It is Just a Humongous Mole

Basal cell carcinoma despite a rare entity is oftentimes overlooked following its vague presentation. This is to a greater extent when it mimics a more congenial lesion such as a skin mole. Herein, we would like to report on incidental finding of basal cell carcinoma of nasal dorsum in an elderly gentleman who reckon the lesion to be a skin mole. Excision biopsy with bilobed flap was carried our successfully with no evidence of recurrence till date.


INTRODUCTION
Basal cell carcinoma (BCC) is considered the most common cancer in the western world. Its occurrence within the Asian region is considered rare. Ultraviolet radiation exposure as well as genetic predisposition remains the most common risk factor. Nearly 80% of BCC locates on the face of which almost 30% involves nose following chronic sun exposure. Despite a slowgrowing entity, disfigurement as well as destruction emanates following delay in diagnosis and prompt treatment of nasal BCC. Additionally, nose has 2.5 higher recurrence risk possibly secondary to incomplete removal following its intricate location.

CASE REPORT
A previously healthy 50-year old Chinese gentleman was referred for incidental finding of enlarging mole over the right nasal dorsum for the past 10 years. Patient's initial complain of bilateral infraauricular swelling which upon investigations turned out to be Warthin's tumour of parotid gland. According to the patient, the blackish mole was not a concerning issue to him as it was not increasing in size and non-tender. Further questioning revealed that the nasal mole was initially reddish and turned black over the few years. There were no prior nasal symptoms or trauma. Upon examination, hyperpigmented lesion was noted over right nasal dorsum. (Figure 1) Rigid nasoendoscopic examination was unremarkable with no extension into the nasal cavity. All cranial nerves were intact and there was no constitutional symptoms. Past and family history were not related. Physical and systemic examinations were unremarkable. Patient also had no allergy. Patient underwent excision biopsy with a bilobed flap. Histopathological examination done revealed tumour arising from the basal layer of the overlying squamous epithelium with basophilic nuclei with palisading peripheral nuclear which was consistent with basal cell carcinoma. Postoperatively there was no complication and patient was discharged home well the following day with one-week course of antibiotics. Patient has no recurrence till date.

DISCUSSION
Basal cell carcinoma (BCC) is considered the most common non-melanoma skin cancer till date with 130 cases diagnosed per 100000 habitants per year(1). It involves the basal cell layer of epidermis and has been linked to prolonged sun exposure. Sun protection is not a common practise amongst Asians as BCC are considered rare as compared to Caucasians. As compared to Caucasians who commonly presents with nodules which are pearly translucent with central ulceration and rolled border, amongst Asians glossy pigmentation which are darker are found (2).
BCC can be classified histopathologically into 3 subtypes: nodular, superficial and infiltrative. The infiltrative and superficial types are more aggressive hence has a higher chances of recurrence. Occurrence of BCC is associated with environmental factors. This includes ultraviolet radiation, immunosuppression, chronic arsenic exposure, therapeutic radiation and basal cell nevus syndrome (3). Risk increases with advanced age, male gender, low socioeconomic condition and outdoor occupation.
Mohs micrographic surgery is the most sought out treatment for BCC as it promises highest cure rates with low recurrence. Having said that, long term follow-up is prudent in accordance with its high recurrence rate. At the same time, it is necessary to educate patients on sun protection.

Conflict of interest
No conflict of interest was declared by the authors.

CONCLUSION
Enlarging skin lesion should be investigated promptly as delaying in diagnosis and treatment will be of no avail. This entails attending physicians to be more aware of this destructive lesion and make early referral as to avoid cataclysmic complications.