Basal Cell Epithelioma - Symptoms, Causes, Treatment of Basal Cell Epithelioma or Rodent Ulcer

Synonym: Rodent ulcer.

Symptoms of Multiple Benign Cystic Epithelioma

Basal Cell Epithelioma develops from the basal cell layer of the epidermis and also from the p Plant derivatives pilo-sebaceous apparatus. It is relatively benign, and is usually only locally malignant, without any tendency to metastasize. The tumor is characterized by slow growth and the presence of a pearly nodule or ulcer with a rolled edge. Ulceration occurs late in the basal cell epithelioma.

The site most commonly affected is the upper part of the face; the lower part of the face, the hands and the trunk are less commonly affected. The lesion is usually single. A typical lesion starts as a firm papule which grows slowly into a nodule or a flat, raised plaque. In the course of time, the plaque shows a depression in the centre and more pearly papules at its periphery. Later, the centre breaks down to form an ulcer with a rolled edge which may also show firm pearly papules (rodent ulcer). The ulcer enlarges slowly; in the process, it destroys the local structures. The course usually extends over years; this fact should be brought out during history-taking.

Besides the typical lesion described above, one may come across several atypical varieties: the nodular type; the invasive destructive type; the scarring type (atrophic, smooth shiny patch); the cystic type (pea- to nut-sized translucent pearly tumor); the multiple superficial type (well-defined reddish-brown patches with thin pearly margin seen usually on the trunk) and the pigmented variety. Some of the features of the typical basal cell epithelioma can be discerned in these atypical varieties. Some basal cell epitheliomas may grow into squamous cell carcinomas. -

Pathology: The typical features are downward projections of the basal cell layer; strands and islands of epidermal cells surrounded by a palisade of typical columnar basal cells containing a large nucleus; deep bluish staining and inflammatory reaction in the corium which is more marked at the periphery of the lesion.

Diagnosis of Multiple Benign Cystic Epithelioma

It is based upon:

• The typical site.
• A slowly growing lesion. The history usually extends over years.
• A typical pearly nodule or ulcer with rolled edge.
• Histopathological characteristics.

Differential diagnosis: It is made from keratoacanthoma, squamous cell epithelioma and chronic granulomas, particularly lupus vulgaris and lupus erythematosus, and tertiary, syphilis. The latter produces confusion in scarring and superficial varieties of basal cell epitheliomas.

Keratoacanthoma : It grows rapidly; is self-healing; has a keratinous crater. Histopathology is characteristic.

Tertiary syphilide : History of syphilis and earlier rashes; rapid and bigger ulceration; punched out ulcer; positive serology.

Squamous cell carcinoma : It grows faster; history is in months. Convex surface in early stages then later ulcer with indurated border, averted margins and granular base develops. More opaque and solid than basal cell epithelioma.

Lupus vulgaris : Onset is in childhood. History is in years. Typical reddish-brown patch with apple jelly nodules is present. No pearly border. Tissue paper wrinkled scar on healing.

Lupus erythematosus : Exposed parts; butter-fly distribution; multiple patches; adherent scaly, follicular plugging.

Prognosis of Multiple Benign Cystic Epithelioma

It is good with a high percentage of cures. Recurrences and relapses are seen especially in cases where removal is incomplete. In sensitive persons, new lesions keep on developing on exposed parts from time to time.

Treatment of Multiple Benign Cystic Epithelioma

The patient should not be frightened with the name cancer since the growth is mainly benign. It is preferable to use the word rodent ulcer when explaining the disease process to the patient. There is no mass approach to treatment. Every case should be individualized. The usual lines of therapy are:

• X-ray therapy gives good cosmetic results as the basal cell epitheliomas are radio-sensitive. The dose is from 2,500 r to 4,000 r in fractional or massive doses. It is contra-indicated in recurrent lesions, in lesions near the eyes, on bones, tendons and cartilages. The author prefers to employ preliminary cauterization and curettage followed by fractionated X-ray therapy. There is an initial inflammatory reaction followed by separation of the crust, and healing takes place in about 6 to 8 weeks. Radium plates have also been successfully employed.
• Excision surgically or by diathermy and curettage. At least 5 mm all around should be excised. Scar can be repaired by plastic surgery. Mohs' chemosurgery or electro-surgery is used by many workers. Small lesions have been successfully treated with liquid nitrogen and topical cytotoxic agents. Every case should be watched for about 3 years because of the likelihood of recurrence.