basal cell carcinoma


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  • Italicized considered aggressive histotypes, n most likely to lead to perineural invasion n/or recurrence. Overall 5 year recurrence is 5%, 1.2% c adequate exc, 12% c tumor in 1 HPF of margin, n 33% if at margin
  • NOTES FOR PRESENTERS: There are a range of different clinical presentations and histological variants of BCC. Superficial BCCs are important to distinguish clinically from other types of BCCs because they can frequently be managed medically, avoiding the need for excision. Nodular: Commonly on the face, cystic, pearly, telangiectasa, may be ulcerated, micronodular and microcystic types may infiltrate deeply. Superficial: Often multiple, usually on upper trunk and shoulders, erythematous well-demarcated scaly plaques, often larger than 20 mm at presentation, slow growth over months or years, may be confused with Bowen’s disease or inflammatory dermatoses, particularly responsive to medical rather than surgical treatment. Morphoeic: Also known as sclerosing or infiltrative BCC, usually found in mid-facial sites, skin-coloured, waxy, scar-like, prone to recurrence after treatment, may infiltrate cutaneous nerves (perineural spread). Pigmented: Brown, blue or greyish lesion, nodular or superficial histology, may resemble malignant melanoma. Basosquamous: Mixed BCC and squamous cell carcinoma (SCC), potentially more aggressive than other forms of BCC.
  • These can be neglected and or treated as benign pathology.
  • Like small patches of scleroderma.
  • Pathology: Fibrous tumour intersected by thin anastomosing bands of basal cells. May be considered a precursor to BCC nodular type.
  • The associated BCC lesions are primarily face and back BCC reported in 76% of patients with Gorlin’s
  • Malignant degeneration in early adult life Death due to metastatic disease Treatment: early aggressive identification and excision of suspicious lesions.
  • Abnormal synthesis and processing of melanin. Two large subtypes with numerous further subclassifications. Oculo Cutaneous Albinism : skin, hair, eyes. Ocular albinism: eyes. Increased risk for skin malignancies is similar to that of type I phototypes.
  • Basophilic cells
  • basal cell carcinoma

    1. 2. Basal cell carcinoma Bhavishya Valder
    2. 3. Epidemiology <ul><li>Most common human cancer(~80-90%) </li></ul><ul><li>600,000 to 800,000 cases per year in U.S. </li></ul><ul><li>Male:Female 2-3:1 </li></ul><ul><li>80% arise in head and neck </li></ul><ul><li>Age </li></ul><ul><li>✔ Likelihood increases with age </li></ul><ul><li>✔ BCCa over 40 years old </li></ul><ul><li>Race </li></ul><ul><li>✔ Most often in light-skinned, rare in dark-skinned races </li></ul>
    3. 4. Etiology <ul><li>Ultraviolet radiation </li></ul><ul><li>ethnicity </li></ul><ul><li>ionizing radiation exposure </li></ul><ul><li>chemical exposure - arsenic </li></ul><ul><li>burns, scarring </li></ul><ul><li>immunosuppression </li></ul>
    4. 5. Basics of BCC <ul><li>Typically slow-growing </li></ul><ul><li>Rarely metastasizes (<0.1%) </li></ul><ul><li>Typically sporadic </li></ul><ul><li>No cellular anaplasia (a true carcinoma?) </li></ul><ul><li>Very low mortality </li></ul><ul><li>Significant morbidity with direct invasion of adjacent tissues, especially when on face or near an eye </li></ul>
    5. 6. Classic presentation of basal cell
    6. 7. Classic superficial basal cell
    7. 8. Variants of Basal Cell Carcinoma <ul><li>Superficial </li></ul><ul><li>Nodular </li></ul><ul><li>Micronodular </li></ul><ul><li>Infiltrating (5%) </li></ul><ul><li>Sclerosing/ morpheaform (5%) </li></ul><ul><li>Metatypical </li></ul><ul><li>Infundibulocystic </li></ul><ul><li>Nodulocystic </li></ul><ul><li>Adenoid </li></ul><ul><li>Clear cell </li></ul><ul><li>Follicular </li></ul><ul><li>Sebaceous </li></ul><ul><li>Perineurally invasive </li></ul>
    8. 9. Types of BCC Nodular Basosquamous © Schofield JK and Kneebone R (2006) Skin lesions: a practical guide to diagnosis management and minor surgery. Superficial Pigmented Morphoeic © (
    9. 10. Basal Cell Carcinoma - Subtypes <ul><li>Superficial </li></ul><ul><ul><li>Single or multiple patches </li></ul></ul><ul><ul><li>Trunk </li></ul></ul><ul><ul><li>Indurated scaly </li></ul></ul><ul><ul><li>D/D- eczema, psoriasis or tinea . </li></ul></ul>
    10. 11. Basal Cell Carcinoma - Subtypes <ul><li>Nodular Ulcerative </li></ul><ul><ul><li>Most common </li></ul></ul><ul><ul><li>Usually on the face </li></ul></ul><ul><ul><li>Small, slow growing </li></ul></ul><ul><ul><li>Firm </li></ul></ul><ul><ul><li>Telangectasias </li></ul></ul><ul><ul><li>Ulceration </li></ul></ul>
    11. 12. Basal Cell Carcinoma - Subtypes <ul><li>Sclerosing (Morpheaform) </li></ul><ul><ul><li>Yellow white plaques </li></ul></ul><ul><ul><li>Ill defined boarders </li></ul></ul><ul><ul><li>Most aggressive </li></ul></ul><ul><ul><li>Most likely to recur </li></ul></ul><ul><ul><li>Central sclerosis & scarring </li></ul></ul>
    12. 13. Basal Cell Carcinoma - Subtypes <ul><li>Pigmented </li></ul><ul><ul><li>Similar to nodular type </li></ul></ul><ul><ul><li>Deep brown pigmentation </li></ul></ul><ul><ul><li>Differential- malignant melanoma </li></ul></ul>
    13. 14. Basal Cell Carcinoma - Subtypes <ul><li>FIBROEPITHELIOMA </li></ul><ul><ul><li>PINKUS TUMOUR </li></ul></ul><ul><ul><li>Raised </li></ul></ul><ul><ul><li>Moderately firm </li></ul></ul><ul><ul><li>Erythematous and smooth </li></ul></ul><ul><ul><li>Lower trunk (lumbosacral area)_ </li></ul></ul>
    14. 15. BCC - Syndromes <ul><li>BASAL CELL NEVUS (GORLIN’S) SYNDROME </li></ul><ul><ul><li>AD, no sex linkage, low penetrance </li></ul></ul><ul><ul><li>? Mutated tumour suppressor at Ch 9q23.1-q31 </li></ul></ul><ul><ul><li>Childhood onset </li></ul></ul><ul><ul><li>BCC (average age 20y) </li></ul></ul><ul><ul><li>Pitting of palms and soles </li></ul></ul>odontogenic keratocysts (epithelial jawline cysts) CNS calcifications (dura), MR
    15. 16. Other Associated Syndromes <ul><li>XERODERMA PIGMENTOSUM </li></ul><ul><ul><li>Incomplete sex-linked recessive </li></ul></ul><ul><ul><li>Deficiency of endonuclease </li></ul></ul><ul><ul><li>Childhood onset </li></ul></ul><ul><ul><li>Extreme sun sensitivity </li></ul></ul><ul><ul><li>BCC,SCC,Melanoma </li></ul></ul>
    16. 17. Other Associated Syndromes ALBINISM Genetic abnormality of the pigment system.
    17. 18. Basal Cell Carcinoma - Histopathology Resemble normal basal cells Hyperchromatic nuclei, scant cytoplasm Clustered separate from stroma Peripheral palisading Desmoplastic reaction Nests or in continuity
    18. 19. Clinical course Nodulo-ulcerarive type begins as a flesh coloured waxy nodule with telangectasia  -> enlarges -> central ulceration -> deepens -> roled out, beaded edges -> destroys structures locally as deep as bone/ cartilage -> aptly named rodent ulcer Rare metastasis, but recurrence known after inadequate treatment
    19. 20. DIFFERENTIAL DIAGNOSIS <ul><li>Cyst </li></ul><ul><li>Infected spot </li></ul><ul><li>Sebaceous hyperplasia </li></ul><ul><li>Naevus </li></ul><ul><li>Molluscum contagiosum </li></ul><ul><li>Wart </li></ul><ul><li>Bowens disease </li></ul><ul><li>Tinea </li></ul><ul><li>Eczema/psoriasis </li></ul><ul><li>Malignant melanoma </li></ul><ul><li>Seborrhoeic keratosis </li></ul><ul><li>Erosions and leg ulcers </li></ul>
    20. 21. Treatment Options <ul><li>Electrodessication and curettage </li></ul><ul><li>Curettage alone </li></ul><ul><li>Surgical excision </li></ul><ul><li>Mohs micrographically controlled surgery </li></ul><ul><li>Cryosurgery </li></ul><ul><li>Ionizing radiation </li></ul><ul><li>Surgical excision plus radiation </li></ul><ul><li>E xenteration </li></ul>
    21. 22. Factors Considered in Treatment Planning <ul><li>Pt preference to keep eye </li></ul><ul><li>Pt age </li></ul><ul><li>Surgical excision-considered definitive tx </li></ul><ul><li>“ Careful frozen section controlled excision of periocular BCCs yields cure rates comparable to Mohs micrographic surgery at 5-year follow-up” </li></ul><ul><ul><li>5 year recurrence of 2.2% in one study </li></ul></ul><ul><li>Therefore, avoiding exenteration was considered a good possibility </li></ul>