Multiple aggregated yellow‐white ( MAY ) globules, a dermoscopic sign to be considered in the presurgical evaluation in Mohs surgery

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LETTER
Multiple aggregated yellow-white globules, a dermoscopic sign
to be considered in the presurgical evaluation in Mohs surgery
Dear Editor,
High-risk basal cell carcinomas (BCCs) are mostly treated with Mohs
micrographic surgery (MMS) due to lower recurrence rate when
treated with this treatment modality.
1
Dermoscopy has a high diag-
nostic accuracy for the diagnosis of BCC and recently, multiple aggre-
gated yellow white globules (MAY) were described as a dermoscopic
sign associated with high-risk BCCs.
2
However, MAY's role in margin
delineation of MMS has not been studied.
A 55-year-old male was referred for an asymptomatic, 18-month
lesion on the nasal sidewall, adjacent to the internal canthus. On phys-
ical examination, he presented with an 8 8-mm ill-defined pearly
papule. On dermoscopy, the lesion showed arborizing telangiectasia,
blue-gray globules, and in-focus dots (Figure 1A,B). A diagnosis of
high-risk BCC was performed, and MMS was suggested given the
high-risk location. When defining the initial surgical margins,
peripheral areas displaying a multitude of MAY globules were noted,
and therefore, they were included on the first stage margin marking
(Figure 1B,C). Tumor diameter increased from 8 8mm to
11 9 mm when considering the peripheral areas with MAY globules.
Despite the above, all peripheral margins were involved on frozen sec-
tions with BCC, micronodular subtype, on first stage (Figure 1E,F). A
whole rim of peripheral and deep margins was subsequently taken.
Margins were clear after a second stage, resulting on an 18 15 mm
surgical defect (Figure 1D,G). A full thickness skin graft was used to
close the defect with excellent cosmetic results.
MAY globules were recently described as new diagnostic criteria
for the diagnosis of BCC correlating with calcium deposits on histo-
pathology, as we see in our case (Figure 1E,F). Besides BCC diagno-
sis, they were also associated with high-risk BCC histologic subtypes
(e.g., morpheaform, micronodular, infiltrative).
2
Herein, we have
FIGURE 1 Basal cell carcinoma (BCC), micronodular, on right lateral side wall of nose adjacent to the internal canthus. (A) Clinical features
and initial demarcation prior to dermoscopy (dashed light blue line). (B) Dermoscopy image showing blue-gray globules, arborizing telangiectasia,
and MAY globules on the periphery (red arrows). Dermoscopic delineation is shown with dashed black lines (Polarized image, original
magnification 10). (C) Final demarcation of intended first stage after including MAY globules. (D) Final defect after 2 stages. (E) Histopathology,
Mohs micrographic surgery (MMS) first stage, en face view, showing tumor islands of micronodular BCC with calcium deposits (black rectangle)
on deep and lateral margins (H&E, 2). (F) Higher magnification of the dystrophic calcification in tumor nodule (center of the image) (H&E, 20).
(G) Second MMS stage, en face view, with no further evidence of tumor (H&E, 2)
Received: 2 January 2022 Revised: 13 January 2022 Accepted: 23 January 2022
DOI: 10.1111/dth.15333
Dermatologic Therapy. 2022;35:e15333. wileyonlinelibrary.com/journal/dth © 2022 Wiley Periodicals LLC. 1of2
https://doi.org/10.1111/dth.15333