules, leaf-like structures, in focus-dots, ulceration, and shiny white blotches and strands
(polarized light, original magnification 10X).




Figure 3. Linear basal cell carcinoma, non-pigmented. (A) Clinical photograph showing 2 linear erythematous plaques on the neck following
Langer lines. (B) Dermoscopic features showing short-fine telangiectasia, ulcerations, and shiny white blotches and strands (polarized light,
original magnification 10X). (C) Clinical photograph showing a linear, inconspicuous pink plaque (demarcated by blue pen) on the neck
following Langer lines. (D) Dermoscopic features showing arborizing vessels and shiny white blotches and strands (polarized light, original
magnification 10X).




4                                                                            Original Article | Dermatol Pract Concept. 2022;12(4):e2022195
Figure 4. Linear basal cell carcinomas, lightly pigmented. (A) Clinical photograph showing a linear erythematous plaque on the back of the
neck following Langer lines. (B) Dermoscopic features showing short-fine telangiectasia, leaf-like structures, concentric structures, and shiny
white blotches and strands (polarized light, original magnification 10X). (C) Clinical photograph showing a linear erythematous plaque on
the anterior chest following Langer lines. (D) Dermoscopic features showing short-fine telangiectasia, leaf-like structures, ulceration, concen-
tric structures, and blue-gray globules (polarized light, original magnification 10X).



1-2). These findings are similar to previous reports on LBCC              microscopy or optical coherence tomography might help to
that showed a higher incidence of pigmented variants [6].                 elucidate in vivo the tumor and stroma interaction [17,18].
However, the rate of pigmented LBCC should be interpreted                     The main limitations of our study are its retrospective na-
with caution, since the pigmentation status of BCC could be               ture, the lack of a control group, cases being non-consecutive
attributed to ethnic features of our population (>70% His-                subject to selection and recall bias, and its small sample size.
panic/Latino) or by ‘inclusion’ bias: non-pigmented variants              Further, larger studies are needed to confirm our findings.
may be harder to visualize as linear than their pigmented                     Dermoscopy might be useful in the differentiation of
counterpart (Figure 3-4).                                                 LBCC from other diagnoses presenting as linear lesions such
    The mechanism behind the linear morphology of LBCC                    as scars, scratches/erosions, and tattoos, among others. Some
has not yet been elucidated. Trauma and Koebner phenom-                   of these lesions can be confused by naked eye examination
enon have been suggested as potential etiologic factors [13].             alone. Additional case-control studies are needed to confirm
Recently, Yamaguchi et al demonstrated lower expression of                our findings. The dermoscopic features seen in LBCC are
p27 and higher expression of PCTAIRE1 and PTCH1 muta-                     similar to those commonly found in classic BCCs.
tion in a LBCC case. They hypothesized that LBCC might be
generated by extensions along the wrinkles or Langer lines,               Acknowledgment: Josefina Worner, MD and Maria Pérez, MD,
due to histological fragility of the sites [15]. Interestingly, more      for their invaluable help gathering data for the manuscript.
than 80% LBCC in this series followed the skin tension lines.
The reason why certain BCCs tend to grow within these lines
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