eMedicine Specialties > Dermatology > Malignant Neoplasms

Basal Cell Carcinoma: Differential Diagnoses & Workup

Author: Michael L Ramsey, MD, Director, Mohs Surgery Fellowship, Co-Director, Procedural Dermatology Fellowship, Department of Dermatology, Geisinger Medical Center
Coauthor(s): Lindsay Dane Sewell, MD, Staff Physician, Department of Dermatology, Geisinger Medical Center
Contributor Information and Disclosures

Updated: Sep 11, 2009

Differential Diagnoses

Actinic Keratosis
Sebaceous Hyperplasia
Bowen Disease
Seborrheic Keratosis
Fibrous Papule of the Face
Squamous Cell Carcinoma
Keratoacanthoma
Trichoepithelioma
Nevi, Melanocytic

Workup

The following clinical guideline summaries may be helpful:

Procedures

  • Skin biopsy: Biopsy is required to confirm the diagnosis and to identify the histologic subtype of the basal cell carcinoma (BCC). Shave or punch biopsy is usually performed. Additional workup is rarely necessary, unless a genetic disorder is suspected.
    • Shave biopsy suffices for the diagnosis of most BCCs. Avoid taking an exceedingly superficial biopsy specimen because missing the tumor is possible. For example, an ulcerated BCC may reepithelialize with normal epidermis while a tumor is present at a deeper level. Part or all of the BCC may be sampled, but avoid going beyond the clinical margins if the biopsy is only for diagnostic purposes.
    • Punch biopsy is an easy method to obtain a thick specimen. The most suspicious area of a lesion may be sampled, or multiple biopsy samples may be taken if the tumor has different appearances in different areas. Avoid punch biopsy if curettage is planned for final treatment.

Histologic Findings

Tumor cells of nodular basal cell carcinoma (BCC), sometimes called basalioma cells, typically have large, hyperchromatic, oval nuclei and little cytoplasm. Cells appear uniform, and, if present, mitotic figures are usually few. Nodular tumor aggregates may be of varying sizes, but tumor cells tend to align more densely in a palisade pattern at the periphery of these nests (see Media File 3). Early lesions usually have some connection to the overlying epidermis, but such contiguity may be difficult to appreciate in more advanced lesions. Increased mucin is often present in the surrounding dermal stroma.


Nodular basal cell carcinoma. Nodular aggregates ...

Nodular basal cell carcinoma. Nodular aggregates of basalioma cells are present in the dermis and exhibit peripheral palisading and retraction artifact. Melanin is also present within the tumor and in the surrounding stroma, as seen in pigmented basal cell carcinoma.

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Nodular basal cell carcinoma. Nodular aggregates ...

Nodular basal cell carcinoma. Nodular aggregates of basalioma cells are present in the dermis and exhibit peripheral palisading and retraction artifact. Melanin is also present within the tumor and in the surrounding stroma, as seen in pigmented basal cell carcinoma.


Cleft formation, known as retraction artifact, commonly occurs between BCC nests and stroma because of shrinkage of mucin during tissue fixation and staining. Some lobules may have areas of pseudoglandular change, and this is the predominant change in adenoid BCC. In other instances, large tumor lobules may degenerate centrally, forming pseudocystic spaces filled with mucinous debris. These changes are seen in the nodulocystic variant of BCC (see Media File 6).

Histology of superficial basal cell carcinoma. N...

Histology of superficial basal cell carcinoma. Nests of basaloid cells are seen budding from the undersurface of the epidermis.

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Histology of superficial basal cell carcinoma. N...

Histology of superficial basal cell carcinoma. Nests of basaloid cells are seen budding from the undersurface of the epidermis.

Numerous variants occur, including pigmented BCC, in which benign melanocytes in and around the tumor produce large amounts of melanin. These melanocytes contain many melanin granules in their cytoplasm and dendrites. Superficial BCC appears as buds of basaloid cells attached to the undersurface of the epidermis. Nests of various sizes are often seen in the upper dermis. The tumor cell aggregates typically show peripheral palisading.

The more aggressive morpheaform and infiltrating BCCs have growth patterns resulting in strands of cells rather than round nests. Morpheaform BCC arises as thin strands of tumor cells (often only 1 cell in thickness) that are embedded in a dense fibrous stroma. The strands of infiltrating BCC tend to be somewhat thicker than those seen in morpheaform BCC, and they have a spiky, irregular appearance. Infiltrating BCC usually does not exhibit the scarlike stroma seen in morpheaform BCC. Peripheral palisading and retraction are less pronounced in morpheaform and infiltrating BCC than in less aggressive forms of the tumor, and subclinical involvement is often extensive.

Another aggressive variant, micronodular BCC, appears as small, nodular aggregates of basaloid cells. Retraction artifact tends to be less pronounced than in the nodular form of BCC, and subclinical involvement is often significant. Basosquamous carcinoma, which exhibits features of both BCC and squamous cell carcinoma, is also considered an aggressive skin cancer.

More on Basal Cell Carcinoma

Overview: Basal Cell Carcinoma
Differential Diagnoses & Workup: Basal Cell Carcinoma
Treatment & Medication: Basal Cell Carcinoma
Follow-up: Basal Cell Carcinoma
Multimedia: Basal Cell Carcinoma
References
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Further Reading

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Contributor Information and Disclosures

Author

Michael L Ramsey, MD, Director, Mohs Surgery Fellowship, Co-Director, Procedural Dermatology Fellowship, Department of Dermatology, Geisinger Medical Center
Michael L Ramsey, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, and American Society for Dermatologic Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Lindsay Dane Sewell, MD, Staff Physician, Department of Dermatology, Geisinger Medical Center
Lindsay Dane Sewell, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Medical Editor

R Stan Taylor, MD, Professor of Dermatology, University of Texas Southwestern Medical School; Director of Skin Surgery and Oncology Clinic, Department of Dermatology, University of Texas Southwestern Medical Center
R Stan Taylor, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, Christian Medical & Dental Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine
Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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