A 68-year-old man from Delhi presents with a painless, slowly enlarging nodule on the left cheek for the past 18 months. On examination, there is a 1.5 cm pearly nodule with central ulceration and rolled edges. The lesion has a shiny appearance and telangiectasia at the margins. He has a history of prolonged sun exposure due to outdoor work. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Basal Cell Carcinoma ### Key Clinical Features Present **Key Point:** The classic presentation of BCC includes a pearly nodule with central ulceration (rodent ulcer), rolled edges, and telangiectasia — all present in this case. ### Pathognomonic Features | Feature | Significance | |---------|-------------| | Pearly nodule | Hallmark of nodular BCC | | Central ulceration | Creates "rodent ulcer" appearance | | Rolled/everted edges | Characteristic border morphology | | Telangiectasia | Visible dilated vessels at margin | | Slow growth over months/years | BCC typically indolent | | Sun-exposed site (cheek) | Face is most common location (80%) | ### Why This Is BCC 1. **Morphology:** Pearly, nodular appearance with central ulceration is pathognomonic for nodular BCC (the most common subtype, 60–80% of cases). 2. **Location:** Face, especially cheek, is the most frequent site due to chronic UV exposure. 3. **Behavior:** Slow growth over 18 months is typical; BCC rarely metastasizes but can be locally destructive. 4. **Risk factors:** Age >60 and outdoor sun exposure are classic risk factors. **High-Yield:** BCC accounts for 80% of all non-melanoma skin cancers. The nodular variant presents as a pearly papule or nodule with telangiectasia and often central ulceration (rodent ulcer). ### Histopathology Correlation BCC shows nests and strands of basaloid cells with peripheral palisading and retraction artifact. The tumor arises from the basal layer of the epidermis. **Clinical Pearl:** BCC has an excellent prognosis with <1% metastatic potential, but local invasion can be destructive if neglected. Early diagnosis and treatment prevent morbidity. ### Treatment Overview - **Surgical excision** (Mohs micrographic surgery preferred for high-risk or recurrent lesions) - **Topical imiquimod or 5-FU** for small, superficial lesions - **Radiotherapy** for elderly or poor surgical candidates - **Hedgehog inhibitors** (vismodegib, sonidegib) for advanced/metastatic BCC **Mnemonic:** **PEARL** = **P**early nodule, **E**verted edges, **A**ltered skin (telangiectasia), **R**odent ulcer (central), **L**ow metastatic potential.