Intended for healthcare professionals

Endgames Picture Quiz

A 79 year old man with a lesion on his cheek

BMJ 2012; 344 doi: (Published 07 February 2012) Cite this as: BMJ 2012;344:e482
  1. A W N Reid, registrar, plastic surgery12,
  2. O P Shelley, consultant plastic surgeon2
  1. 1Department of Plastic Surgery, Lister Hospital, Stevenage SG1 4AB, UK
  2. 2St Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex
  1. Correspondence to: A W N Reid awnr2{at}

A 79 year old man was referred to the plastic surgery outpatients department because he was worried about a 7 mm diameter lesion on his right cheek (fig 1).

He first noted this lesion a year earlier, and it had slowly grown in size since. It crusts over occasionally, but it does not bleed. He had spent most of his adult life in Africa. His medical history includes hypertension, for which he takes atenolol and ramipril. He has no drug allergies and is a non-smoker.


  • 1 What is the most likely diagnosis?

  • 2 Is this a benign or malignant lesion?

  • 3 What are the risk factors for developing this lesion?

  • 4 Is this a “high risk” or “low risk” lesion?

  • 5 What treatment options are available?


1 What is the most likely diagnosis?

Short answer

Basal cell carcinoma.

Long answer

Basal cell carcinomas are slow growing malignant tumours that arise from the stratum germinativum, the deepest layer of the epidermis.1

Dermatoscopy (examination of skin lesions with a handheld dermatoscope) typically shows a cystic pearly appearance with raised areas of telangiectasia. However, several histological subtypes exist, and their morphology and …

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