basal cell carcinoma

Basal cell carcinoma

Bhavishya Valder

Epidemiology

Most common human cancer(~80-90%)600,000 to 800,000 cases per year in U.S.Male:Female 2-3:180% arise in head and neckAge✔Likelihood increases with age✔ BCCa over 40 years oldRace✔Most often in light-skinned, rare in

dark-skinned races

Etiology

Ultraviolet radiationethnicityionizing radiation exposurechemical exposure - arsenicburns, scarringimmunosuppression

Basics of BCCTypically slow-growingRarely metastasizes (<0.1%)Typically sporadicNo cellular anaplasia (a true carcinoma?)•Very low mortality•Significant morbidity with direct invasion of adjacent tissues, especially when on face or near an eye

Classic presentation of basal cell

Classic superficial basal cell

Variants of Basal Cell Carcinoma

• Superficial• Nodular• Micronodular• Infiltrating (5%)• Sclerosing/

morpheaform (5%)• Metatypical• Infundibulocystic

• Nodulocystic • Adenoid• Clear cell• Follicular

• Sebaceous• Perineurally

invasive

Types of BCC

Nodular

Basosquamous

© Schofield JK and Kneebone R (2006) Skin lesions: a practical guide to diagnosis management and minor surgery.

Superficial

PigmentedMorphoeic

©dermNetNZ.org (http://dermnetnz.org)

Basal Cell Carcinoma - Subtypes

SuperficialSingle or multiple patchesTrunkIndurated scalyD/D- eczema, psoriasis or tinea.

Basal Cell Carcinoma - SubtypesNodular UlcerativeMost commonUsually on the faceSmall, slow growingFirmTelangectasiasUlceration

Basal Cell Carcinoma - SubtypesSclerosing (Morpheaform)Yellow white plaquesIll defined boardersMost aggressiveMost likely to recurCentral sclerosis & scarring

Basal Cell Carcinoma - Subtypes

PigmentedSimilar to nodular typeDeep brown pigmentationDifferential- malignant melanoma

Basal Cell Carcinoma - Subtypes

FIBROEPITHELIOMAPINKUS TUMOURRaisedModerately firmErythematous and smoothLower trunk (lumbosacral area)_

BCC - SyndromesBASAL CELL NEVUS (GORLIN’S) SYNDROMEAD, no sex linkage, low penetrance? Mutated tumour suppressor at Ch 9q23.1-q31Childhood onsetBCC (average age 20y)Pitting of palms and soles

odontogenic keratocysts (epithelial jawline cysts)CNS calcifications (dura), MR

Other Associated Syndromes

XERODERMA PIGMENTOSUMIncomplete sex-linked recessiveDeficiency of endonucleaseChildhood onsetExtreme sun sensitivityBCC,SCC,Melanoma

Other Associated Syndromes

ALBINISM Genetic abnormality of the pigment system.

Basal Cell Carcinoma - Histopathology

Resemble normal basal cellsHyperchromatic nuclei, scant cytoplasmClustered separate from stromaPeripheral palisadingDesmoplastic reactionNests or in continuity

Clinical courseNodulo-ulcerarive type begins as a flesh coloured waxy nodule with telangectasia→ enlarges → central ulceration → deepens → roled out, beaded edges → destroys structures locally as deep as bone/ cartilage → aptly named rodent ulcer

Rare metastasis, but recurrence known after inadequate treatment

DIFFERENTIAL DIAGNOSIS

• Cyst

• Infected spot

• Sebaceous hyperplasia

• Naevus

• Molluscum contagiosum

• Wart

• Bowens disease

• Tinea

• Eczema/psoriasis

• Malignant melanoma

• Seborrhoeic keratosis

• Erosions and leg ulcers

Treatment Options

• Electrodessication and curettage• Curettage alone

• Surgical excision• Mohs micrographically controlled surgery• Cryosurgery• Ionizing radiation• Surgical excision plus radiation

• Exenteration

Factors Considered in Treatment Planning

Pt preference to keep eyePt ageSurgical excision-considered definitive tx“Careful frozen section controlled excision of periocular BCCs yields cure rates comparable to Mohs micrographic surgery at 5-year follow-up”5 year recurrence of 2.2% in one studyTherefore, avoiding exenteration was considered a good possibility