Gautam Paul, Nilanjan Thakur, Nagesha CK, Chanchal Poddar, Pranab Chakraborty. “Pigmented basal cell carcinoma – an unusual presentation and its management”. Journal of Evolution of Medical and Dental Sciences 2013; Vol2, Issue 37, September 16; Page: 7066-7068.
CASE SUMMARY: A 45year old lady presented to outpatient clinic with pain & swelling in the medial canthal area and watering from Left eye simulating acute dacryocystitis. Patient was treated for the same but with no response. After 4-5visits, she developed non healing ulcer over the same area. The patient was otherwise healthy, with no history of excessive sun exposure or any predisposing factors for skin cancer.
Examination revealing 2cm×2cm ulcer with slightly elevated pigmented margin (fig: 1) involving the puncta posed a real diagnostic dilemma.
The lesion was subjected for excisional biopsy with 3mm clear margin under local anaesthesia. As the punta were also involved, a medial 25% of full thickness lid was excised along with main lesion (Fig: 2). Concomitant dacryocystectomy was carried out.
Canthal reconstruction was done followed by direct approximation of lid defects to newly formed canthus. A myo cutaneous glabellar flap was transposed to the defect area with inverted V-Y closure (fig: 3).
Histopathological examination under low power showed solid islands of tumor cells with peripheral palisading; there is also a clefting artifact in between the stroma and epithelium. High power shows pigments within solid highland basal cells and in macrophages suggestive of pigmented basal cell carcinoma.
1month Postoperative period was uneventful, with acceptable cosmetic appearance.
Unusual presentation of pigmented chronic ulcer with watering in a middle aged lady diverted our attention towards non-malignant pathology resulting in erroneous initial diagnosis & treatment.
DISCUSSION: Basalcellcarcinomas (BCC) are the most common malignant neoplasms in humans. Clinical misdiagnoses are not uncommon. It is the most common cancer among Caucasians, being three to six times more frequent than squamous cell carcinoma (SCC) 1. Approximately 5%–10% of all skin cancers occur in the eyelid and BCC accounts for ~80%–90% of all nonmelanoma skin cancers affecting the periocular area2.
Pigmented BCC is rare representing close to 1% of eyelid’s BCC. Pigmentary deposits of melanin can mimic a nodular melanoma or atypical nevi3. Azzam et al reported an unusual case of combined pedunculated and pigmented basal cell carcinoma which he rarely encountered4.
Clinical behaviour of BCC is highly variable. It can present as nodular, ulcerative, chronic dermatitis, atypical nevi etc. Baker HE5 reported a case of BCC that presented as ectropion, then entropion, and finally medial canthal dystopia. An inflammatory mass with watering in our case resulted in erroneous diagnosis, a pigmented ulcer which developed later again mislead us from thinking of BCC.
Excision of upper eyelid skin cancer often leads to moderate to large defect. Numerous procedures are available to reconstruct such defects. Yan J et al6 described tarso conjunctival flap and skin flaps for skincarcinomaon his leftmedialcanthus, which also involvedmedialtarsal palate of the upper eyelid.
Other type of flaps like tunneled forehead flap7, Triple-flapmedialcanthal reconstruction8 , glabellar flap modification "flap in flap" technique9, Radix nasi transposition flap10 have been described in literature for varying amount of defects with satisfactory results.
In present case, a combined transposition flap with lid defect closure appealed to be a viable option in extensive lid and canthal defects.
CONCLUSION: Clinical misdiagnoses of BCC are not uncommon. They exhibit distinct malignant behaviours hence it is important to be aware of the different clinical presentations both for the accurate diagnosis and tumour management. A combined reconstruction reported in this present case a valuable technique in large defects.
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