Basal cell carcinoma_0112 Derm Clinic
A man aged 73 years presented with a “pimple” on his nose that just would not go away. He reported that he first noticed the lesion four months earlier, and since then, it has been slowly increasing in size, occasionally bleeding when scratched.The man had no history of skin cancer, although he described frequent sunbathing as a child during the summer. Clinical exam revealed a 5 x 6 mm pink, pearly papule on the nasal dorsum. On dermoscopy, the lesion was found to have arborising blood vessels, flecks of pigment, and structureless areas. Submit your answer and read the full explanation below. If you like this activity or have a suggestion, tell us about it in the comment box at the bottom of the page.Do you have related images that you would like to share? Click on the “+Image” link under the comment box to upload your photos. By submitting your photo, you agree that the patient in the photo is not identifiable or has signed a waiver in compliance with HIPAA regulations.
HOW TO TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit, you must also read Linear pink plaques, and Pigmented macular lip lesion; the post-test will include questions related to all three articles. To obtain CME/CE credit, please click here after reading the articles to take the post-test on myCME.com.
Submit your diagnosis to see full explanation.
Occurring with an estimated frequency of 0.3%-1% in the general population, basal cell carcinoma (BCC) — a non-melanoma skin cancer — is the most common malignancy in the United States and in countries with a fair-skinned population. Incidence increases greatly with advancing age, particularly after the fifth decade of life.Although it is most commonly found on sun-exposed areas — including the scalp, face, ears, upper chest, back, and legs — BCC may appear anywhere on the body. Both sexes are equally affected, but incidence on the anterior shins is greater in women, and incidence on the bald scalp is greater in men.
The greatest risk factor for BCC appears to be intermittent intense sun exposure in childhood, particularly with a history of blistering sunburns. In addition, lighter-skin complexion, radiation therapy, a family history of BCC1 and immunosuppresion are all known contributing conditions. The role of smoking2 and trauma with subsequent scar formation is debated.
Because BCCs are generally slow-growing, they are usually detected when still localized and amenable to surgical removal. Left untreated, however, they tend to grow locally, and at times aggressively, leading to considerable disfigurement. Very rarely, BCC may metastasize to regional lymph nodes or elsewhere; once this occurs, the prognosis is poor.
Although several variants exist, the classic presentation is that of the nodular BCC that presents as a shiny waxed semi-translucent nodule with spreading telangiectases and a characteristic rolled border. Crusting, bleeding and ulceration may occur. The pigmented variant is frequently mistaken for a melanocytic lesion, but the shiny pearliness and absence of pigment network can differentiate it.
The morpheaform BCC, often mistaken for a scar, appears as a white sclerotic plaque. Superficial BCC, appearing mostly on the trunk and extremities, may resemble an eczematous or psoriasiform pink, scaly plaque. Infiltrative BCCs are poorly circumscribed, have an irregular spiky appearance at the edges, and tend to penetrate deeper. The term “rodent ulcer” refers to an ulcerating BCC that is likely the result of longstanding neglect. Finally, fibroepithelioma of Pinkus is a variant of BCC that appears as a flesh-colored sessile papule on the lower trunk and resembles a neuroma.
BCCs originate from the basal cells, which reside in the lower level of the epidermis. Ultraviolet radiation is believed to induce mutation in the cells’ DNA, promoting the growth of carcinogens. Genetic inheritance may also be a factor.
Shave biopsy is usually sufficient to correctly diagnose a BCC. Further imaging is reserved for select cases in which deep invasion is suspected.
Histologically, BCC presents distinctively based on subtype, although most growths exhibit cohesive nests or islands of basaloid tumor cells and palisading of nuclei at the periphery of cell nests. There may be variable inflammatory infiltrate and ulceration. Immunohistochemical stains may be used to highlight the tumor cells.
Several acceptable treatment modalities exist, and the ultimate goal is complete cure with maximal function and cosmetic outcome. Factors that must be considered to determine the most appropriate treatment include patient age, location and size of the tumor, and clinical and histopathologic subtype.
Standard treatment options include Mohs micrographic surgery, excisional surgery and electrodesiccation and curettage (ED&C). The most recent National Comprehensive Cancer Network guidelines recommend ED&C for BCC in a non-hair-bearing area in a young, low-risk patient or excision with confirmation of negative margins.3 Higher-risk patients should undergo Mohs micrographic surgery, a staged removal of the tumor, which has the lowest recurrence rate. Micronodular, infiltrative, and morpheaform BCCs have the highest incidence of positive tumor margins after excision — as well as the highest recurrence rates — and these should be treated with Mohs surgery.
Alternate treatment options include topical chemotherapeutic and immune-modulating agents, radiation, and photodynamic therapy, among others. Topical therapy is generally reserved for superficial BCC only. Although imiquimod 5% cream (Aldara) is FDA-approved for use five times a week for six to eight weeks, many studies conclude that more frequent use may be more effective.4
Similarly, 5-fluorouracil (Efudex) interferes with DNA synthesis and cell proliferation. Radiation therapy is generally reserved for individuals who cannot undergo surgical procedures or for use in cases of recurrence. Photodynamic therapy appears to be somewhat effective for areas of extensive and diffuse BCC,5 but its use for this purpose is not FDA-approved. Interferon-alfa and topical tazarotene (Tazorac) are considered experimental treatments.
All patients should be warned regarding the dangers of sun and artificial ultraviolet radiation exposure. In addition, 30%-50% of patients with a history of BCC will develop another nonmelanoma skin cancer within the subsequent five years.3 Clinical yearly skin examinations and monthly self-examinations will aid in the early detection of any new or recurrent tumors.
This patient was treated with Mohs micrographic surgery, and the tumor was completely excised in two stages. The defect was closed with a full-thickness skin graft, providing excellent cosmetic results.
Esther Stern, NP-C, is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J. The author has no relationships to disclose relating to the content of this article.
2. Boyd AS, Shyr Y, King LE Jr. “Basal cell carcinoma in young women: an evaluation of the association of tanning bed use and smoking.” J Am Acad Dermatol. 2002;46:706-709.
4. Geisse JK, Rich P, Pandya A et al. Imiquimod 5% cream for the treatment of superficial basal cell carcinoma: A double-blind, randomized, vehicle-controlled study. J Am Acad Dermatol. 2002;47:390-398.
5. Oseroff AR, Shieh S, Frawley NP et al. “Treatment of diffuse basal cell carcinomas and basaloid follicular hamartomas in nevoid basal cell carcinoma syndrome by wide-area 5-aminolevulinic acid photodynamic therapy.” Arch Dermatol. 2005;141:60-67.
All electronic documents accessed January 9, 2011.