Basal Cell Carcinoma

• Fred F. Ferri, M.D.

 Basic Information

Definition

Basal cell carcinoma (BCC) is a malignant tumor of the skin arising from basal cells of the lower epidermis and adnexal structures. It may be classified as one of six types: nodular, superficial, pigmented, cystic, sclerosing or morpheaform, and nevoid. The most common type is nodular (21%); the least common is morpheaform (1%). A mixed pattern is present in approximately 40% of cases. BCC advances by direct expansion and destroys normal tissue.

Synonyms

1. BCC

ICD-10CM CODES
C44.01	Basal cell carcinoma of skin of lip
C44.111	Basal cell carcinoma of skin of unspecified eyelid, including canthus
C44.112	Basal cell carcinoma of skin of right eyelid, including canthus
C44.119	Basal cell carcinoma of skin of left eyelid, including canthus
C44.211	Basal cell carcinoma of skin of unspecified ear and external auricular canal
C44.212	Basal cell carcinoma of skin of right ear and external auricular canal
C44.219	Basal cell carcinoma of skin of left ear and external auricular canal
C44.310	Basal cell carcinoma of skin of unspecified parts of face
C44.311	Basal cell carcinoma of skin of nose
C44.319	Basal cell carcinoma of skin of other parts of face
C44.41	Basal cell carcinoma of skin of scalp and neck
C44.510	Basal cell carcinoma of anal skin
C44.511	Basal cell carcinoma of skin of breast
C44.519	Basal cell carcinoma of skin of other part of trunk
C44.611	Basal cell carcinoma of skin of unspecified upper limb, including shoulder
C44.612	Basal cell carcinoma of skin of right upper limb, including shoulder
C44.619	Basal cell carcinoma of skin of left upper limb, including shoulder
C44.711	Basal cell carcinoma of skin of unspecified lower limb, including hip
C44.712	Basal cell carcinoma of skin of right lower limb, including hip
C44.719	Basal cell carcinoma of skin of left lower limb, including hip
C44.81	Basal cell carcinoma of overlapping sites of skin
C44.91	Basal cell carcinoma of skin, unspecified

Epidemiology & Demographics

1. •

   Most common cutaneous neoplasm

2. •

   85% of cases appear on the head and neck region

3. •

   Most common site: nose (30%)

4. •

   Increased incidence with age >40 yr

5. •

   Increased incidence in men

6. •

   Risk factors: fair skin, increased sun exposure, use of tanning salons with ultraviolet A or B radiation, history of irradiation (e.g., Hodgkin’s disease), personal or family history of skin cancer, impaired immune system

Physical Findings & Clinical Presentation

Variable with the histologic type:

1. •

   Nodular: dome-shaped (Fig. 1), painless lesion that may become multilobular and frequently ulcerates (rodent ulcer) (Fig. 2); prominent telangiectatic vessels are noted on the surface. Border is translucent, elevated, pearly white (Fig. 3). Some nodular BCCs may contain pigmentation (Fig. 4), giving an appearance similar to a melanoma.

   

   

   

   

2. •

   Superficial: circumscribed, scaling, black appearance with a thin, raised, pearly-white border; a crust and erosions may be present. Occurs most frequently on the trunk and extremities.

3. •

   Cystic: dome-shaped, blue-gray cystic nodules, appearing clinically similar to eccrine and apocrine hidrocystomas (Fig. 5).

   

4. •

   Morpheaform: flat or slightly raised yellowish or white appearance (similar to localized scleroderma); appearance similar to scars; surface has a waxy consistency.

Diagnosis

Differential Diagnosis

1. •

   Keratoacanthoma

2. •

   Melanoma (pigmented BCC)

3. •

   Xeroderma pigmentosa

4. •

   Basal cell nevus syndrome

5. •

   Molluscum contagiosum

6. •

   Sebaceous hyperplasia

7. •

   Psoriasis

Workup

Biopsy to confirm diagnosis

Treatment

Variable with tumor size, location, and cell type:

1. •

   Excision surgery: preferred method for large tumors with well-defined borders on the legs, cheeks, forehead, and trunk.

2. •

   Mohs’ micrographic surgery: preferred for lesions in high-risk areas (e.g., nose, eyelid), very large primary tumors, recurrent BCCs, and tumors with poorly defined clinical margins.

3. •

   Electrodesiccation and curettage: useful for small (>6 mm) nodular BCCs.

4. •

   Cryosurgery with liquid nitrogen: useful in BCCs of the superficial and nodular types with clearly definable margins; no clear advantages over the other forms of therapy; generally reserved for uncomplicated tumors.

5. •

   Radiation therapy: generally used for BCCs in areas requiring preservation of normal surrounding tissues for cosmetic reasons (e.g., around lips); also useful in patients who cannot tolerate surgical procedures or for large lesions and surgical failures.

6. •

   Imiquimod 5% cream can be used for treatment of small, superficial BCCs of the trunk and extremities. Efficacy rate is approximately 80%. Its main advantage is lack of scarring, which must be weighed against higher cure rates with surgical intervention.

7. •

   Vismodegib and sonidegib are orally active hedgehog pathway inhibitors FDA approved for metastatic BCC, recurrent basal cell carcinoma post-surgery, and locally advanced BCC in patients who are not candidates for surgery or radiation.

8. •

   Table 1 summarizes advantages and disadvantages of BCC treatment options.

   TABLE1 Advantages and Disadvantages of Basal Cell Carcinoma Treatment OptionsFrom Wiznia LE, Federman DG: Treatment of basal cell carcinoma in the elderly; what nondermatologists need to know, Am J Med 129:655–660, 2016.

   Modality	Advantages	Disadvantages
   Mohs micrographic surgery	Complete margin analysis Well tolerated by elderly Gold standard treatment	Cost Longer procedure (stages)
   Conventional surgical excision	Well tolerated by elderly	Cost Lack of complete margin analysis
   Electrodesiccation and curettage	Shorter procedure Does not require return visit Patients can avoid surgery	Lack of histologic confirmation of malignancy removal Not appropriate for lesions with extension into deep dermis
   Cryosurgery	Patients can avoid surgery	Higher recurrence rates than surgery Lack of histologic confirmation of malignancy removal Recurrent carcinoma could be extensive (can be obscured by fibrous scar tissue) Hypertrophic scarring Postinflammatory pigment changes
   Imiquimod	Patient self-administration Excellent cosmetic results	Local skin reactions Lack of histologic confirmation of malignancy removal Cost
   Photodynamic therapy	Excellent cosmetic outcome	Higher recurrence rates than with surgery Lack of histologic confirmation of malignancy removal
   5-FU	Patient self-administration	Higher recurrence rates than with surgery
   Radiation therapy	Good option in patients who are not surgical candidates	Cost Higher recurrence rates than with surgery Scars tend to worsen with time Can require 15-30 visits Side effects are considerable
   Vismodegib	Approved for metastatic BCC and locally advanced BCC that has recurred following surgery; option in patients who are not surgical or radiation therapy candidates	Cost
   Observation	Patients can avoid surgery Cost	No standard as to length of time for which it is appropriate to monitor patients clinically More dangerous neoplasms may be missed (such as Merkel cell carcinoma or amelanotic melanoma)
   BCC, Basal cell carcinoma; 5-FU, 5-fluorouracil.

Disposition

1. •

   More than 90% of patients are cured; however, periodic evaluation for at least 5 yr is necessary because of increased risk of recurrence of another BCC (<40% risk within 5 yr of treatment).

2. •

   A lesion is considered low risk if it is >1.5 cm in diameter, is nodular or cystic, is not in a difficult-to-treat area (H zone of face), and has not been previously treated.

3. •

   Nodular and superficial BCCs are the least aggressive.

4. •

   Morpheaform lesions have the highest incidence of positive tumor margins (<30%) and the greatest recurrence rate.

Prevention

Oral nicotinamide, a form of vitamin B₃ available without prescription (500 mg bid), has been reported to prevent development of new nonmelanoma skin cancer in high-risk patients.

Suggested Reading

• A.C. Chen, et al.: A phase 3 randomized trial of nicotinamide for skin cancer prevention. N Engl J Med. 373:1618 2015 26488693

• L. Wiznia, D.G. Federman: Treatment of basal cell carcinoma in the elderly: what nondermatologists need to know. Am J Med. 129:655–660 2016 27046242

Related Content

1. Basal Cell Skin Cancer (Patient Information)

2. Actinic Keratosis (Related Key Topic)

3. Melanoma (Related Key Topic)

4. Squamous Cell Carcinoma (Related Key Topic)