BASAL CELL CARCINOMA

By:- Dr.Ajmal Rashid

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BASAL CELL CARCINOMA

A

group of malignant cutaneous tumors characterized by the presence of lobules, columns, bands or cords of basaloid cells (germinative cells).

1. BASAL CELL CARCINOMA

Slow growing At least 75% tumours are on face locally invasive, aggressive, and destructive there is a limited capacity to metastasize.

EPIDEMIOLOGY
Most

common skin cancer More in fair skin More common in males

On

the lower leg, three times more common in women

AETIOLOGY

The most important risk factor is solar

radiation

ultraviolet

acute episodes of intense burning sun exposure are a greater risk factor than cumulative lifetime sun exposure

Other factors Arsenic exposure Ionizing radiation air pollutants burns

Mutations in the PTCH1 gene

In Naevoid basal

cell carcinoma syndrome and in sporadic BCC tumour

Nodular

Morpheic

Types
Ulcerated

Nodular Ulcerated Superficial Morpheic Pigmented Fibroepithelioma

Superficial

Pigmented

of Pinkus (FEP) Naevoid basal cell carcinoma syndrome

Nodular

Ulcerated

Superficial

Morpheic

Pigmented

may be multiple

Sites
Majority

on the head and neck

predilection for the upper central part of the face

Morphoeic

type - almost exclusively

on face. Superficial type - mainly on the trunk. Palms and soles - rarely affected

Characteristic Features
Translucency Ulceration Telangiectasias Rolled

border

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Characteristics may vary for different clinical sub-types

1. BASAL CELL CARCINOMA

NODULAR TYPE
most

commonly on the sun-exposed areas of the head and neck translucent papule or nodule usually telangiectasias often a rolled border
Differential diagnosis traumatized dermal nevus Amelanotic melanoma

Basal cell carcinoma, nodular type

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BCC nodular type

A solitary, shiny, red nodule with large telangiectatic vessels on the ala nasi, arising on skin with dermatoheliosis (solar elastosis).

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Nodular basal cell carcinoma in danger zone

TYPES OF BCC (Ulcerated)

NODULAR Usually begin as a small pink pearly papule

Develop a depression in the centre Rolled edge

BCC (Ulcerated)

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Basal cell carcinoma: ulcer type

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BCC (SUPERFICIAL)

Erythematous patch (often well demarcated) that resembles eczema Usually found on the trunk May be multiple D/D Usually have typical Eczema beaded edge

Psoriasis Pagets disease Bowens disease

Superficial basal cell carcinoma

An isolated patch of eczema that does not respond to treatment should raise suspicion

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Superficial basal cell carcinoma

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BCC (MORPHOEIC) or

sclerodermiform

Ivory White or waxy Always on face Presents as a spontaneous scar Margins are usually much wider than what is clinically visible
dense fibrosis of the stroma produces a thickened plaque rather than a tumour palpation reveals a firm skin texture that extends irregularly beyond the visible changes

Basal cell carcinoma: MORPHOEIC

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Basal cell carcinoma: MORPHOEIC

D/D morphoea
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Basal cell carcinoma: MORPHOEIC

appearance of scar tissue in the absence of trauma or previous surgical procedure or the appearance of atypicalappearing scar tissue at the site of a previously treated skin lesion should alert the clinician to the possibility of morpheaform BCC and the need for biopsy.

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BCC

(PIGMENTED)

exhibits increased melanization hyperpigmented, translucent papule may also be eroded D/D- nodular melanoma.

Basal cell carcinoma, pigmented

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Basal cell carcinoma pigmented

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FIBROEPITHELIOMA OF PINKUS

Clinically, the lesion is a benign-appearing, pedunculated, pink tumor that may resemble an acrochordon

H/P - atypical basaloid cells in fibrotic and mucinous stroma

BCC (Multifocal)

Bowenoid

usually found on lower legs of women with sun damaged skin. Diagnosis by biopsy
Poorly

differentiated

Multiple superficial basal cell carcinomas

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Naevoid basal cell carcinoma Basal cell naevus syndrome syndrome Gorlins syndrome

Autosomal dominant Other systems

Skin
multiple

skeletal malformations

BCCs palmoplantar pits skin tags milia epidermoid cysts

(mandibular keratocysts),

soft tissue Eyes

Strabismus, hypertelorism, dystopia canthorum, congenital blindness

Characteristic
Frontal

facies

CNS endocrine organs Internal Neoplasms

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bossing broad nasal root hypertelorism.

Fibrosarcoma of the jaw,ovarian fibromas, teratomas, and cystadenomas

Basal cell nevus syndrome: basal cell carcinomas

Multiple nodular BCCs on the right side of the face, frontal bossing, and a large scar on the right cheek at the site of excision of an odontogenic cyst.

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Naevoid basal cell carcinoma syndrome:

palmar pits
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Naevoid basal cell carcinoma syndrome

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Follicular atrophoderma and basal cell carcinoma BazexDuprChristol syndrome

Rare

genodermatosis (X-linked inheritance) Predisposition to multiple BCCs Follicular atrophoderma

ice-pick marks, enlarged follicular ostia on the dorsa of hands,elbows, feet and face

Hypotrichosis Hypohidrosis

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H/P Of BCC
Basaloid

tumor cells
Palisading of nuclei

Budding from epidermis or follicle or within the dermis

Peripheral

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well-circumscribed nodule made up of islands of basaloid cells

Peripheral palisading (arrowheads) Clefting (arrows)

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A solid group of atypical basaloid cells is present at the dermo-epidermal junction showing peripheral palisading and cleft formation between tumour nest and dermis

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BCC

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Basal cell carcinoma, nodular type, pigmented

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typical nodular basal cell carcinoma with the additional feature of melanin pigmentation of the tumour nests

BCC

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Basisquamous or metatypical BCC

Tumours

that on pathological study appear to have features of both BCC and SCC Significantly higher incidence of metastatic spread small aggregates of cells lacking classic palisading

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Course BCC
slow progressive course

of peripheral extension, which producing thread-like margin doubling time is estimated to be between 6 months and 1 year

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Spread
Local

Periorbital tissues; bones of the face, skull ,meninges Perineural Invasion - Uncommon most often in histologically aggressive or recurrent lesions

may manifest as pain, paraesthesia, weakness, or paralysis

Dissemination

- Rare

Inhalation ulceration involves the airway inhaled and become implanted in the lungs bloodstream metastasis

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in the viscera or spinal column spread via lymphatics

deposits

Factors influencing prognosis in basal cell carcinoma

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TREATMENT
Destructive

therapies Surgical excision Mohs micrographic surgery Photodynamic therapy Radiation therapy Topical therapy

Imiquimod 5-FU

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Destructive therapies
INDICATION

small primary tumors at non-critical sites

MODALITIES curettage and cautery cryotherapy

Disadvantages risk of recurrence morbidity associated with cryotherapy

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Surgical excision
3

4 mm margin
Tumor less than 2 cm in diameter

3-mm margin clear the tumour in 85% of cases and a 4

5-mm margin in 95% of cases

5-mm

margin

morphoeic

BCC large BCCs (more than2 cm in diameter) smaller nodular BCCs with poorly defined clinical margins recurrent BCCs

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Mohs surgery
offers

superior histologic analysis of tumor margins while permitting maximal conservation of tissue compared with standard excisional surgery Usually reserved for high risk lesions eyelids, nose, lips, ears
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 Repeated

cycles of surgery and intraoperative microscopic examination of the entire surgical margin of the excised tissues allows accurate and dependable identification and removal of all residual invasive tumour

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Indications for Mohs Surgery for Basal Cell Carcinoma

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Recurrence rate after MMS

Primary Recurrent

1 percent 5.6 percent

superior to the rate for other modalities excision curettage and desiccation XRT cryotherapy (10 percent) (7.7percent) (8.7 percent) (7.5 percent)

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Radiation Therapy
Advantages
minimal

patient discomfort avoidance of an invasive procedure for a patient unwilling or unable to undergo surgery

Disadvantages
lack

of histologic verification of tumor removal prolonged treatment course cosmetic result that may worsen over time predisposition to aggressive and extensive recurrences

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IMIQUIMOD (5 percent cream)

Imiquimod is

a Toll-like receptor 7 agonist believed to induce interferon- and other cytokines to boost T helper 1 type immunity.

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Photodynamic Therapy
involves

the activation of a photosensitizing drug (-aminolevulinic acid) by visible light to produce activated oxygen species that destroy the constituent cancer cells

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Flow chart BCC treatment

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ED&C = electrodesiccation and curettage

FOLLOW UP
Counseling

about sun

protection Periodic full-body skin examinations

A patient who has had one BCC should undergo periodic full-body skin examinations for :

local recurrence to detect fresh tumors arising elsewhere

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