Nodular basal cell carcinoma masquerading as traumatic laceration
- 1 Ophthalmology, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, UK
- 2 Ophthalmology, Birmingham and Midland Eye Centre, Birmingham, Birmingham, UK
- Correspondence to Dr Sohail Ahmed; sohailahmed1002480@gmail.com
Abstract
A woman in her 80s was referred to us as an emergency for repair of a traumatic laceration. She had a history of hypertension and dementia and lived alone; she had an increasing frequency of falls recently and presented to her local hospital following another fall. The medical team noted a left medial canthus defect with bleeding and unopposed edges. This was suspected to have been secondary to her fall. She was referred to us for emergency repair of the supposed laceration. Ophthalmic review revealed a large ulcerated lesion at the left medial canthus with indurated edges and oozing of blood. Rather than a traumatic aetiology, clinically it appeared more like basal cell carcinoma (BCC), so, instead of repair, punch biopsies were taken: histology later confirmed BCC. This highlights the variable clinical presentation of BCC and the importance of keeping a high index of suspicion for all periocular lesions.
Background
Basal cell carcinoma (BCC) is the most common periocular malignancy.1 2 Most commonly it affects the lower lid or the medial canthus, and the typical clinical manifestation is a single lesion with ulceration or central scarring and keratosis.3 4 Clinical presentation can however be variable, and the diagnosis of periocular malignancy can prove challenging.5 BCC may be mistaken for other malignant or even benign lesions. The common benign masquerading lesions include papilloma, naevus or hidrocystoma, and if there is no biopsy, this may lead to a missed diagnosis of malignancy. To confirm the diagnosis, all suspicious lesions must be submitted for histopathological diagnosis.6
In this report, the authors highlight an unusual case of an elderly woman with advanced BCC masquerading as a traumatic laceration following a fall. The importance of this case is evident due to the common frequency of presentation of lid lacerations to the emergency department (ED). As such, this presentation is often attended to by clinicians of varying experience and so can present a diagnostic challenge. It is of paramount importance that an uncommon but significant pathology such as a BCC masquerading as a presumed traumatic lid laceration is detected in a timely manner. Otherwise, we run the risk of a primary repair in ED with no subsequent follow-up resulting in a missed sinister presentation of an eyelid tumour.
Case presentation
We present the case of a woman in her 80s referred to our tertiary-care ophthalmology centre after hours for repair of a traumatic eyelid laceration. She had presented to her local hospital, a few days prior, following a fall. She had a history of hypertension, type 2 diabetes and heart failure. She lived alone and normally mobilised by herself without a stick but had recently been diagnosed with dementia. On presentation to the ED, she was noted to have an abnormality at the left medial canthus, which featured unopposed skin edges and bleeding. At the time this was diagnosed as a traumatic laceration, despite the patient highlighting there was no trauma to her face at the site of the lesion. The patient was referred to our eye centre and transferred out of normal working hours as an urgent case for repair of this large laceration. Due to her dementia, the history of presenting complaint was vague and limited; however, the patient denied any facial injury. Collateral history was subsequently sought from next of kin over the telephone, who reported that they first noticed the lesion at the left medial canthus around a year previously. Examination revealed a large ulcerated lesion with tissue loss and granulated wound edges at the left medial canthus. The lesion originated at the lower corner of the glabella and extended inferiorly to the upper cheek. The surrounding skin had scalloped edges, and there was slow oozing of blood (figures 1 and 2). The lid margins were not involved. The clinical picture was more in line with a chronic rather than acute pathology, and we suspected BCC. The rest of the ophthalmic examination was unremarkable apart from bilateral advanced cataracts. We suspected that the bleeding was coincidental from one of the branches of the angular vessels.
A large ulcerated lesion on medial canthus of left eye with oozing of blood that was suspected to arise secondary to a traumatic laceration by the emergency department.
Characteristic features of a nodular basal cell carcinoma with pearly rolled edges and scabbing with a large central ulcer.
Rather than performing an emergency repair of the defect, we undertook biopsies to confirm our clinical suspicion. Two 4 mm punch biopsies were taken from the borders of the lesion, and the patient was discharged back to her referring centre where it was recommended to undergo CT imaging of the orbits. Biopsy result later confirmed an ulcerated nodular BCC.
Investigations
The patient underwent a punch biopsy of the left medial canthus. Histopathology findings were supportive of ulcerated nodular BCC.
Differential diagnosis
The variable clinical presentation of BCC includes nodular, cystic, superficial, morphoeic (sclerosing), keratotic and pigmented variants. Other causes of similar changes include a squamous cell carcinoma, melanoma and sebaceous gland carcinoma. This as well as the potential for masquerades in the form of other malignant and benign lesions can make the diagnosis of BCC challenging.
Treatment
The patient underwent an urgent biopsy which showed a nodular BCC on histopathological examination. We had a high clinical suspicion for this because of the site of the lesion and the extensive ulceration with the presence of haemorrhage. Advanced age, large size and medial canthus location are all risk factors for orbital invasion, so CT orbits were recommended.7
Outcome and follow-up
The patient later refused further imaging or surgical intervention at her local centre and would not consent to excision and reconstruction.
Discussion
The typical presentation of BCC is a single ulcerated lesion and although it can be mistaken for another malignant or benign lesion; in our case, it was mistaken to be a traumatic laceration. This kind of presentation is unusual and, to our knowledge, has not been reported before. However, due to the presence of confounding factors such as dementia and attendance as a mechanical fall through ED, the diagnosis can be unclear and easily labelled as a traumatic laceration. Despite a diagnosis of dementia, the patient appeared to clearly relay that the lesion was not new and unrelated to her recent fall. Therefore, this case highlights the importance of good collateral history and clinical examination in formulating a broader differential diagnosis so that sinister pathology is not misdiagnosed. With cases where the defect is smaller, we run the risk of primary repair in ED with subsequent discharge on the assumption it was just a laceration/wound. As well as the inherent challenges in diagnosing periocular malignancies in any patient, in elderly patients with dementia, the challenge becomes more difficult due to the absence of a reliable history of presenting complaint. Such a scenario in a patient living alone with a degree of cognitive impairment also poses potential for delayed presentation since the patient may not recognise that something is wrong and so may not seek medical attention.
BCC is a slow-growing tumour, and although it rarely metastases, it can cause extensive localised destruction. Timely diagnosis is therefore essential. Although the diagnosis of periocular malignancies can prove challenging, maintaining a high clinical suspicion for periocular lesions and having a low threshold for biopsy are advisable to prevent missed diagnosis of malignancy.
This case adds to the literature that even lesions suspected to be traumatic should have malignancy on the list of differential diagnoses. Emergency and non-ophthalmic practitioners should undertake collateral history where possible in cases of an unreliable historian. Presence of granulation tissue at wound edges indicates chronicity and should alert the attending physician to think about possible sinister lesions. BCCs are most likely to occur at the lower lid (50%) and medial canthus (30%),8 and as such an abnormal lesion at this site should prompt further specialist input from an ophthalmologist as soon as possible for further investigation and management.
Management of BCCs can vary significantly and is often dependent on many factors but is often guided by surgeon experience, size of the lesion, extent of spread, location and patient factors. Treatment protocols are usually guided by British Association of Dermatology. Although the mainstay of treatment remains to be surgical excision, other treatment modalities can include topical creams, cryotherapy, photodynamic therapy or radiotherapy.9 A typical presentation of a BCC to the eye clinic will most likely undergo a biopsy to help confirm the aetiology, particularly when there is diagnostic uncertainty or a high-risk type lesion.10 Small lesions which are unlikely to distort significant anatomy are often amenable to excision and direct closure in a one-stage process. However, bigger BCCs often need more meticulous planning with a first-stage excision to help identify the nature of the lesion as well as margin clearance and a second-stage dedicated for reconstruction and further margin clearance if deemed necessary.11 In certain more complex cases where the anatomical location merits little room for manoeuvre, Mohs micrographic surgery is usually employed. This process involves removal of the lesion with immediate subsequent analysis under the microscope to determine clarity of the margins; this is repeated until satisfactory margin clearance is obtained. Other treatment options pertain to superficial BCCs where surgical excision with curettage and cautery, topical creams such as 5-fluorouracil and imiquimod, or cryotherapy (liquid nitrogen) is used to freeze the BCC.9 Certain complex or large BCCs may need radiotherapy as either an adjunct to surgery or a primary form of treatment if surgery is not indicated.12 In cases where the BCC is locally advanced or spread to a distant site, it may not be amenable to either surgery or radiotherapy. In these patients, a chemotherapy agent called vismodegib may be indicated.13
Learning points
-
Diagnosis of memory problems does not disqualify a patient of capacity at that present time, so it is always good practice to consider the history provided to be accurate until proven otherwise.
-
Patients presenting to an emergency department with memory problems should always have a corroborating history ascertained from next of kin at the earliest opportunity to ensure accurate treatment is provided.
-
Traumatic lid lacerations should always be assessed in context, and if the primary attending physician feels confident to manage by themself, they should always endeavour to arrange an outpatient follow-up with an ophthalmologist to ensure masquerading conditions are not missed.
-
Lesions suspected to be traumatic should have malignancy on the list of differential diagnoses.
Ethics statements
Patient consent for publication
Footnotes
-
Contributors SA: Involved in care of the patient and subsequent write up. DS: Involved in care of the patient and subsequent write up. YG: Consultant responsible and involved in care of the patient, subsequent write up and overlooking the whole case.
-
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
-
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
-
Competing interests None declared.
-
Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
References
Use of this content is subject to our disclaimer