Effect of Tumor Size on Dermoscopic Features of Pigmented Basal Cell Carcinoma
Basal cell carcinoma (BCC) remains the most prevalent cutaneous malignancy globally, with an increasing incidence attributed to factors such as aging populations and cumulative ultraviolet exposure. While BCC is typically slow-growing and rarely metastatic, its clinical presentation can become atypical as lesions enlarge, complicating diagnosis. Giant BCCs, defined by excessive size, have garnered attention due to their potential for local destruction and diagnostic ambiguity. Dermoscopy has emerged as a critical non-invasive tool for improving the accuracy of BCC diagnosis, particularly in distinguishing pigmented variants from other neoplasms like melanoma. This study investigates the influence of tumor size on dermoscopic features of pigmented BCC, focusing on how key morphological characteristics evolve with lesion progression.
The retrospective analysis included 98 histopathologically confirmed BCC cases diagnosed between January 2017 and January 2020 at Beijing Luhe Hospital. Ethical approval was obtained, and patient consent ensured. Dermoscopic images were acquired using a non-contact polarizing electronic dermoscope (Jiangsu Jieda, China) and evaluated by two independent observers. Thirteen predefined dermoscopic features were assessed: multiple blue-gray globules, large blue-gray ovoid nests, spoke-wheel areas, maple leaf-like areas, concentric structures, blue-gray dots, arborizing vessels, superficial fine telangiectasia (SFT), shiny white-red structureless areas, short white streaks/chrysalis, multiple small erosions, ulceration, and large blue-gray structureless areas. The latter was defined as extensive, peripheral blue-gray patches distinct from other pigmented structures.
Lesions were stratified by size into small (<1 cm) and large (≥1 cm) groups, aligning with prior literature. Pigmentation extent was categorized as light (70%). Statistical analyses using SPSS 22.0 involved Chi-squared or Fisher’s exact tests, with P < 0.05 considered significant.
The cohort comprised 98 patients (mean age 65.4 ± 12.9 years), with 48 large BCCs (49.0%) and 50 small BCCs (51.0%), the latter ranging from 1.0 to 6.0 cm. Comparative analysis revealed significant differences in dermoscopic features between size groups. Large BCCs exhibited higher frequencies of arborizing vessels (64.0% vs. 43.8%; P < 0.05), blue-gray dots (66.0% vs. 41.7%), ulceration (56.0% vs. 22.9%), short white streaks/chrysalis (58.0% vs. 29.2%), and large blue-gray structureless areas (56.0% vs. 18.8%; P < 0.001). These findings suggest that tumor growth dynamically alters vascular patterns, fibrosis, and pigmentation distribution.
Subgroup analysis by pigmentation intensity further clarified these trends. In moderately pigmented BCCs, large lesions demonstrated a higher prevalence of arborizing vessels (80.0% vs. 45.0%) and large blue-gray structureless areas (65.0% vs. 20.0%). Among heavily pigmented BCCs, large tumors more frequently exhibited large blue-gray structureless areas (85.7% vs. 30.8%), short white streaks (85.7% vs. 15.4%), and ulceration (78.6% vs. 15.4%). Notably, the term “large blue-gray structureless areas” described amorphous patches hypothesized to result from coalescence of smaller pigmented structures, such as ovoid nests or leaf-like areas. These regions, observed in 56.0% of large BCCs, were critical in distinguishing advanced lesions and occasionally mimicked melanoma’s blue-white structures, necessitating careful differentiation.
The study contrasts with prior reports. Popadic´ and Vukic´evic´ identified arborizing vessels, SFT, and erosions as size-dependent features but found no pigment-related differences. Emiroglu et al. reported a correlation between lesion size and blue-gray ovoid nests, which this study did not replicate. Instead, the prominence of large blue-gray structureless areas in large BCCs underscores the potential role of pigment aggregation in advanced tumors.
Clinical implications arise from these findings. Arborizing vessels, typically hallmark features of BCC, become more pronounced in larger lesions, possibly due to increased vascular demand. Ulceration and fibrosis (reflected by short white streaks) correlate with tumor expansion and stromal response. The high prevalence of large blue-gray structureless areas in sizable BCCs emphasizes their diagnostic utility, particularly in heavily pigmented subtypes. These features, when combined with ulceration or chrysalis structures, may mimic melanoma, necessitating histopathological confirmation.
Limitations include the retrospective design and reliance on dermoscopic image interpretation, which may introduce observer bias. Nonetheless, the study robustly quantifies how tumor size modulates dermoscopic morphology, offering insights for clinicians managing atypical or advanced BCCs. Future research could prospectively validate these findings and explore molecular correlations between dermoscopic features and tumor biology.
In summary, this work delineates the dynamic evolution of dermoscopic features in pigmented BCCs as they enlarge. Arborizing vessels, ulceration, and large blue-gray structureless areas emerge as hallmarks of advanced tumors, with pigment density influencing their expression. Recognition of these patterns enhances diagnostic accuracy, particularly in challenging cases where clinical presentation is ambiguous.
doi.org/10.1097/CM9.0000000000001571
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