Basal Cell Carcinoma

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Fifth stage 

Dermatology 

Lec-19

 .د

  عمر

18/4/2016

Basal Cell Carcinoma

Epidemiology: 

  Most common human cancer(~80-90%) 
  600,000 to 800,000 cases per year in U.S. 
  Male:Female 2-3:1 
  80% arise in head and neck 
  Age 

o  Likelihood increases with age 
o  BCCa over 40 years old 

  Race 

o  Most often in light-skinned, rare in dark-skinned races 

Etiology: 

  Ultraviolet radiation 
  ethnicity 
  ionizing radiation exposure 
  chemical exposure - arsenic 
  burns, scarring 
  immunosuppression 

Basics of BCC: 

  Typically slow-growing 
  Rarely metastasizes (<0.1%) 
  Typically sporadic 
  No cellular anaplasia (a true carcinoma?) 

o  Very low mortality 
o  Significant morbidity with direct invasion of adjacent tissues, especially when on 

face or near an eye  

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Variants of Basal Cell Carcinoma: 

  Superficial 
  Nodular 
  Micronodular 
  Infiltrating (5%) 
  Sclerosing/ morpheaform (5%) 
  Metatypical 
  Infundibulocystic 
  Nodulocystic  
  Adenoid 
  Clear cell 
  Follicular 
  Sebaceous 
  Perineurally invasive 

Basal Cell Carcinoma – Subtypes: 

Superficial 

  Single or multiple patches 
  Trunk 
  Indurated scaly 
  D/D- eczema, psoriasis tinea. 

Nodular Ulcerative 

  Most common 
  Usually on the face 
  Small, slow growing 
  Firm 
  Telangectasias 
  Ulceration 

Sclerosing (Morpheaform) 

  Yellow white plaques 
  Ill defined boarders 
  Most aggressive 
  Most likely to recur 
  Central sclerosis & scarring 

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Pigmented 

  Similar to nodular type 
  Deep brown pigmentation 
  Differential- malignant melanoma 

FIBROEPITHELIOMA PINKUS TUMOUR 

  Raised 
  Moderately firm 
  Erythematous and smooth 
  Lower trunk (lumbosacral area)_ 

BCC - Syndromes 

BASAL CELL NEVUS (GORLIN’S) SYNDROME 

  AD, no sex linkage, low penetrance 
  ? Mutated tumour suppressor at Ch 9q23.1-

q31 

  Childhood onset 
  BCC (average age 20y) 
  Pitting of palms and soles 

odontogenic keratocysts (epithelial jawline cysts) 

CNS calcifications (dura), MR 

Other Associated Syndromes: 

XERODERMA PIGMENTOSUM 

  Incomplete sex-linked recessive 
  Deficiency of endonuclease 
  Childhood onset 
  Extreme sun sensitivity 
  BCC,SCC,Melanoma 

ALBINISM  

  Genetic abnormality of the pigment system. 

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Basal Cell Carcinoma - Histopathology 

  Resemble normal basal cells 
  Hyperchromatic nuclei, scant cytoplasm 
  Clustered separate from stroma 
  Peripheral palisading 
  Desmoplastic reaction 
  Nests or in continuity 

Clinical course: 

Nodulo-ulcerarive type begins as a flesh coloured waxy nodule with telangectasia → 
enlarges → central ulceration → deepens → rolled 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 

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  Surgical excision plus radiation 
  Imiquimod cream 

Factors Considered in Treatment Planning: 

Pt preference to keep eye 

Pt age 

Surgical 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 study 

Therefore, avoiding exenteration was considered a good possibility