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Dermoscopy in Vulvar Basal Cell Carcinoma

Dermoscopy in Vulvar Basal Cell Carcinoma Report of a Case A 65-year-old multiparous white woman was referred to our clinic with a large erythematous lesion on the vulva featuring partially pigmented areas. The case history revealed that the patient had been aware of the lesion for about 1 year and that the lesion had been treated unsuccessfully for some time with topical corticosteroid therapy following diagnosis as eczema. The lesion had grown progressively larger, causing troublesome itching. On clinical examination, an erythematous lesion, approximately 3 × 2 cm, was found on the right labium minor and also involving the base of the clitoris. The lesion was asymmetric with irregular and ill-defined borders. Partial pigmentation was irregularly located, with gray-blue color at the periphery. The lesion was barely palpable, with slightly raised borders (Figure 1). Dermoscopic examination revealed the presence of telangiectasias and blue ovoid nests, which, in the absence of melanocytic dermoscopic parameters such as pigmented network, brown globules, and pseudopods, allowed us to formulate the diagnosis of basal cell carcinoma (BCC) (Figure 2). Figure 1. View LargeDownload Vulvar basal cell carcinoma also involving the base of the clitoris, erroneously treated for about 1 year with corticosteroids and antibiotics. Figure 2. View LargeDownload Dermoscopic examination revealed the presence of telangiectasias and blue ovoid nests. The units indicated by the scale are centimeters. During dermoscopy, the lesion's margins, not usually well definable by naked eye examination in this site, were marked off. The lesion was surgically removed about 1 cm from the margins previously marked. The histopathologic features were consistent with a diagnosis of BCC, multifocal superficial type. All margins of excision were free of disease. The postoperative course was uneventful, and the patient was clinically free of disease at her recent follow-up 1 year after treatment. Comment Basal cell carcinoma of the vulva, an anatomic site not exposed to sunlight, is not as rare an occurrence as is generally believed: it accounts for about 2% of all BCCs diagnosed in a recent study by our research group.1 In the vulvar area, BCC is characterized by poor pigmentation and a clinical appearance often mimicking other dermatologic abnormalities like eczema or psoriasis. The correct diagnosis is often delayed after inappropriate treatment for inflammatory or infectious dermatoses has been attempted, thus allowing the neoplasm to grow (average size, 2.1 cm; ulceration in 28% of cases). Vulvar neoplasias like BCC, squamous cell carcinoma, and melanoma are usually diagnosed late, and their presentations may vary clinically from macules to papules and nodules of varying color. The dominant symptom itself, itching, often induces both patient and physician to dismiss the complaint as a simple irritation or intertrigo.1-3 In these cases, the use of dermoscopy may improve the early diagnosis of mucosal neoplasias and thus play a role in the preoperative classification of these lesions,2,4,5 but its use has been limited so far because little is known about the dermoscopic features of lesions of the vulva. Researchers in our group have already described the dermoscopic characteristics of vulvar melanoses of melanoma and seborrheic keratoses, common benign pigmented lesions of the vulva that frequently mimic melanoma in this site.2,4,5 In our experience, the dermoscopic features of vulvar BCC are the same as those of the cutaneous forms. In particular, in this case we found telangiectasias and typical blue ovoid nests. The absence of dermoscopic parameters of melanocytic proliferation allowed us to formulate a diagnosis of BCC. In our case, an early and correct diagnosis would have limited the excision, thus sparing the clitoris. Dermoscopy can also be more useful than the naked eye in outlining the margins of excision, as in our case. However, owing to the particular vascularization of this specific anatomic region, the typical vascular pattern of BCC can be confused with the abundant blood vessels normally found in this area. Thus, at the current state of experience, delimitation with another method (such as imiquimod or fluorouracil cream) can be more selective than dermoscopy to avoid neoplastic involvement of the excision margins. Histopathologic examination reveals involved margins in 25% of cases subjected to excisional biopsy, and a second surgical procedure is then required.1 This is owing to the difficult demarcation of the lesion's margins, since this particular site is frequently and exclusively erythematous. Correspondence: Dr de Giorgi, Department of Dermatology, University of Florence, Via degli Alfani, 37-50121 Firenze, Italy (vdegi@tin.it or vincenzo.degiorgi@unifi.it). Financial Disclosure: None reported. References 1. de Giorgi VSalvini CMassi DRaspollini MRCarli P Vulvar basal cell carcinoma: retrospective study and review of literature. Gynecol Oncol 2005;97192- 194PubMedGoogle ScholarCrossref 2. de Giorgi VMassi DSalvini CMannone FCattaneo ACarli P Thin melanoma of the vulva: a clinical, dermoscopic-pathologic case study. Arch Dermatol 2005;1411046- 1047PubMedGoogle Scholar 3. de Giorgi VMassi DLotti T Basal cell carcinoma. N Engl J Med 2006;354769- 771PubMedGoogle ScholarCrossref 4. Carli PDe Giorgi VCattaneo AGiannotti B Mucosal melanosis clinically mimicking malignant melanoma: noninvasive analysis by epiluminescence microscopy. Eur J Dermatol 1996;6434- 436Google Scholar 5. Mannone FDe Giorgi VCattaneo AMassi DDe Magnis ACarli P Dermoscopic features of mucosal melanosis. Dermatol Surg 2004;301118- 1123PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

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Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.143.3.426
pmid
17372116
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Abstract

Report of a Case A 65-year-old multiparous white woman was referred to our clinic with a large erythematous lesion on the vulva featuring partially pigmented areas. The case history revealed that the patient had been aware of the lesion for about 1 year and that the lesion had been treated unsuccessfully for some time with topical corticosteroid therapy following diagnosis as eczema. The lesion had grown progressively larger, causing troublesome itching. On clinical examination, an erythematous lesion, approximately 3 × 2 cm, was found on the right labium minor and also involving the base of the clitoris. The lesion was asymmetric with irregular and ill-defined borders. Partial pigmentation was irregularly located, with gray-blue color at the periphery. The lesion was barely palpable, with slightly raised borders (Figure 1). Dermoscopic examination revealed the presence of telangiectasias and blue ovoid nests, which, in the absence of melanocytic dermoscopic parameters such as pigmented network, brown globules, and pseudopods, allowed us to formulate the diagnosis of basal cell carcinoma (BCC) (Figure 2). Figure 1. View LargeDownload Vulvar basal cell carcinoma also involving the base of the clitoris, erroneously treated for about 1 year with corticosteroids and antibiotics. Figure 2. View LargeDownload Dermoscopic examination revealed the presence of telangiectasias and blue ovoid nests. The units indicated by the scale are centimeters. During dermoscopy, the lesion's margins, not usually well definable by naked eye examination in this site, were marked off. The lesion was surgically removed about 1 cm from the margins previously marked. The histopathologic features were consistent with a diagnosis of BCC, multifocal superficial type. All margins of excision were free of disease. The postoperative course was uneventful, and the patient was clinically free of disease at her recent follow-up 1 year after treatment. Comment Basal cell carcinoma of the vulva, an anatomic site not exposed to sunlight, is not as rare an occurrence as is generally believed: it accounts for about 2% of all BCCs diagnosed in a recent study by our research group.1 In the vulvar area, BCC is characterized by poor pigmentation and a clinical appearance often mimicking other dermatologic abnormalities like eczema or psoriasis. The correct diagnosis is often delayed after inappropriate treatment for inflammatory or infectious dermatoses has been attempted, thus allowing the neoplasm to grow (average size, 2.1 cm; ulceration in 28% of cases). Vulvar neoplasias like BCC, squamous cell carcinoma, and melanoma are usually diagnosed late, and their presentations may vary clinically from macules to papules and nodules of varying color. The dominant symptom itself, itching, often induces both patient and physician to dismiss the complaint as a simple irritation or intertrigo.1-3 In these cases, the use of dermoscopy may improve the early diagnosis of mucosal neoplasias and thus play a role in the preoperative classification of these lesions,2,4,5 but its use has been limited so far because little is known about the dermoscopic features of lesions of the vulva. Researchers in our group have already described the dermoscopic characteristics of vulvar melanoses of melanoma and seborrheic keratoses, common benign pigmented lesions of the vulva that frequently mimic melanoma in this site.2,4,5 In our experience, the dermoscopic features of vulvar BCC are the same as those of the cutaneous forms. In particular, in this case we found telangiectasias and typical blue ovoid nests. The absence of dermoscopic parameters of melanocytic proliferation allowed us to formulate a diagnosis of BCC. In our case, an early and correct diagnosis would have limited the excision, thus sparing the clitoris. Dermoscopy can also be more useful than the naked eye in outlining the margins of excision, as in our case. However, owing to the particular vascularization of this specific anatomic region, the typical vascular pattern of BCC can be confused with the abundant blood vessels normally found in this area. Thus, at the current state of experience, delimitation with another method (such as imiquimod or fluorouracil cream) can be more selective than dermoscopy to avoid neoplastic involvement of the excision margins. Histopathologic examination reveals involved margins in 25% of cases subjected to excisional biopsy, and a second surgical procedure is then required.1 This is owing to the difficult demarcation of the lesion's margins, since this particular site is frequently and exclusively erythematous. Correspondence: Dr de Giorgi, Department of Dermatology, University of Florence, Via degli Alfani, 37-50121 Firenze, Italy (vdegi@tin.it or vincenzo.degiorgi@unifi.it). Financial Disclosure: None reported. References 1. de Giorgi VSalvini CMassi DRaspollini MRCarli P Vulvar basal cell carcinoma: retrospective study and review of literature. Gynecol Oncol 2005;97192- 194PubMedGoogle ScholarCrossref 2. de Giorgi VMassi DSalvini CMannone FCattaneo ACarli P Thin melanoma of the vulva: a clinical, dermoscopic-pathologic case study. Arch Dermatol 2005;1411046- 1047PubMedGoogle Scholar 3. de Giorgi VMassi DLotti T Basal cell carcinoma. N Engl J Med 2006;354769- 771PubMedGoogle ScholarCrossref 4. Carli PDe Giorgi VCattaneo AGiannotti B Mucosal melanosis clinically mimicking malignant melanoma: noninvasive analysis by epiluminescence microscopy. Eur J Dermatol 1996;6434- 436Google Scholar 5. Mannone FDe Giorgi VCattaneo AMassi DDe Magnis ACarli P Dermoscopic features of mucosal melanosis. Dermatol Surg 2004;301118- 1123PubMedGoogle Scholar

Journal

Archives of DermatologyAmerican Medical Association

Published: Mar 1, 2007

References