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## Importance of Both Clinical and Dern Findings in Predicting High-Risk Histopa Subtype in Facial Basal Cell Carcin

Hannah Ceder1,2, Eva Backman1,2, Ashfaq Marghoob3, Cristián Nav Sam Polesie1,2, Ofer Reiter5, John Paoli1,2

- 1 Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University Sweden
- 2 Department of Dermatology and Venereology, Region Västra Götaland, Sahlgrenska University Hospital, Go
- 3 Dermatology Service, Memorial Sloan Kettering Cancer Center, Hauppague, New York
- 4 Melanoma and Skin Cancer Unit, Department of Dermatology, Escuela de Medicina, Pontificia Universidad Santiago, Chile
- 5 Dermatology Division, Rabin Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Key words: basal cell carcinoma, dermoscopy, clinical decision-making, interobserver agreement, Mohs micro

Citation: Ceder H, Backman E, Marghoob A, et al. Importance of Both Clinical and Dermoscopic Findings in Histopathological Subtype in Facial Basal Cell Carcinomas. *Dermatol Pract Concept*. 2024;14(3):e2024212. dpc.1403a212

Accepted: May 5, 2024; Published: July 2024

**Copyright:** ©2024 Ceder et al. This is an open-access article distributed under the terms of the Creative Corr NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrest distribution, and reproduction in any medium, provided the original authors and source are credited.

Funding: Hannah Ceder, Eva Backman, Sam Polesie and John Paoli were financed by grants from the Swedis between the Swedish government and the county councils, the ALF-agreement (ALFGBG-728261). Ash Mar Memorial Sloan Kettering Cancer Center's NIH/National Cancer Institute Cancer Center support grant P30

Competing Interests: Ash Marghoob has received honoraria for lectures from Fotofinder, DermLite and Can no conflicts of interest to report.

A A TEAH AT THE CONTRACT OF A DESCRIPTION

Dermatology Practical &amp; Conceptual

<jats:p>Introduction: Being able to recognize high-risk facial basal cell carcinoma (BCC) may lead to fewer incomplete excisions and inappropriate treatments. Objectives: We sought to investigate clinical and dermoscopic criteria for predicting facial BCC subtypes, analyze the interobserver agreement between readers, and develop a diagnostic algorithm to predict high-risk histopathological subtype. Methods: In this single-center, retrospective investigation, 6 independent readers evaluated predefined clinical and dermoscopic criteria in images of histopathologically verified primary facial BCCs including: topography, border demarcation, vessels, ulceration, white porcelain areas, shiny white blotches and strands, and pigmented structures and vessels within ulceration. Results: Overall, 297 clinical and dermoscopic image pairs were analyzed. The strongest associations with high-risk subtype were: “bumpy” topography (OR 3.8, 95% CI, 3.1-4.7), ill-defined borders (OR 3.4, 95% CI 3.1-4.7), white porcelain area (OR 3.5, 95% CI 2.8-4.5), and vessels within ulceration (OR 3.1, 95% CI 2.4-4.1). Predominantly focused vessels were a positive diagnostic criterium for either nodular (OR 1.7, 95% CI 1.3-2.2) or high-risk (OR 2.0, 95% CI 1.6-2.5) subtypes and a strong negative diagnostic criterium for superficial BCC (OR 14.0, 95% CI 9.6-20.8). Interobserver agreement ranged from fair to substantial (κ=0.36 to 0.72). A diagnostic algorithm based on these findings demonstrated a sensitivity of 81.4% (95% CI, 78.9-83.7%) and a specificity of 53.3% (95% CI, 49.7-56.9%) for predicting high-risk BCC subtype. Conclusions: Integration of both clinical and dermoscopic features (including novel features such as topography and vessels within ulceration) are essential to improve subtype prediction of facial BCCs and management decisions.</jats:p>

Being able to recognize high-risk facial basal cell carcinoma (BCC) may lead to fewer incomplete excisions and inappropriate treatments.
We sought to investigate clinical and dermoscopic criteria for predicting facial BCC subtypes, analyze the interobserver agreement between readers, and develop a diagnostic algorithm to predict high-risk histopathological subtype.
In this single-center, retrospective investigation, 6 independent readers evaluated predefined clinical and dermoscopic criteria in images of histopathologically verified primary facial BCCs including: topography, border demarcation, vessels, ulceration, white porcelain areas, shiny white blotches and strands, and pigmented structures and vessels within ulceration.
Overall, 297 clinical and dermoscopic image pairs were analyzed. The strongest associations with high-risk subtype were: "bumpy" topography (OR 3.8, 95% CI, 3.1-4.7), ill-defined borders (OR 3.4, 95% CI 3.1-4.7), white porcelain area (OR 3.5, 95% CI 2.8-4.5), and vessels within ulceration (OR 3.1, 95% CI 2.4-4.1). Predominantly focused vessels were a positive diagnostic criterium for either nodular (OR 1.7, 95% CI 1.3-2.2) or high-risk (OR 2.0, 95% CI 1.6-2.5) subtypes and a strong negative diagnostic criterium for superficial BCC (OR 14.0, 95% CI 9.6-20.8). Interobserver agreement ranged from fair to substantial (κ = 0.36 to 0.72). A diagnostic algorithm based on these findings demonstrated a sensitivity of 81.4% (95% CI, 78.9-83.7%) and a specificity of 53.3% (95% CI, 49.7-56.9%) for predicting high-risk BCC subtype.
Integration of both clinical and dermoscopic features (including novel features such as topography and vessels within ulceration) are essential to improve subtype prediction of facial BCCs and management decisions.

Importance of Both Clinical and Dermoscopic Findings in Predicting High-Risk Histopathological Subtype in Facial Basal Cell Carcinomas

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