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Table of Contents
Year : 2022  |  Volume : 24  |  Issue : 1  |  Page : 17-21

Basal cell carcinoma and its burden on sudanese patients

1 Sudan Medical Specialization Board, Dermatology Council, Khartoum, Sudan
2 National University, Faculty of Medicne, Department of Community, Khartoum, Sudan
3 Omdurman Dermatology Hospital, Department of Dermatology, Omdurman, Sudan
4 Faculty of Medicine, Almaarefa University, Riyadh, Saudi Arabia

Date of Submission18-Oct-2021
Date of Acceptance18-Dec-2021
Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Sami Fatehi Abdalla Billal
P.O. Box 71666, Riyadh 11597
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_46_21

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Background: Basal cell carcinoma (BCC) is the most frequent malignant tumor in dermatology. The burden of advanced BCC is not fully understood and was not well studied in Sudan. Objective: The objectives of this work were to study the BCC disease characteristics, burden, and morbidity on a group of Sudanese patients. Patients and Methods: This is a retrospective, hospital-based study of patients' records presented to the Military Dermatology Hospital and diagnosed with BCC. The study period was 2012–2017. Results: Our team identified a total number of 27 patients to have BCC. 15 (55.6%) were males and 12 (44.4%) were females. The mean age was 54 years (with a range of 26–75 years). The site of the location of the lesions was mostly the face in 22 (81.5%), face and extremities in 4 (14.8%) patients, and in only one (3.7%) patient, it was on the abdomen. The face distribution includes the forehead (14.5%), periocular (18.5%), nose (18.5%), nose, mouth, and cheek (7.4%). The clinical presentation of the lesions includes pigmentation (70.4%), ulcers (63%), plaques (55.6%), nodules (40.7%), scars (11.1%), and deformity associated with advanced BCC in (48.2%) of the patients. The associated comorbidities were (11.1%), albinism (11.1%), and basal cell nevus syndrome (BCNS) (3.7%). Concerning the outcome and prognosis, 11 (40.7%) had a good prognosis and 16 (59.3%) had a bad prognosis. Conclusions: BCC has similar epidemiological and clinical presentation as many international studies with younger age incidence. Delay presentation results in local disease advancement and increases severity and burden. This bad burden could be attributed to inadequate health facilities.

Keywords: Basal cell carcinoma in Sudanese, basal cell nevus syndrome, nonmelanoma skin cancer, skin of color

How to cite this article:
Ali SE, El Khatim HS, Elnur S, Asiri SM, Billal SF. Basal cell carcinoma and its burden on sudanese patients. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:17-21

How to cite this URL:
Ali SE, El Khatim HS, Elnur S, Asiri SM, Billal SF. Basal cell carcinoma and its burden on sudanese patients. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2022 Dec 5];24:17-21. Available from: https://www.sjohns.org/text.asp?2022/24/1/17/341363

  Introduction Top

Basal cell carcinoma (BCC) is a nonmelanoma skin cancer (NMSC) and one of the frequent malignant tumors in dermatology,[1],[2] being the first malignancy in Caucasians, Spanish American, Chinese, and the second skin cancers in African − Americans and Asian Indians,[3] with an annual incidence in the USA of 2.8 million cases.[4],[5],[6] The development of BCC depends on both genetic susceptibly and exposure to risk factors. About 70%–80% of NMSC are with considerable patients' morbidity. The annual worldwide incidence of BCC increases by 10%, with high susceptibility of future BBC and other malignancies.[7],[8] The ultraviolet radiation (UVR) is known as the key etiologic reason, but still, the relationship between exposure and host phenotype is uncertain. The cumulative effects of multiple genes have been suggested to play a role in the development of BCC.[7],[9] Elderly men who have high chronic diseases and comorbidities represent the frequent descriptions of BCCs patients rather than those with occasional diseases. Moreover, the incidence and prevalence of the locally advanced and distantly metastasized BCC, the locally advanced BCC (LABCC) and metastatic BCC (MBCC), respectively, are the highest in the older age categories and more elevated in males than in females, on sun-exposed areas of the head and neck, irrespective of the skin type.[3],[10] Unlike BBC, the squamous cell carcinoma (SCC) among the skin of color ethnic groups occurs in nonsun-exposed areas with little effects for ultraviolet rays. Many risk factors have been approved to have a role in the development of BCC among blacks, which include albinism, scars, ulcers, chronic infections, sebaceous nevus, arsenic poising, immunosuppression, previous radiation treatment, xeroderma pigmentosum, and physical and chemical trauma.[10],[11]

BCC's common sites were the head and neck, trunk, extremities,[12] nose, cheeks, forehead, back, and temple[13] but, palms, soles, penis, popliteal fossae rarely been involved.[14] Interestingly, BCCs are rare on heavily sun-exposed areas of the hands and the dorsal portions of forearms in all ethnic groups.[10],[15],[16] There are no differences in the clinical and histological features of BCC among all ethnic groups. Lesions can occur as nodules, plaques, papules, ulcers, indurated, or pedunculated masses. In contrast to SCC, BCC has a low morbidity rate,[10],[12] locally invasive with a low risk of metastasis in Blacks compared to Caucasians.[17] The hyperpigmentation of BCC is a great diagnostic challenge and may make it hard to discriminate from other pigmented lesions, such as seborrheic keratoses, epidermal inclusion cysts, nevocellular nevi, blue nevi, Bowen disease, lentigines, or malignant melanoma. Nodular BCC represents the common histopathological type in all ethnics groups compared to the morpheoform variety, which is rare in blacks and appears less frequently than in Caucasians. The morpheoform type usually presents as a marble-colored plaque with indeterminate smooth margins that may be indurated, flat or depressed, smooth, shiny, or atrophic.[10],[12] The common treatment modalities of BCCs include topical therapy, excision, Mohs micrographic surgery, curettage and electrodesiccation, cryosurgery, ablative lasers, and radiation. However, in some cases, BCCs increase in size, infiltrate deeply into subcutaneous structures, and progress to advanced BCC (aBCC), with resultant disfigurement, morbidity, or death.[1],[2],[6] This study focuses on the BCC disease characteristics, burden, and morbidity on a group of pigmented skin represented by Sudanese patients.

  Patients and Methods Top

Study design

It was a retrospective, hospital-based descriptive study during the period from 2012 to 2017. The study included all Sudanese patients irrespective of gender or racial background who presented to the Military Dermatology Hospital (MDH) during the study period and have been diagnosed with BCC based on the clinical features histopathological studies. We reviewed medical records and other documents of patients for primary demographic data, clinical characteristics, disease severity, associated conditions, and prognosis.

Study area

The MDH is a referral and central hospital located in Omdurman, the most populated Khartoum State City, Sudan's Capital. The hospital services are dedicated in the first place to the Sudanese military personnel and their families from all ethnic groups distributed throughout Sudan states. Our service not limited to military employees only but extends to civilian residents.

Data processing and storing at Military Dermatology Hospital

The demographic data of all patients who have been seen at the MDH outpatient's clinics have been recorded beside the clinical information including clinical history, examination, and investigation results. Photoimaging is routine, as all medical files include patient's images for follow-up and documentation purposes.

Ethical approval and legal permissions

The Ethics committee at Military Hospital approved the study proposal includes design and methods and images pressing permissions have been obtained.

  Results Top

A total number of 27 patients were identified to have BCC. 15 (55.6%) were males and 12 (44.4%) were females [Table 1]. The mean age was 54 years (with a range of 26–75 years) [Table 2]. The site of the location of the lesions was mostly the face in 22 (81.5%), face and extremities in 4 (14.8%) patients, and in only 1 (3.7%) patient, it was on the abdomen [Figure 1], [Figure 2] and [Table 3]. The face distribution includes the forehead (14.5%), periocular (18.5%), the nose (18.5%), the nose, mouth, and cheek (7.4%), the nose and cheek (7.4%), the cheek alone (7.4%), and the nasolabial fold in (7.4%) [Figure 3] and [Table 4]. Other sites include multiple sites (the face, body, and extremities) in 14.8%, generalized in 1 (3.7%) patient, and one patient (3.7%) had an abdominal lesion [Table 5]. The clinical presentation of the lesions includes pigmentation (70.4%), ulcers (63%), plaques (55.6%), nodules (40.7%), scars (11.1%), and deformity associated with advanced BCC in (48.2%) of the patients [Table 6]. Disease severity, most of our patients presented with severe disease, 7 (25.9%) had genodermatoses, 5 (18.5%) had severe ulcers, and 4 (14.8%) presented with intense eye involvement [Table 7]. The associated diseases were mainly genodermatoses, xeroderma pigmentosum (11.1%), albinism (11.1%), and basal cell nevus syndrome (BCNS) (3.7%) [Figure 4], [Figure 5], [Figure 6] and [Table 8]. Concerning the outcome and prognosis, 11 (40.7%) had a good prognosis, and 16 (59.3%) had a poor prognosis [Table 9].
Figure 1: Basal cell carcinoma: Multiple lesions, ulceration, nodules, and contracture disfigurement of the mouth, nose, and the eye in a 72-year-old male

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Figure 2: Basal cell carcinoma (BCC): (a) Big nodular lesion on the lower right infraorbital region and obliterating the visual field and retracting the eye in a 45-year-old male. (b) Advanced BCC destroying the left eye in a 35-year-old male with failure of different therapeutic interventions

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Figure 3: (a) Advanced basal cell carcinoma: Ulceration infiltration and destruction of the left cheek, nasal bridge, and the left eye. (b) The same patient, 1 year later with invasion of the left eye and nasal bridge and exposure of the left nasal sinus

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Figure 4: (a) Basal cell carcinoma in xeroderma pigmentosum at presentation and 2 years later. (b) Infiltration of the nose and destruction of the nasal bridge

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Figure 5: Basal cell carcinoma in an albinism. (a) At first presentation with an ulcerative nodule with pigment spots. (b) The same patient after 1 year, he was referred for surgery but didn't do it

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Figure 6: Basal cell nevous syndrome, with hundreds of basal cell carcinoma lesions all over he body. (a) A huge ulcer infiltrationg the left scalp and destroying the left ear. (b) The patient had all signs of basal cell nevus syndrome and had strong family history of similar condition

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Table 1: Gender of the study group

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Table 2: Age distribution of basal cell carcinoma patients

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Table 3: Disease sites of basal cell carcinoma lesions at presentation

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Table 4: Face distribution of the lesions of basal cell carcinoma who present with facial lesions

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Table 5: Basal cell carcinoma lesions distribution of sites other than the face

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Table 6: Clinical features of basal cell carcinoma patients at presentation

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Table 7: Case severity of patients at presentation

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Table 8: Comorbidities and associated conditions of basal cell carcinoma patients

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Table 9: Prognosis of basal cell carcinoma patients

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  Discussion Top

In this retrospective study of a group of Sudanese (skin of color) with BCC, the majority (55.6%) were males of old age (>60 years), and the lesions were mostly on the face (81.5%). This presentation pattern shows the classical gender, age, and body site incidences of the disease and indicates the relation to sun exposure and hence UVR as a significant factor in the pathogenesis of BCC in all races, including black or colored skin as in this group of patients.[1],[2],[4] The nose (18.5%) and the periorbital areas were the most affected sites in our cases. The nose was the number one involved site in many literature reports and the orbital region.[18] Many of our patients' (25.9%) conditions were related to certain genetic cutaneous diseases, as xeroderma pigmentosum, albinism, and BCNS, accorded with many similar literature studies.[5] In this study, we included albino patients who had initially been black to complete the disease spectrum. This was done in other similar research on black patients.[19],[20] One would expect that albino patients in Africa would readily develop BCC, but this does not happen for some unknown reason. In black albinos, BCC is less prevalent than SCCS that mainly involved the head and neck, while the cutaneous melanoma of the head and neck is rare.[21],[22] While the Cuna albino Indians are almost always develop SCCs. The Caribbean coast of Lower Panama has the highest prevalence of albinism globally, about 45 per 100,000.[23],[24],[25]

Clinically, most patients in this group presented with pigmented BCC (PBCC); this is classical because PBCC is the dominant clinical type in blacks and Hispanics.[26] Pigmented BCC (PBCC) may have the features suggestive of melanoma, such as an irregular border, and dark or variable pigment, or hypermelanotic nevi.[19]

The case severity ranges from mild superficial to severe mutilating disease, destroying the eye partially in 2.0 (7.4%) of cases and completely in 2.0 (7.4%) of cases, and one case destroying the left ear causing a big ulcer. In most of our patients, the presentation was severe (14.8%) with direct eye involvement, (18.5%) were ulcers, and 25.9% associated with genodermatoses, which is usually severe and multiple. Concerning clinical severity, BCC is classified into BCC, LABCC, and MBCC.[27] In this study and according to this classification, we can identify 40.7% as BCC, 33.3% as LABCC, 25.9% associated with genodermatoses, which can harbor cases from both categories. MBCC was not diagnosed in our cases because no typical criteria for this condition were identified except in one patient with BCNS, who had hundreds of BCCs all over the body; one was a huge ulcer that destroyed his left ear and the left side of the scalp.[28],[29]

  Conclusions Top

According to our study, BCC has similar epidemiological and clinical presentation as many international studies, with younger age incidence. There was a tremendous long delay between the disease's onset and the patient's first dermatology visit. This delay would explain the crust formation, ulceration, aggression, and mutilated character of the lesions. The frequent localization of the BCC lesions at the sun-exposed parts of the body suggests the role of solar exposition. BCC association with genodermatoses was significant.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]


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