TEXTBOOK DISCUSSION

Basal cell carcinoma is the most common cutaneous

tumor. Composing 70% of the primary skin cancer, BCC is
most commonly found on the face, the neck, and the
hands and arms, but it can occur anywhere.
The BCCs can grow in size and result in significant cosmetic and functional
morbidity. Although they can be any size, lesions typically range between 3 and 15
mm in dimension at initial presentation. A large BCC can become very destructive.
Large lesions are more likely to erode into muscles, cartilage or bone. BCC is
derived from the same cell line as SCC, the keratinocytes. These basal cells or
keratinocytes, are situated at the lowest layer of the epidermis, just above the
basement membrane that attaches the epidermis to the dermis. When one basal
cell divides, one daughter cell advances slowly upward through the epidermis as a
keratinocyte, while the other remains a basal cell into the basal layer to reproduce
again. Basal cells that fail to mature into keratinocytes retain their capacity for
mitotic division, later forming a tumor.

Etiology and Risk Factors

The risk of BCC and SCC increases with age, this type of skin cancer is
relatively uncommon (although it is becoming more common) in persons younger
than the age of 40. Individuals who freckle easily or who have fair skin, red or
blonde hair, blue or green eyes are at the greatest risk for the development of BCC.
Several inherited syndromes make early onset of BCC more likely: these include
albinism, xerodema pigmentosum or nevoid BCC syndrome. There is growing
evidence that psoralen and ultraviolet A (PUVA) therapy for psoriasis increases the
risk for NMSC.

Sunlight exposure (ultraviolet (UV) radiation) causes almost all cases of basal
and squamous cells cancer and is amajor cause of melanoma. Ultraviolet radiation
initiates and promotes carcinogens by (1) DNA point mutations, (2) oncogene
activation, (3) tumor suppressor gene inactivation, (4) cellular proliferation, (5)
inflammation. Disruption of the earth’s ozone layer and the relationship of that
phenomenon to skin cancer are both complicated and numerous. Further studies
are needed to determine the varying effects that ozone layer depletion may have
on skin cancer development and trends.

Indoor training. Some people believe tans that are a result of artificial light
(tanning beds and lamps) are safer tans and will protect them from the skin damage
and skin cancer. A study done in 2002 revealed that participants who used tanning
devices were 1.5 times more likely ro develop BCC and 2.5 times more likely to
develop SCC than people who did not use tanning beds and lamps.

There are five types of Basal Cell Carcinoma

• Nodular- the most common type of basal cell cancer, most often appears on
the face, neck, and head. The tumor is made up of masses of cells that
resemble epidermal basal cells and grow in a bulky, nodular form from lack of
keratinization. In early stages, the tumor is a papule that looks like a smooth
pimple. It is often pruritic and continues to grow at a steady rate, doubling in
size every 6 to 12 months. As the tumor grows, the epidermis thins,but it
remains intact. The skin over the tumor is shiny, and either pearly white,
pink, or skin colored. Telangectasis may be visible over the area of the tumor.
 As the tumor continues to increase in size, the center or periphery may
ulcerate, and the tumor develops well-circumscribed borders. It bleeds easily
from mild injury.

• Superficial- found most often on the trunk and extremities, is the second
most common type of basal cell cancer. This tumor is a proliferating tissue
that attaches to the under surface of the epithelium. The tumor is a flat
papule or plaque, often erythematous, with well defined borders. The tumor
may ulcerate and be covered with crusts or shallow erosions.

• Pigmented- found on the head, neck, and face, is less common. This tumor
concentrates melanin pigment in the center of the basal cancer cells, giving it
a dark brown, blue, or black appearance. The border of the tumor is shiny
and well defined.

• Morpheaform- the rarest form of basal cell cancer, usually develops on the
head and neck. The tumor forms finger-like projections that extends in any
directions along dermal tissue planes. The tumor resembles a flat ivory or
flesh-colored scar. This form is more likely to extend into and destroy
adjacent tissue, especially muscle, nerve, and bone. It is often more difficult
to diagnose because of its appearance.

• Keratotic(basosquamous)- found on the preauricular and postauricular. It

contains both basal cells and squamoid-appearing cells that keratinize. Its
appearance is much like that of nodular basal cell cancer. This type of basal
cell cancer tends to recur locally and also is the type most likely to
metastasize.

Clinical Features

Basal cell Cancer may start as a transluscent growth that has pink and white
tones, a shiny border, giving it a pearly appearance, and a tendency to crust. This
pearly like lesion can have an overlying telangiectasis. Often these nodules become
quite friable and may develop a hemorrhagic ulceration. If left untreated, they can
severely damage underlying tissue and the skin. As the lesion enlarges, the center
may flatten or ulcerate, but the border is still raised, giving a rolled edge
appearance.

Diagnosis and Staging

A complete skin examination is the key diagnostic component. Once

suspected clinically, basal cell carcinoma must always be definitely diagnosed by
histology. Evaluate and suspicious cutaneous lesions or lymph adenopathy with
biopsy to rule out metastasis or new primary lesions. Typical techniques used to
perform the biopsy include a small punch biopsy or shave biopsy. A shave biopsy
(top lesion into depth of middermis) is performed using local anesthesia. Punch
biopsy (sharp, small circular “punc” similar to a cookie cutter approach) is used if
the tumor is suspected to be deeper layers of the skin. The tissue sample is
examined to determine the clinical diagnosis and identifying features of the various
classifications.

Histologic grading for BCGs and SCCs is similar to the grading system for
other cancers. G1 signifies well-differentiated tumor cells, G2 refers to moderately
well-differentiated, G3 signifies poorly differentiated cells and G4 signifies
undifferentiated cells. Confirmation of cutaneous or subcutaneous spread and the
extent of disease by biopsy is imperative.
Metastases and Recurrence

Metastatic BCC is extremely rare. It usually occurs via hematologic or

lymphatic spread. The malignant characteristic of the tumor are based on the
destructive growth of the primary tumor rather than metastasis. A patient who
develops one BCC has 35% to 50% chance of developing a second BCC lesion within
the next 3.5 to 5 years, as well as other skin cancers. Close observation of the
patient for the recurrence is recommended.

Management

A. Medical management

1. Use of cefazolin 1g IVTT q8h.

2. A complete skin examination should be done and regional lymoh nodes

checked for evidence of possible metastasis.

B. Surgical management

Surgical excision

Both basal cell and squamous cell cancers are excised surgically. The
surgery may be minor or major, depending on the size and location of the tumor.
Surgery for small tumors is most often performed in the outpatient surgery
department or in the surgeon’s office. Surgical excision allows a rapid healing and
yields good cosmetic result carries the risk of infection.

The goal of surgical excision is to remove the tumor completely, so some

surrounding tissue is excised along with the tumor. If the tumor is on the face, the
incision is made along normal wrinkle or anatomic lines so that the scars will be less
obvious. The incision is closed in layers to leave the smallest possible scar. A
pressure dressing is usually applied over the incision to provide support.

If a large tumor is removed, a skin graft or skin flap may be performed to

cover the excised area. It grafting is necessary, the client is hospitalized.

Mohs micrographic surgery

It is a technique used to excise advanced, recurrent or poorly defined basal

cell or squamous cell carcinoma of the skin with minimal excision of normal tissue.
The bulk of the clinically evident tumor is excised initially. Then the lesion is
resected by serial tangential excision.

C. Nursing management

• Maintaining tissue integrity

• Provide careful skin care to prevent further skin irritation, drying and
damage. Handle skin over the affected area gently; avoid rubbing and use of
hot or cold water, soaps, powders, lotions and cosmetics.

• Instruct patient to wear loose-fitting clothes and avoid clothes that constrict,
irritate or rub the affected area.

• Provide aseptic wound care on area of moist desquamation.

• Watch for excessive bleeding and tight dressings that compromise
circulation.

• Dental works should be avoided until the area is completely healed.

• Managing malignant skin lesions

• Carefully assess and cleanse the skin, reducing superficial bacteria,

controlling bleeding, reducing odor and protecting skin from pain and further
trauma.

• Assist and guide the patient and family regarding care for these skin lesions
at home

• Preventing infection

• Assess factors that can promote infection, such as impaired skin,

chemotherapy, radiation and other therapy; malignancy; medications; age,
etc.

• Monitor laboratory studies such as WBC count for leukopenia or neutropenia.

• Monitor patient for sepsis, particularly if invasive catheters or infusion lines

are in place.

• Teaching self-care

• The wound is usually covered with a dressing to protect the site from physical
trauma, external irritants and contaminants. Advise the patient when to
report for a dressing change or is given written and verbal information on
how to change dressing.

• Instruct patient to seek treatment for any moles that are subject to repeated
friction and irritation and to watch for indications of potential malignancy in
moles.
 SIGNS AND SYMPTOMS
Based on Textbook Manifested by Client
Telangiectasia -
Pearly, shiny appearance + 2004, pearly, shiny appearance,1 cm in
Inflammation diameter
Thickening/Lumping +May 2009, after hit by a bamboo
Ulceration +2004, approx 1 cm; May 2009 approx
Weight Loss 2cm
Bladder/ bowel changes +May 2009, ulceration after hit by a
Unusual discharges/ bleeding bamboo
Indigestion or difficulty -
swallowing -
-
-

SCHEMATIC DIAGRAM
Predisposing Precipitating
Age—below 40 Sun exposure:
fisherman
Gender—Male (3:2, compared to female) Alcohol drinking
Sunburn
Smoking

DNA cross-linking between thymidine residues

While DNA repair removes most UV-induced

damage, not all crosslinks are excised

cumulative DNA damage leading to mutations

Basal Cell Mitosis

Daughter cell 1 do not enter G0 Daughter cells 2 continue to

phase of cell cycle produce more basal cells

Uncontrolled
TUMORproduction
GROWTH of basal
cells
Daughter cells 1 fail to mature into keratinocytes
(to be developed into keratin)

Daughter cells 1 remain as basal

cells

Thickening/Lumping
Tumor develops own blood supply and receives nutrition by
diffusion
Pearly, shiny
Tumor grows to 1 cm, however diffusion is
appearance
efficient
approximately 1 cm
Cells in the center of the tumor becomes hypoxic and
starts to die

Telangiectasia
Tumor develops tumor angiogenesis
Weight Loss
Bladder/ bowel factor (TAF) which triggers capillaries Inflammation
changes and other blood vessel in the area to
Unusual discharges/ grow new branches into the tumor for
bleeding continued nourishment
Indigestion or difficulty
swallowing

As tumor cells continue to divide, Ulceration

they change features from the
original cells

The changes/ differences allow

them to live and divide no matter
the condition: selective advantage

As tumor cells continue to have

fewer and fewer normal cell
features, they become malignant

BASAL CELL CARCINOMA