section name header

Basics ⬇

Clinical Manifestations ⬆ ⬇

Clinical Variant ⬆ ⬇

Superficial Basal Cell Carcinoma !!navigator!!

  • A superficial BCC occurs as a scaly pink to red-brown patch with a thread-like border (Fig. 31.27).

  • The lesions tend to be indolent, asymptomatic, and the least aggressive of BCCs.

  • Lesions are sometimes multiple, occurring primarily on the trunk and proximal extremities.

  • When solitary, a lesion of superficial BCC may resemble psoriasis, eczema, a seborrheic keratosis, or Bowen disease (SCC in situ).

  • There is no clear association between superficial BCC and sun exposure.

Morpheaform Basal Cell Carcinoma !!navigator!!

  • This is the least common and most aggressive form of BCC.

  • Lesions appear as whitish, scarred atrophic plaques with surrounding telangiectasia (Fig. 31.28).

  • The margins of these lesions are often difficult to evaluate clinically; as with icebergs, what is seen on the surface is not always what lies under the surface.

  • Consequently, morpheaform BCCs are generally more difficult to treat than other BCCs.

  • A morpheaform BCC may be mistaken for scar tissue.

Outline

Diagnosis ⬆ ⬇

Diagnosis-icon.jpg Differential Diagnosis

SCC (see earlier discussion)

Actinic keratosis (see earlier discussion)

Intradermal nevus (seeChapter 30: Benign Cutaneous Neoplasms)

Melanoma pigmented (see later discussion)

Angiofibroma (fibrous papule of the nose [seeFig. 30.45]), easily confused with BCC

Sebaceous Hyperplasia

  • Yellow or cream-colored papules are often doughnut-shaped with a dell (umbilication) (seeFig. 30.28).

  • Telangiectasias radiate in a spoke-like fashion (seeFig. 30.29).

  • Generally dome-shaped, flesh-colored, pale or pink firm papules with a shiny appearance.

Seborrheic Keratosis

  • May be indistinguishable from a pigmented BCC.

Trichoepithelioma

  • Individual lesions may be confused clinically and pathologically with BCC, which is more common but usually arises as a solitary lesion.

Management-icon.jpg Management

Prevention

  • Techniques involve sun avoidance, use of sunscreens with a sun protection factor (SPF) of at least 15, and wearing protective clothing.

  • People with a history of skin cancer should learn skin self-examination and should have annual skin examinations.

Treatment

  • Electrodesiccation and curettage (see Chapter 35: Diagnostic and Therapeutic Techniques). The overall cure rate exceeds 90% for low-risk BCCs. This method is quick, simple, and less expensive than most other procedures.

  • Excision allows for histologic diagnosis of margins. Cosmetic results compare favorably with those of curettage; however, surgical excision is more time-consuming and costly than curettage.

  • Immunotherapy with 5% imiquimod cream (Aldara), a topical immunomodulator, is approved for the treatment of superficial BCCs. It is applied five times per week for a full 6 weeks.

  • Micrographic (Mohs) surgery (see Chapter 35: Diagnostic and Therapeutic Techniques [Figs. 35.25A-D]) for morpheaform, recurrent, or large lesions, as well as for lesions in “danger zones” (e.g., the nasolabial area, around the eyes, behind the ears, in the ear canal, and on the scalp).

    • Mohs micrographic surgery is a microscopically controlled method of removing skin cancers that allows for controlled excision and maximum preservation of normal tissue. Excisions are repeated in the areas proven to be cancerous until a completely cancer-free plane is reached.

    • Mohs surgery is time-consuming and expensive, and it may require extensive reconstruction of surgical wounds. However, it provides the most reliable method of determining adequate margins, it has a very high cure rate of 98% to 99% for BCCs, and it preserves the maximum amount of normal tissue around the cancer.

  • Radiation therapy for elderly debilitated patients or for those who are physically unable to undergo excisional surgery. The disadvantages include the potential for late radiation changes in the skin, as well as the inability to examine skin margins because tissue is not obtained. It is less often used today.

  • Cryosurgery with LN2. Superficial BCCs may be treated rapidly using this method. However, nodular basal cell carcinomas, particularly selected lesions on the eyelid and ear, are ideally treated with a temperature probe before cryosurgery is performed. Successful treatment is highly dependent on the experience of the operator. This technique is also less often used today.

  • Vismodegib (Erivedge) is an oral inhibitor of the Hedgehog pathway approved by the FDA as a targeted treatment for locally advanced or metastatic basal cell carcinoma that is not amenable to surgery and radiation.

Helpful-Hint-icon.jpg Helpful Hints

  • Avoidance of exposure to ultraviolet radiation is encouraged. Preventive measures include carefully planning outdoor activities before 10 AM and after 4 PM, wearing a broad-brimmed hat during outdoor activities, and using sunscreens with an SPF of 15 or greater.

  • In the rare instances of an advanced or metastatic BCC or one that is inoperable, treatment with an oral anticancer medication vismodegib (Erivedge), a selective hedgehog pathway inhibitor, given as a 150-mg tablet daily, has shown an overall response rate of 43% and 30% in patients who are not candidates for surgery, and those with advanced and metastatic BCC.

Point-Remember-icon.jpg Points to Remember

  • BCC is, by far, the most common type of skin cancer.

  • As with SCC and AKs, BCCs are induced by ultraviolet radiation in susceptible persons.

  • Almost 50% of patients with BCC will have another one within 5 years.

  • Recurrent BCCs are generally more aggressive than primary lesions.

  • Patients with BCC have an increased risk of melanoma.

SEE PATIENT HANDOUT “Sun Protection Advice” IN THE COMPANION eBOOK EDITION.

SEE PATIENT HANDOUT “Basal Cell Carcinoma” IN THE COMPANION eBOOK EDITION.

Other Information ⬆

Histopathology !!navigator!!

  • Cells of nodular BCC typically have large, hyperchromatic, oval nuclei and very little cytoplasm. The cells appear rather uniform, and, if present, mitotic figures are usually scant.

  • Nodular tumor aggregates may be of varying sizes, but tumor cells tend to align more densely in a palisade pattern at the periphery of these nests. Cleft formation, known as “retraction artifact,” commonly occurs between BCC nests and stroma because of shrinkage of mucin during tissue fixation and staining.

Risk Factors !!navigator!!

  • Many of the same risk factors that predispose to actinic keratoses and SCCs are responsible for the development of BCCs, although BCCs tend to occur at a younger age than actinic keratosis, SCC, and KA.

  • Risk factors for BCC include the following:

    • Age older than 40 years.

    • Male sex.

    • Positive family history of BCC.

    • Light complexion (as in SCCs and actinic keratoses, BCCs are rare in blacks and Asians) with poor tanning ability.

    • A history of long-term sun exposure.

Distribution of Lesions !!navigator!!

  • Lesions occur on the head and neck in 85% of all affected persons.

  • Occur on sun-exposed areas, for example, the face, especially on the nose, cheeks, forehead, periorbital area, lower face, and the back of the neck.

Outline