Endgames Picture Quiz

A 79 year old man with a lesion on his cheek

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e482 (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}cam.ac.uk

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 distribution on the body differ, as summarised in the table).

Subtypes of basal cell carcinoma

View this table:

2 Is this a benign or malignant lesion?

Short answer


Long answer

Basal cell carcinoma is a malignant tumour that invades the epithelial basement membrane. Although slow growing, it may cause extensive tissue damage and morbidity by invading surrounding tissues. The older term “rodent ulcer” comes from the Latin “rodens”—to gnaw. Basal cell carcinomas almost always remain localised to the site of presentation. Metastasis is rare (0.0028%),5 and when reported it is usually related to neglected or recurrent lesions.6

3 What are the risk factors for developing this lesion?

Short answer

The main risk factor for basal cell carcinoma is exposure to ultraviolet light.2 Genetic risk factors include having fair skin, blue eyes, or red hair and having a family history of skin cancer. Acquired risk factors include exposure to ultraviolet light, radiation injury, immunosuppressive drugs, and trauma.

Long answer

Exposure to ultraviolet light (natural and artificial) is the main risk factor for developing basal cell carcinoma (box 1).2 Ultraviolet light leads to the formation of thymine dimers in the DNA of basal cells. Despite cellular mechanisms to repair this damage, some thymine dimers may not be repaired, resulting in permanent DNA damage. Cumulative DNA damage can lead to DNA mutations.

Box 1 Risk factors for developing basal cell carcinoma37

Genetic factors
  • Appearance

    • o Fitzpatrick skin type 1

    • o Red or blonde hair

    • o Blue or green eyes

  • Family history of skin cancer

  • Genetic conditions

    • o Gorlin’s syndrome (naevoid basal cell carcinoma syndrome)

    • o Bazex syndrome

    • o Xeroderma pigmentosum

    • o Albinism

  • Freckling or sunburn during childhood

  • Immunosuppressive treatment

  • Ingestion of arsenic

  • Previous basal cell carcinoma

About 2% of skin cancers develop in people with a strong genetic predisposition. In patients with multiple tumours, conditions such as Gorlin’s syndrome (naevoid basal cell syndrome, in which a tumour suppressor gene at chromosome 9q22.3 is mutated) should be considered.

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

Short answer

This is a high risk lesion because it is on the central face, one of the areas identified by the National Cancer Peer Review Programme as having a high risk of recurrence after treatment.8

Long answer

This lesion has a high risk of recurrence because it is on the central face around the eyes. Basal cell carcinomas are classified into high or low risk depending on their likelihood of recurrence after treatment. Box 2 summarises the features associated with a high risk of recurrence. For the purpose of referral, low risk basal cell carcinoma is considered to be any other basal cell carcinoma.

Box 2 Features of a high risk lesion8

Any of the following:

  • Site: Central face (especially around eyes, nose, lips, or ears) and scalp5

  • Size: >2 cm

  • Circumstances: Immunocompromised patients and genetically predisposed patients (such as those with Gorlin’s syndrome)

Surgery remains the treatment of choice for high risk lesions. Non-surgical treatments may be considered for low risk lesions.2

5 What treatment options are available?

Short answer

This basal cell carcinoma should be treated by surgery (wide local excision or Mohs micrographic surgery).

Long answer

This basal cell carcinoma should be treated by surgery (wide local excision or Mohs micrographic surgery).

The choice of treatment depends on the anatomical location, size of the tumour, histological diagnosis (if available), and fully informed patient preference.2

Wide local excision of this basal cell carcinoma requires a 4-5 mm clinical margin of healthy tissue around the lesion horizontally and that all of the dermis (down to the next layer) is included.5 Specimens are sent for histological analysis.

In Mohs micrographic surgery, resection occurs in stages, with comprehensive histological analysis of the margins between each resection in a process that takes hours or days. The technique may be indicated in high risk tumours around the face, those with poor clinical definition of margins, recurrent lesions, or those with perineural or perivascular involvement. Mohs micrographic is more expensive than wide local excision, and the comparative cure rates of the two treatments are unclear.5

Patient outcome

The patient opted for wide local excision of the lesion with direct closure. Histopathology showed a basal cell carcinoma excised with clear margins. No follow-up was needed.


Cite this as: BMJ 2012;344:e482


  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent obtained.


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