eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pathology

Skin Cancer: Basal Cell Carcinoma: Treatment & Medication

Author: M Abraham Kuriakose, MD, DDS, FRCS, Chairman, Head and Neck Institute, Amrita Institute of Medical Sciences
Contributor Information and Disclosures

Updated: Dec 11, 2006

Treatment

Medical Care

The treatment of BCC is surgical. Chemotherapy does not play a role in the management of BCC. In patients with unresectable tumors, radiotherapy may be attempted as palliative treatment. Radiotherapy may be considered as an adjuvant to surgery in patients with advanced tumors or as a definitive treatment in selected patients with early tumors.

Surgical Care

Curettage, cryotherapy, and laser ablation may be used to treat small superficial BCC. Surgical excision with a margin of normal tissue is generally recommended for all other lesions. This practice allows histologic examination of the specimen for confirmation of the adequacy of excision. Surgery also provides a high cure rate. Excise early tumors with a margin of normal tissue; the defect can be closed primarily or with skin grafts or local flaps. Advanced-stage tumors require a multidisciplinary approach, involving head and neck surgical oncologists, Mohs micrographic surgeons, pathologists, reconstructive plastic surgeons, prosthodontists, and anaplastologists. Neurosurgeons, ophthalmic surgeons, and radiotherapists may be included in selected patients.

• The principal aim of surgical treatment is to obtain complete excision of tumor with uninvolved margins. Cosmetic and functional concerns are secondary. The extent of surgical margin required depends on the histologic types. Although tumor clearance can be achieved with a narrow margin in noduloulcerative BCC, morpheaform BCC requires a wider margin. Expect deeper and/or wider infiltration in tumors arising in the midface, patients with a previous history of radiation, and patients with recurrent tumors. Smaller tumors can be excised in the clinic under local anesthesia with or without sedation. Larger lesions or lesions involving selected anatomic subsites (eg, eyelids) are best managed in the operating room.
• Two distinct surgical approaches are practiced in BCC excisions: en bloc excision and Mohs micrographic surgery. In the first option, perform en bloc surgical resection with the aim to remove tumor with a clear margin. After clearly orienting the specimen, check margins by using frozen section. Histologic studies have confirmed that the subclinical extension of disease varies from 1-6 mm. Tumors larger than 2 cm have wider subclinical invasion than smaller lesions; therefore, a tumor smaller than 2 cm requires a margin of only 4 mm to achieve adequate clearance. Larger morpheaform BCC requires a resection margin of 1-2 cm. The incidence of recurrence following surgical excision is 30% for patients with positive margin, 12% with close margin, and less than 5% for complete excision.
• In Mohs micrographic surgery, excise the tumor with close margins and process specimens by using frozen section. This technique identifies the precise anatomic location of the residual tumors, which then can be re-excised. By serial frozen section examination and re-excision, this procedure allows complete excision of tumor and limited removal of normal structures, thereby preserving function and cosmoses without compromising the cure rate. Mohs micrographic surgery is a labor-intensive procedure. Current indications of Mohs micrographic surgery are recurrent tumors, tumors larger than 2-cm diameter, morpheaform BCC, and tumors located at the high-risk periorbital and nasal region.
• Depending on complexity of the procedure, the principle of reconstructive ladder may be followed in reconstructing BCC surgical defects. This principle includes allowing healing by means of secondary intention, primary closure, skin graft, local flap, free flap, or prosthesis use. The reconstructive procedure can be performed concurrent with surgery or as a secondary procedure after obtaining final pathologic result.

Consultations

Although early BCC can be treated adequately by means of local excision, advanced and recurrent tumors are best managed by a multidisciplinary approach involving head and neck surgical oncologists, Mohs micrographic surgeons, reconstructive plastic surgeons, pathologists, prosthetists, and radiation oncologists. During the initial consultation, counsel the patient regarding the extent of resection, type of reconstructive procedure, and attendant morbidity. Attach great importance to adequately preparing the patient regarding the cosmetic and functional result of treatment. During posttreatment follow-up, counsel the patient regarding sunlight exposure and the risk of second primary skin tumors.

Diet

No dietary restrictions are indicated.

Activity

No restrictions in physical activities are indicated. To prevent second primary skin tumors, counsel the patient to avoid lifestyles that risk excessive sunlight exposure.

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