Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obervation Letter
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Quiz
2019:85:5;555-558
doi: 10.4103/ijdvl.IJDVL_1141_16
PMID: 29582788

Solitary nodular lesion on forehead in a 56-year-old woman

Charu Agarwal, Kanika Singh, Mukta Pujani, Pragya Verma, Varsha Chauhan
 Department of Pathology, ESIC Medical College, Faridabad, Haryana, India

Correspondence Address:
Mukta Pujani
Department of Pathology, ESIC Medical College, Faridabad, Haryana
India
How to cite this article:
Agarwal C, Singh K, Pujani M, Verma P, Chauhan V. Solitary nodular lesion on forehead in a 56-year-old woman. Indian J Dermatol Venereol Leprol 2019;85:555-558
Copyright: (C)2019 Indian Journal of Dermatology, Venereology, and Leprology

A 56-year-old woman came to the surgical out-patient department of ESIC Medical College and Hospital, Faridabad, Haryana, with a swelling above the left eyebrow which she noticed since 5 years. There was no history of trauma. There was no significant past history or other relevant complaints. Systemic examination was within normal limits. On local examination, a well-circumscribed reddish nodular lesion of size 2 × 2 cm was seen just above the left eyebrow [Figure - 1]. It was non-tender and soft to firm in consistency.

Figure 1: Clinical presentation of the patient with a well-circumscribed nodular reddish lesion above left eyebrow

Fine-needle aspiration was done; smears were moderately cellular, comprising of tight clusters of small basaloid cells with scant cytoplasm, round to oval bland nuclei and inconspicuous nucleoli. Basement membrane material was seen lying in between the tumor cells with cells embedded in it. A few histiocytes along with multinucleated giant cells were seen in the background.

An excision biopsy was advised. A grey-white soft tissue mass measuring 2 × 1 cm was excised, from which multiple sections were taken. There was a well-circumscribed lesion in the dermis comprising lobules of basaloid tumor cells, separated by fibrous septa [Figure - 2]. On further sections, a few of the lobules showed presence of retraction artifacts [Figure - 3], mitotic figures (3-4/10 high power field) [Figure - 4] and a few horn cysts. No amyloid or melanin was seen in the sections examined. An immunohistochemistry panel comprising of CD10 [Figure - 5], CD34, bcl-2 [Figure - 6], epithelial membrane antigen and cytokeratin 20 was advised.

Figure 2: Histopathology smear showing skin covered tissue. Sub-epidermis shows a well-circumscribed lesion comprising lobules of basaloid tumor cells, separated by fibrous septa (hematoxylin and eosin, ×100)
Figure 3: Histopathology smear with some of the lobules showing presence of retraction artifact (hematoxylin and eosin, ×400)
Figure 4: Histopathology smears with presence of mitotic figures (hematoxylin and eosin, ×400)
Figure 5: Immunohistochemistry: CD10 showed focal cytoplasmic membranous positivity in tumor cells and stromal negativity (×400)
Figure 6: Immunohistochemistry: Bcl-2 showed diffuse cytoplasmic positivity in tumor cells (×100)

What is Your Diagnosis?

Answer

Basal cell carcinoma.

On immunohistochemistry, CD10 showed focal cytoplasmic membranous positivity in tumor cells and stromal negativity. Bcl-2 was diffusely positive in the cytoplasm of tumor cells, although weak; while CD34, epithelial membrane antigen and cytokeratin 20 came out to be negative. So a final diagnosis of basal cell carcinoma was arrived at. The margins of the lesion were free of the tumor. On follow-up, it was found that the patient was doing well.

It is very difficult to differentiate between trichoepithelioma and basal cell carcinoma, which poses a great difficulty for both the clinicians as well as the pathologists.[1] Trichoepithelioma is a benign neoplasm derived from basal cells in the hair follicle. It may occur sporadically or is inherited in an autosomal dominant pattern. The principal feature of a common genetic disorder called multiple familial trichoepithelioma is the presence of many small tumors, predominantly on face.[2] Both basal cell carcinoma and trichoepithelioma can present as solitary, slow-growing, flesh-colored papules or nodules with a pearly appearance, commonly located on the face.[1] Similarly in the present case, the patient presented with a flesh-colored nodule on the face.

Microscopically, both basal cell carcinoma and trichoepithelioma are composed of nests of basaloid cells within the dermis. Histopathological features of basal cell carcinoma include connection to the epidermis, apoptosis, mitosis and loose fibromyxoid stroma with peritumoral retraction.[1] Horn cysts are the most characteristic histologic feature of trichoepithelioma. Tumor cells in trichoepithelioma have similar appearance to the cells in basal cell carcinoma but lack high-grade atypia and mitosis. In trichoepithelioma, the fibroblasts encircle the basaloid islands and are tightly associated with them, lacking the retraction artifact, typical of basal cell carcinoma. A connection between tumor cell formations and the surface epidermis has been shown to exist in approximately 90% of basal cell carcinomas.[3] In the present case, a focal connection with epidermis, retraction artifact, mitosis and few horn cysts was found after extensive search, thereby creating a dilemma.

There is a variant of basal cell carcinoma that histologically resembles a benign follicular neoplasm and is designated as trichoepithelioma-like basal cell carcinoma. These are often small, circumscribed, symmetrical basaloid tumors. These tumors often have a relatively low number of mitotic figures and the stroma often lacks significant retraction artifact.[4] Another rare subtype of basal cell carcinoma is infundibulocystic basal cell carcinoma. Histopathologically, it is also a well-circumscribed, superficially located, basaloid cell tumor with hyperchromatic, pleomorphic nuclei and rare mitoses. However, it is formed by anastomosing cords of basaloid keratinocytes with several tiny cornifying cysts.[5] We observed some of the overlapping features of the above-mentioned rare variants of basal cell carcinoma in our case.

Basal cell carcinomas are seen almost exclusively on hair-bearing skin, especially on face. It usually occurs as a single lesion. It has five clinical types: (a) superficial, (b) nodular, (c) micronodular, (d) infiltrating and (e) fibroepithelioma. Nodular basal cell carcinoma begins as a small, waxy nodule that often shows a few small telangiectatic vessels on its surface.[3]

There are few immunohistochemical markers which are able to differentiate between trichoepithelioma and basal cell carcinoma. CD10 expression has been shown in tumors of follicular differentiation, including trichoepithelioma, pilomatricoma, basaloid follicular hamartoma and basal cell carcinoma. There is a difference in staining patterns of CD10 in these tumors: basaloid cells in basal cell carcinoma and stroma in trichoepithelioma.[2] The present case shows focal membranous staining in the basaloid cells, suggesting basal cell carcinoma.

Diffuse bcl-2 expression by basaliomatous cells was observed in basal cell carcinoma, while expression of this marker only in the outermost layers of basaloid nests was observed in trichoepitheliomatous tumors.[6] In our case also, although bcl-2 expression was diffuse it was only weakly positive.

Follicular stem cell marker, pleckstrin homology-like domain, family A, member 1 (also known as T-cell death-associated gene 51), and cytokeratin 20 are positive in trichoepithelioma and negative in basal cell carcinoma. [Table - 1] depicts immunohistochemical markers that help to differentiate between trichoepithelioma and basal cell carcinoma.[7] However, in spite of availability of immune marker panel, histopathological criteria along with clinical data remain the best tool to differentiate between trichoepithelioma and basal cell carcinoma.[6]

Table 1: Immunohistochemical markers to differentiate trichoepithelioma and basal cell carcinoma

In the present case, a diagnosis of basal cell carcinoma was favored over trichoepithelioma due to some supporting histomorphological features like focal connection with the epidermis, retraction artifact and mitosis along with focal membranous staining of CD10 in the basaloid cells and weak diffuse positivity of bcl-2 on immunohistochemistry.

Both the tumors share similar clinical as well as histological features. It is very important to distinguish these neoplasms because they have variable clinical behavior and require different therapeutic planning. Basal cell carcinoma is a locally aggressive neoplasm and must be totally excised with safe margins. However, trichoepithelioma is a benign neoplasm, which may be partially excised by shaving.[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for the images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References
1.
Pham TT, Selim MA, Burchette JL Jr., Madden J, Turner J, Herman C, et al. CD10 expression in trichoepithelioma and basal cell carcinoma. J Cutan Pathol 2006;33:123-8.
[Google Scholar]
2.
Heidarpour M, Rajabi P, Sajadi F. CD10 expression helps to differentiate basal cell carcinoma from trichoepithelioma. J Res Med Sci 2011;16:938-44.
[Google Scholar]
3.
Klein W, Chan E, Seykora JT. Tumours of epidermal appendages. In: Elder DE, editor. Lever's Histopathology of the Skin. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 867-926.
[Google Scholar]
4.
Carr RA, Taibjee SM, Sanders DS. Basaloid skin tumours: Basal cell carcinoma. Diagn Histopathol 2007;13:252-72.
[Google Scholar]
5.
Roldán-Marín R, Leal-Osuna S, Lammoglia-Ordiales L, Toussaint-Caire S. Infundibulocystic basal cell carcinoma: Dermoscopic findings and histologic correlation. Dermatol Pract Concept 2014;4:51-4.
[Google Scholar]
6.
Tebcherani AJ, de Andrade HF Jr. Sotto MN. Diagnostic utility of immunohistochemistry in distinguishing trichoepithelioma and basal cell carcinoma: Evaluation using tissue microarray samples. Mod Pathol 2012;25:1345-53.
[Google Scholar]
7.
Agarwal P, Agarwal C, Bhardwaj M, Ahuja A, Rani S. Trichoepithelioma and basal cell carcinoma with squamous differentiation: Is it causal or coincidental? Indian J Dermatol 2015;60:394-6.
[Google Scholar]

Fulltext Views
450

PDF downloads
98
Show Sections