Dermatology Book

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Basal Cell CarcinomaAka: Basal Cell Cancer

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  1. See Also
    1. Nonmelanoma Skin Cancer
    2. Basal Cell Nevus Syndrome
  2. Epidemiology
    1. Most common cutaneous malignancy
    2. Incidence (1998, US): 400,000-500,000 per year
  3. Pathophysiology
    1. Derived from Basal Cell Layer of Keratinocytes
    2. Deepest cell layer of Epidermis
  4. Signs
    1. Distribution
      1. 90% in chronic sun exposed areas (head and neck)
    2. Characteristics
      1. "Pearly" or translucent Papule
      2. Overlying telangiectases
      3. Waxy or translucent surface
      4. Central Ulceration
      5. Raised, rolled border
      6. Friable, non-healing lesions that bleed frequently
    3. Atypical presentations
      1. Pigmented basal cell carcinoma (uncommon)
        1. Differentiate from Melanoma
  5. Diagnosis: Skin Biopsy
    1. Raised lesion: Shave Biopsy if not pigmented
      1. Any suspicion of Melanoma needs full-thickness sample
    2. Flat lesions: Punch Biopsy or full excision
  6. Management
    1. Electrodesiccation and curettage (ED&C)
      1. Indications
        1. Intermediate size lesions
        2. Maintains dermal integrity with minimal scar
        3. More difficult if prior Punch Biopsy
      2. Technique
        1. Scrape with curette
        2. Electrodessication to base with radiofrequency
        3. Repeat "scrape and burn" 3 times
        4. Send first curettage sample to pathology
        5. Keep area moist afterward (e.g. Bacitracin)
    2. Full thickness excisional surgery
      1. Indications
        1. Deeper, diffuse or more advanced lesions
        2. Basosquamous carcinoma
    3. Topical therapy for non-aggressive, superficial lesions
      1. Topical 5-Fluorouracil (Efudex)
      2. Topical Imiquimod 5% daily for 7 weeks
        1. Used in superficial and non-aggressive lesions only
        2. Geisse (2004) J Am Acad Dermatol 50:722
      3. PDT with 5-aminolevulinic acid
    4. Mohs' Micrographic Surgery
      1. Efficacy
        1. Maximum cure rates
        2. Maximum normal tissue preservation
      2. Indications
        1. Recurrent basal cell carcinoma
        2. Certain primary basal cell lesions
        3. Positive biopsy margins (see below)
    5. Large, advanced growths
      1. Radiation therapy
      2. Chemotherapy
  7. Management: Positive biopsy margins (incomplete excision)
    1. Seen with Shave Biopsy or Punch Biopsy
      1. Re-excision often yields negative sample
      2. Yet high rate of recurrence
    2. Most recommend Mohs Micrographic Surgery
      1. Berlin (2002) J Am Acad Dermatol 46(4):549
      2. Bieley (1992) J Am Acad Dermatol 26:754
      3. Holmkvist (1999) J Am Acad Dermatol 41(4):600
    3. Observing low-risk sites may be acceptable
      1. Less than 1 cm diameter lesions
      2. Not located on nose or ears
      3. Marginal involement of 4% or less
  8. Course
    1. Slow growing tumors
    2. Rarely metastasize
    3. Locally Invasive!
    4. Histologic characteristics for local extensive spread
      1. Sclerosing pattern (tumor strands in fibrous stroma)
      2. Perineural or perivascular invasion
      3. Focal areas of squamous differentiation
    5. Clinical characteristics for local extensive spread
      1. Basal cell carcinoma on nose
      2. Morpheaform basal cell carcinoma on cheek
      3. Basal Cell Carcinoma involving neck
      4. Recurrent basal cell carcinoma in men
      5. Basal cell carcinoma involving eyelid, temple, or ear
      6. Basal cell carcinoma lesions >10 mm in diameter
      7. Batra (2002) Dermatol Surg 28:107
  9. Resources
    1. Basal Cell Carcinoma Nevus Syndrome Support Network
      1. http://www.bccns.org
  10. Prevention
    1. See Sun Exposure (lists general preventive measures)
    2. See Sunscreen
  11. References
    1. Habif (2004) Dermatology p. 724-35
    2. Stulberg (2004) Am Fam Physician 70:1481

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