Dr Patrick Treacy shares some of his most challenging cases. This month he talks about treating basal cell cancer

1. 48
S K I N/ D E RMATOLOGY
Aesthetic Medicine • November 2014
SPONSORED BY
Dr Patrick Treacy shares some of his most challenging
cases. This month he talks about treating basal cell cancer
Dr Treacy’s
CASEBOOK
DR PATRICK TREACY
is chairman of the Irish
Association of Cosmetic
Doctors and Irish regional
representative of the British
College of Aesthetic Medicine
(BCAM). He is European medical
advisor to Network Lipolysis
and Consulting Rooms and
holds higher qualifications in
dermatology, laser technology
and skin resurfacing. In 2012
and 2013 he won awards for
‘Best Innovative Techniques’
for his contributions to
facial aesthetics and hair
transplants. Dr Treacy also
sits on the editorial boards
of three international
journals and features regularly
on international television and
radio programmes. He was a
faculty member at IMCAS
Paris 2013, AMWC Monaco
2013, EAMWC Moscow 2013
and a keynote speaker for
the American Academy of
Anti-Ageing Medicine in
Mexico City this year.
>>
A 43-year-old Irish male patient was referred to Ailesbury with a slowly
enlarging lesion on the right side of his neck that wouldn’t heal and bled
when traumatised. The patient described it as an acne lump that had
appeared about a year before and he felt in the beginning that he could
express some pus or fluid from it from time to time. More recently he
had become concerned because a course of antibiotics from his GP had failed
to make any impact on the lesion. The patient gave a history of occupational
sun exposure as he worked in the construction industry. There was no relevant
medical history and the patient did not have any clinical evidence of autoimmune
or allergic diseases.
On examination the lesion appeared eroded and ulcerated and bled easily when
traumatised. There was some crusting at the anterior margins. The presence of
rolled borders, pearly edges and telangiectases gave a clinical suspicion of basal
cell carcinoma (BCC) and a decision was made to proceed to removal rather than do
a biopsy. The author feels that any doctor should consider BCC in any patient with
a history of a sore or skin anomaly that does not heal within four to six weeks and
occurs on sun-exposed skin, especially if it is dimpled in the middle. These tumors
may take many months or years to reach even 1cm in diameter.
TREATMENT (EXCISIONAL SURGERY)
After numbing the area with local anesthesia, an 11 scalpel to remove the entire growth
along with a surrounding border of normal skin as a safety margin. The skin around
the surgical site is then closed with a number of stitches, and the excised tissue is
sent to the laboratory for microscopic examination to verify that all the malignant
cells have been removed.
People who sunburn are more likely to develop skin cancer than those who
do not; however, sunlight damages the skin with or without sunburn. History of
any prior treatment to the index tumor should be elicited, as well as history of
any prior non-melanoma skin cancer. In patients with recurrent tumors, deeper
invasion should be expected. Recurrence following radiation therapy is often
biologically more aggressive.
CASE FILES www.aestheticmed.co.uk
ABOVE AND OPPOSITE PAGE: Resection of basal cell carcinoma from neck area of patient with deep sutures and primary closure

2. SKIN/DERMATOLOGY
Characteristic features of BCC tumors include the following: Slow growing (0.5 cm in 1-2 y) Erosion or ulceration, often central Telangiectases over the surface Rolled (raised) border Waxy papules with central depression Pearly appearance Bleeding, especially when traumatized Crusting Translucency
BCC seldom causes regional or distant metastasis, with the exception of the basosquamous type. To evaluate for lymph node metastasis, particular attention should be taken to examine the parotid posterior auricular, suboccipital, and upper cervical groups of lymph nodes.
HISTOPATHOLOGICAL TYPES
There are several different histopathological types of BCC exist, each with distinct clinical presentation.1 Nodular - Cystic, pigmented, keratotic Infiltrative Micronodular Morpheaform Superficial
Nodular basal cell carcinoma
Nodular basal cell carcinoma is the most common type of basal cell carcinoma and usually presents as a round, pearly, flesh- colored papule with telangiectases. More than 60% of BCCs belong to this subtype. As it enlarges, it frequently ulcerates centrally, leaving a raised, pearly border with telangiectases, which aids in making the diagnosis. The tumor may present as a cyst or pigmented with brown-black macules making it like a melanoma. Keratotic BCC is a variant of nodular BCC and is usually clinically indistinguishable from nodular BCC histologically.
Infiltrative basal cell carcinoma
With this variant of BCC, tumor infiltrates the dermis in thin strands between collagen fibers, making tumor margins less clinically apparent. Mohs micrographic surgery is the treatment of choice for infiltrative basal cell carcinoma. Because of its growth pattern, electrodessication and curettage has a significantly higher recurrence rate when used to treat infiltrative BCC compared to the treatment of nodular BCC; other treatment methods should be sought.
Micronodular basal cell carcinoma
This aggressive BCC subtype has the typical BCC distribution. It is not prone to ulceration, it may appear yellow-white when stretched, and it is firm to the touch. It may have a seemingly well-defined border.
Morpheaform (sclerosing) basal cell carcinoma
Morpheaform basal cell carcinoma is an uncommon variant in which tumor cells induce a proliferation of fibroblasts within the dermis and an increased collagen deposition (sclerosis) that clinically resembles a scar. This form accounts for 10% of lesions. Such lesions appear as flat or slightly depressed, fibrotic, and firm. The morpheaform (sclerosing) type of basal cell carcinoma is often the most difficult type to diagnose, as it bears little resemblance to the typical nodular BCC. Ulceration, bleeding, and crusting are uncommon and these tumors are commonly mistaken for scar tissue.
49
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3. 50 Aesthetic Medicine • November 2014
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Superficial basal cell carcinoma
Superficial basal cell carcinomas are seen mostly on the upper
trunk or shoulders. This type of BCC grows slowly, has minimal
tendency to be invasive, and appears clinically as an erythematous,
well-circumscribed patch or plaque, often with a whitish scale.
Occasionally, minute eschars may appear within the patch or
plaque. The tumor often appears multi-centric, with areas of
clinically normal skin intervening among clinically involved areas.
Gorlin syndrome or basal cell nevus syndrome
Basal cell carcinoma (BCC) is also a feature of basal cell
nevus syndrome (Gorlin syndrome)2 an autosomal dominant
inherited condition. The gene responsible for this syndrome
is located on arm 9q, and chromosome abnormalities
develop in some patients. Multiple BCCs begin to appear
after puberty on the face, trunk, and extremities. In many
cases, the tumors are highly invasive and may involve areas
around the eyes and nose.3
CONCLUSION
With an incidence of 70 to over 800 new cases per 100,000
persons per year, basal cell carcinoma (BCC) is the
commonest skin cancer, accounting for about 80% of all
cases of non-melanoma skin cancer. BCCs are slow-growing,
locally invasive, epidermal skin tumours which mainly affect
white skinned people and very rarely metastasize. Of all
BCCs, 85% occur in the head and neck region4 and the
incidence of this carcinoma (BCC) is increasing worldwide.
As a result therefore, the cosmetic outcome is a particularly
important issue the demand for novel and effective
treatment modalities for BCC is high.5
BCC is commonly treated with surgical excision, curettage,
carbon dioxide (CO2) laser ablation or cryotherapy, depending
on the tumor depth and the histological subtype of the BCC6.
The effectiveness of excisional surgery does not match that
of Mohs, but produces cure rates around 90%. Photodynamic
therapy (PDT) has been widely used for the treatment of
superficial BCC in preference to excision due to its minimal
invasiveness and satisfactory cosmetic results.7,8 However,
the efficacy of this treatment modality is limited in the
treatment of deeper lesions and the more aggressive subtypes
of BCC9. Retreatment and recurrences of the disease are
frequent if the tumor depth is >2 mm.10 In order to improve
the outcomes of BCC treatment, it is possible to combine
CO2 laser ablation with topical methyl aminolevulinate (MAL)
PDT and modified cryotherapy for the treatment of variable
BCC. Conventional cryotherapy following PDT additionally
kills the remaining cancer cells by interrupting vital metabolic
cycles, destabilizing cell membranes, creating an adverse
hyperosmolar environment and forming water crystals.9 The
gold standard of treatment is Mohs surgical excision with
histological control of excision margins, which has a five-year
recurrence rate of less than 3% on the face. For superficial
BCC, approved medications such as imiquimod (total remission
rate, 82-90%) and topical 5-fluorouracil (80%) are available,
as is photodynamic therapy (71-87%). Other ablative methods
(laser, cryosurgery) are applicable in some cases. Radiotherapy
is an alternative treatment for invasive, inoperable BCC, with
five-year tumor control rates of 89-96%. Recently, drugs that
inhibit an intracellular signaling pathway have become available
for the treatment of locally advanced or metastatic BCC.11. AM
REFERENCES
1. (Medscape) Robert S Bader, MD Dermatologist, Section of Dermatology,
Department of Medicine, Broward Health - North Coauthor(s) Luigi Santacroce,
MD Assistant Professor, Medical School, State University at Bari, Italy Laura
Diomede University of Bari School of Medicine, Italy Andrew Scott Kennedy,
MD Physician-in-Chief, Radiation Oncology
2. Gorlin RJ. Nevoid basal cell carcinoma (Gorlin) syndrome: unanswered issues.
J Lab Clin Med. Dec 1999;134(6):551-2
3. Bernardini FP. Management of malignant and benign eyelid lesions. Curr Opin
Ophthalmol. Oct 2006;17(5):480-4.
4. Miller SJ. Biology of basal cell carcinoma (Part I) J Am Acad Dermatol. 1991;24:1–13.
5. Barry J, Oon SF, Watson R, Barnes L. The management of basal cell carcinomas.
Ir Med J. Jun 2006;99(6):179-81
6. Arits AH, Schlangen MH, Nelemans PJ, Kelleners-Smeets NW. Trends in the
incidence of basal cell carcinoma by histopathological subtype. J Eur Acad
Dermatol Venereol. 2011;25:565–569
7. Szeimies RM, Ibbotson S, Murrell DF, et al. A clinical study comparing methyl
aminolevulinate photodynamic therapy and surgery in small superficial basal
cell carcinoma (8–20 mm), with a 12-month follow-up. J Eur Acad Dermatol
Venereol. 2008;22:1302–1311.
8. Fantini F, Greco A, Del Giovane C, et al. Photodynamic therapy for basal cell
carcinoma: clinical and pathological determinants of response. J Eur Acad
Dermatol Venereol. 2011;25:896–901.
9. Dandurand M, Petit T, Martel P, Guillot B. Management of basal cell carcinoma in
adults Clinical practice guidelines. Eur J Dermatol. Jul-Aug 2006;16(4):394-401
10. J, Oon SF, Watson R, Barnes L. The management of basal cell carcinomas. Ir Med
J. Jun 2006;99(6):179-81
11. Messeguer F, Serra-Guillen C, Echeverria B, et al. A pilot study of clinical efficacy
of imiquimod and cryotherapy for the treatment of basal cell carcinoma with
incomplete response to imiquimod. J Eur Acad Dermatol Venereol. 2012;26:879–881.
12. Dtsch Arztebl Int. 2014 May 30;111(22):389-95. doi: 10.3238/arztebl.2014.0389.
Basal cell carcinoma-treatments for the commonest skin cancer. Berking C1,
Hauschild A, Kölbl O, Mast G, Gutzmer R.
S K I N/ D E RMATOLOGY
HISTOLOGY
CLINICAL DETAILS: Rule out basal cell carcinoma.
MACROSCOPY: Labelled NC. R pos triangle neck:
5.2cm x 3.2cm of cream skin. All embedded. 1/1.
MICROSCOPY: Skin, R pos triangle, Basal cell
carcinoma, nodular and invasion of 1mm.
PATHOLOGISTS: Prof.Kieran Sheahan MCRN 02276