Basal cell carcinoma : BCC

Skin cancer ---> Non melanoma skin cancer ---> Basal cell carcinoma

Basal cell carcinoma (rodent ulcer) is a slow-growing, locally invasive tumor with virtually no capacity to metastasize.
Epidemiology
Basal cell carcinoma is the most common type of skin cancer, approximately 4 times more common than squamous cell carcinoma.
Pathology
The most significant etiological factor is chronic excess ultraviolet radiation exposure. As a result, exposed areas such as the head and neck are most commonly involved. Other risk factors include increasing age, male gender, and skin phototypes I and II. Histologically there is a proliferation of atypical basal keratinocytes.
Clinical features
The clinical appearances and morphology are diverse and include nodular, morphoeic, superficial multifocal, keratotic and pigmented varieties.
The nodular basal cell carcinoma tends to arise on the forehead, nose or adjacent to the inner canthus of the eye as a skin-colored or pigmented, translucent nodule with surface telangiectasia. Gradual enlargement leads to central ulceration (ulcerated basal cell carcinoma) with a peripheral, 'rolled' pearly edge. There may also be cystic change (cystic or nodulocystic basal cell carcinoma). The morphoeic (sclerosing) basal cell carcinoma presents as a firm, indurated, skin-colored, scar-like plaque with ill-defined edges, commonly on the nasolabial fold or forehead. Superficial multifocal basal cell carcinomas tend to arise on extra-facial sites as red, scaly plaques and have no relation to sun exposure. Pigmented basal cell carcinomas may be brown, blue or black with a smooth glistening surface. Keratotic basal cell carcinomas have evidence of keratinization on histology.
Initial investigations
Skin biopsy
A skin biopsy confirms the diagnosis and determines the histological subtype. Alternatively, cytology can be performed on skin scrapings.
Initial management
Multidisciplinary team approach
Depending on the size and site of the basal cell carcinoma, dermatologists, clinical oncologists and plastic surgeons may all be involved in the management. Therefore, a multidisciplinary approach is favored.
Surgical management
Curettage and cautery
Curettage and cautery is a suitable option for patients with low-risk lesions (small, well-defined, primary lesion) and can achieve 5-year cure rates of up to 97%. Patients with recurrent morphoeic tumors in high-risk sites such as the nose, nasolabial folds and around the eyes should undergo formal surgical excision.
Cryotherapy
Cryotherapy can be used on low-risk lesions with non-aggressive histology that are not recurrent lesions.
Surgical excision
The main aim of surgery is complete excision with a clear surgical margin.
Medical management
Radiotherapy
Radiotherapy is useful for treatment of basal cell carcinoma in locations where disfigurement results from surgical excision (although atrophy telangiectasia may develop in the long term and affect the cosmetic results). The 5-year cure is approximately 90%. Patients with recurrent lesions after radiotherapy should undergo surgical excision.
Topical 5-fluorouracil
Topical 5-fluorouracil is usually the treatment of choice for multiple superficial basal cell carcinomas on the trunk and lower limbs.
Palliative management options
Aggressive treatment can be inappropriate in elderly debilitated patients, especially for asymptomatic low-risk lesions. Palliative treatment such as debulking the tumor or radiotherapy may be more appropriate.
RECENT ADVANCES
Intralesional interferon and photodynamic therapy are still under investigation with some early promising results.
Prognosis
Metastasis is extremely rare and the morbidity is related to local tissue invasion and destruction. Patients with a single tumor are at a significant increased risk of developing subsequent basal cell carcinomas.