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Skin Malignancies, Basal Cell Carcinoma
Updated: Dec 18, 2008
Basal Cell Carcinoma: Evaluation, Diagnosis, and Management
Basal cell carcinoma is the most common human malignancy. Although this lesion can be significantly invasive and locally destructive, distant metastases are uncommon. Most of these lesions are located on the face and scalp, with the nose, cheek, and periorbital regions the most common sites. Basal cell carcinoma rarely is found on the lip or hand.
The increasing incidence of skin cancer has raised concerns about congenital and acquired skin lesions. These lesions range from benign conditions such as a freckle or keratosis to malignant lesions such as basal or squamous cell carcinoma. The incidence of these lesions varies, ranging from 500-1000 cases per 100,000 people. Annually, more than 400,000 people find out they have skin cancer. Etiology is related to various factors that includes skin type, age, and sun exposure.
Predisposing factors include individuals with a fair or light complexion, a history of severe sunburns, and poor tanning capability. All physicians should possess a basic understanding and knowledge of the types and characteristics of common skin lesions because they are frequently asked to evaluate them. Early recognition and biopsy of suspected lesions greatly improves outcomes. This article provides a framework for the surgeon to facilitate the evaluation, diagnosis, and management of cutaneous basal cell carcinoma.
For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education articles Skin Cancer and Skin Biopsy.
Histopathology
The natural history of basal cell carcinoma is that of a slowly growing lesion increasing in size and depth over months and years. Histologically, basal cell carcinomas arise from the basal layer of the epidermis and the pilosebaceous adnexa. The 5 subtypes of basal cell carcinoma include nodular, superficial, micronodular, infiltrating, and morpheaform (ie, sclerosing).1 The classification into subtypes, first described by Lang and Maize, has strong implications for clinical management.2 The basosquamous variant is relatively uncommon but more aggressive and does have significant metastatic potential.
The morpheaform and infiltrative subtypes are more aggressive in nature with higher recurrence rates.3 They comprise approximately 10% of basal cell cancers. The infiltrating and morpheaform basal cell carcinomas exhibit islands of tumor extending into the tissue and may exhibit perineural invasion in 3% of patients. This finding helps classify these two histotypes as the most aggressive, with the highest rates of recurrence and positive margins after excision. Nodular and superficial histotypes exhibit the least aggressive growth. Micronodular patterns are intermediate between most and least aggressive. For histological subtypes, the location of occurrence is most often the face, followed by the neck.
Presentation
The most common presentation of basal cell carcinoma is in a Caucasian male older than 60 years. Patients commonly present with multiple coexisting tumors. There is a well-documented association of basal cell carcinoma with previous ionizing radiation and immunosuppression, as observed in patients with organ transplantation.
Basal cell carcinoma often is described as a pearly or translucent mass with raised borders and telangiectasias coursing throughout. The lesion may ulcerate, giving rise to the term "rodent ulcer." This classic presentation often is observed in nodular histotypes. Superficial basal cell carcinoma often presents as an erythematous patch or plaque. The lesion may be scaly, with areas of atrophy or scarring, and can be mistaken for eczema or psoriasis. Infiltrating and morpheaform tumors often do not have distinctive characteristics. They may present like scars with indistinct borders. As previously mentioned, the tumor often extends beyond the apparent borders of the lesion, with islands of tumor extending into the tissue.
Diagnosis
Accurate diagnosis of suspicious lesions requires biopsy. Biopsy techniques include shave, punch, incision, and excision. Ensuring that the full thickness of the lesion is incorporated into the specimen is important. Shave biopsy is a safe and simple technique for skin lesions of unknown histotype; it does not require suturing. This technique is recommended for superficial lesions with a low suspicion of malignancy. Incisional, punch, and excisional biopsy allow removal of the full thickness of the specimen, which permits accurate diagnosis. These techniques are recommended if a higher possibility of malignancy exists.
Treatment
Electrodesiccation and curettage
Electrodesiccation and curettage is the most common treatment method used by dermatologists. Separate the well-circumscribed tumor from surrounding normal skin and remove any extension of disease with electrodesiccation. Use this method for primary treatment of nodular basal cell carcinoma smaller than 2 cm and superficial basal cell carcinoma of any size. The cure rates for this treatment modality reportedly are 90-98%. Recurrence rates of 50% are reported for tumors wider than 3 cm.
Cryotherapy
This modality is indicated in the management of primary lesions smaller than 2 cm. Overall cure rates of more than 95% are reported using cryosurgery. Significant scarring, hypopigmentation, and potential injury to adjacent nerves are associated with this treatment. Most significantly, there is no microscopic confirmation of tumor eradication by this method. Cryosurgery is contraindicated in patients with cryoglobulinemia and the more aggressive basal cell carcinomas such as the infiltrating and morpheaform subtypes. It is also contraindicated when scar contracture may cause problems such as periorbital or perioral lesions.
Surgical excision
Cure rates for surgical excision of basal cell carcinoma are higher than 90%. The size, histotype, and anatomic location of the lesion help determine cure rates. Margins of 2-5 mm are recommended to achieve cure. "The larger the lesion, the wider the margin" is a good general rule. The reconstruction of the defect most often can be achieved by undermining the skin edges and by primary closure. Smaller lesions can be safely excised by general practitioners; patients with larger or more complex lesions are best referred to a plastic surgeon.
Mohs micrographic surgery may prove advantageous in certain critical areas, such as the medial and lateral canthal area, perioral area, and in the area of the nasal ala. Cure rates for this technique, which uses horizontal frozen sections of the entire undersurface of the excised tissue, are reportedly 99% for primary lesions and 96% for recurrent lesions. Examine the sections microscopically and plan the extent of the resection accordingly.
Recurrence
Recurrence rates are higher in tumors wider than 3 cm or in areas where maximum tissue preservation is required, such as those mentioned above. Basal cell carcinomas with positive margins after primary resection must be re-excised for cure. Histologic features associated with higher recurrence rates include cellular palisading, ulceration, and lymphatic infiltration.4 Recurrent tumors require larger surgical margins than those used in primary resections. Mohs micrographic technique also is indicated in the management of recurrent lesions.
Medical Legal Considerations
- Failure to document the appearance and behavior of all suspicious lesions and explain to the patient the recommendations for observation or biopsy5
- Failure to refrain from labeling or coding a skin lesion of uncertain behavior as a carcinoma until after it is biopsied and the final pathology is determined
- Failure to obtain informed consent (which is mandatory) prior to any operative procedure5
- Failure to be absolutely sure that specimens are labeled correctly and sent in separate containers when more than one lesion is removed
- Failure to ensure that the correct lesion or lesions are being removed (photographs and mirrors are useful)
- Failure to inform patients that biopsies will leave scars and additional procedures may be necessary depending on the final pathology
- Failure to notify the patient of the results once they are available, rather than waiting for the patient to call, once the final pathology is available
- Most centers now require a "time out" prior to any surgical procedure to ensure that the entire operative team is in agreement regarding the exact site of the lesion(s) to be removed.
Multimedia
 | Media file 1: This translucent pink papule has telangiectases and a crusted erosion characteristic of nodular basal cell carcinoma (Image courtesy of Michael L Ramsey, MD). |
 | Media file 2: Nodular basal cell carcinoma presenting as a waxy translucent papule with central depression and a few small erosions (Image courtesy of Michael L Ramsey, MD) |
 | Media file 3: Nodular basal cell carcinoma. Nodular aggregates of basalioma cells are present in the dermis and exhibit peripheral palisading (PP) and retraction artifact (RA). Melanin also is present within the tumor and in the surrounding stroma, as seen in pigmented basal cell carcinoma (Image courtesy of Michael L Ramsey, MD). |
 | Media file 4: Scale, erythema, and a threadlike raised border are present in this superficial basal cell carcinoma on the trunk (Image courtesy of Michael L Ramsey, MD). |
 | Media file 5: Larger superficial basal cell carcinoma (Image courtesy of Michael L Ramsey, MD) |
 | Media file 6: Histology of superficial basal cell carcinoma. Nests of basaloid cells are seen budding from the undersurface of the epidermis (Image courtesy of Michael L Ramsey, MD). |
 | Media file 7: Pigmented basal cell carcinoma has features of nodular basal cell carcinoma with the addition of darker pigmentation from melanin deposition. The pigmentation often has the appearance of dark droplets within the lesion, as seen in this picture (Image courtesy of Michael L Ramsey, MD). |
 | Media file 8: This infiltrating basal cell cancer has ill-defined borders and telangiectases (Image courtesy of Michael L Ramsey, MD). |
 | Media file 9: Postoperative wound after Mohs micrographic surgery demonstrates extensive subclinical involvement typical of many infiltrating and morpheaform basal cell carcinomas (Image courtesy of Michael L Ramsey, MD). |
 | Media file 10: Large scarlike morpheaform basal cell cancer (Image courtesy of Michael L Ramsey, MD) |
 | Media file 11: Basal cell carcinoma (Image courtesy of Hon Pak, MD) |
 | Media file 12: A 68-year-old patient presenting with an advanced basal cell carcinoma (BCC) of the right periorbital region, frontal view (Images courtesy of M Abraham Kuriakose, DDS, MD) |
 | Media file 13: Lateral view of face showing extent of tumor (Images courtesy of M Abraham Kuriakose, DDS, MD) |
Keywords
basal cell carcinoma, BCC, basal cell carcinoma treatment, malignancy, basil cell carcinoma, basel cell carcinoma, skin cancer, malignant lesions, melanoma, squamous cell carcinoma, SCC, skin lesions, malignant skin lesion, skin lesion removal, skin cancer removal, skin lesion surgery, acquired skin lesion, congenital skin lesion, nodular basal cell, superficial basal cell, micronodular basal cell, infiltrating basal cell, morpheaform basal cell, sclerosing basal cell, basosquamous variant, basosquamous, electrodesiccation, curettage, skin biopsy, cryotherapy, surgical excision, Mohs surgery, Mohs micrographic surgery
More on Skin Malignancies, Basal Cell Carcinoma |
| References |
References
Sexton M, Jones DB, Maloney ME. Histologic pattern analysis of basal cell carcinoma. Study of a series of 1039 consecutive neoplasms. J Am Acad Dermatol. Dec 1990;23(6 Pt 1):1118-26. [Medline].
Lang PG Jr, Maize JC. Histologic evolution of recurrent basal cell carcinoma and treatment implications. J Am Acad Dermatol. Feb 1986;14(2 Pt 1):186-96. [Medline].
Brown CI, Perry AE. Incidence of perineural invasion in histologically aggressive types of basal cell carcinoma. Am J Dermatopathol. Apr 2000;22(2):123-5. [Medline].
Dixon AY, Lee SH, McGregor DH. Factors predictive of recurrence of basal cell carcinoma. Am J Dermatopathol. Jun 1989;11(3):222-32. [Medline].
Gorney M, Martello J. The genesis of plastic surgeon claims. A review of recurring problems. Clin Plast Surg. Jan 1999;26(1):123-31, ix. [Medline].
Constantino D, Lowe L, Brown DL. Basosquamous carcinoma: An under recognized, high risk cutaneous neoplasm - case study and review of literature. J. Plast Reconstr Aesthet Surg. 2006;59 (4):424-8. [Medline].
Miller SJ, Malden MA, eds. Cutaneous Oncology: Pathophysiology, Diagnosis, and Management. Blackwell Science Inc; 1998.
Raasch B, Wooley T. Management of primary superficial basal cell carcinoma. Aust Fam Physician. 2006;35:455-8. [Medline].
Raasch BA, Buettner PG, Garbe C. Basal cell carcinoma: histological classification and body site distribution. Br J Dermatol. 2006;155(2):401-7. [Medline].
Further Reading
Keywords
basal cell carcinoma, BCC, basal cell carcinoma treatment, malignancy, basil cell carcinoma, basel cell carcinoma, skin cancer, malignant lesions, melanoma, squamous cell carcinoma, SCC, skin lesions, malignant skin lesion, skin lesion removal, skin cancer removal, skin lesion surgery, acquired skin lesion, congenital skin lesion, nodular basal cell, superficial basal cell, micronodular basal cell, infiltrating basal cell, morpheaform basal cell, sclerosing basal cell, basosquamous variant, basosquamous, electrodesiccation, curettage, skin biopsy, cryotherapy, surgical excision, Mohs surgery, Mohs micrographic surgery
