History

Fact Explanation
Skin lesion Basal cell carcinoma is one of the most common cancers in human.It is more prevalent among men over 40 years of age and most often in light-skinned people than in dark-skinned people. It more commonly occurs in the skin which is exposed to the sun light. Majority (85%) of cases are reported in head and neck with 25-30% occurring on the nose alone. [1,2,3] Basal cell carcinomas are slow growing, locally aggressive tumors that arise from the basal layer of the epidermis. Clinical pattern varies according to the sub types of basal cell carcinomas. Nodular or cystic varieties raise above the skin whereas pigmented, sclerosing or superficial varieties do not raise above the skin. Skin lesions may be single or multiple. [1,2,3,4] There are several sub types of basal cell carcinoma. Nodular/ nodular ulcerative type : Most common type, well defined pearly rolled edge and central ulceration. Bleeding is evident especially when traumatized. Cystic : Large cystic nodule. The following sub types ar not raised above the skin. Pigmented : These lesions contain melanin. so that they can be confused with malignant melanoma. Sclerosing : This is a flat or depressed tumour with ill defined edge. Superficial : Well demarcated erythematous scaly patches that can be confused with Bowen's disease. Often multiple and usually presents on upper trunk and shoulders. [1,2,3,4]
Predisposing factors Ultraviolet radiation, exposure to ionizing radiation, chemical exposures such as arsenic, burns and scarring are thought to be risk factors in developing basal cell carcinomas. Acquires predisposing factors are ultraviolet light in the sunlight, carcinogens such as cigarette smoke and arsenic, previous radiotherapy and malignant transformation of pre-excisting skin lesions such as naevus sebaceous. Congenital causes are rare. Xeroderma pigmentosum and Gorlin's syndrome are among them. [1,2,5] (Gorlin's syndrome is also known as basal cell nevus syndrome which is a childhood onset, autosomal dominant disease characterized by skin pits on palms and soles, epithelial jaw line cysts, splayed or bifid rib abnormalities, abnormal calcifications in dura and mental retardation) Exposure to the sun burn is usually chronic. It includes recreational and occupational sun exposure. [1,2,3]
Past history of recurrence of similar lesions The risk of recurrence is high if there were prior incidents of recurrence. That risk multiplies if the tumor is more than 2cm, centrally placed on the face, signs of vascular and neural invasion and in sclerosing and micronodular sub types. [2,3,6]
Small plaque/papule which ulcerates and bleeds sometimes Basal cell carcinoma presents as a small palque or papule in its initial stage. They are usually covered with small dilated blood vessels. (telangiectasias) Occasionally there may be some crust over a wound which bleeds during shaving and does not heal. [1,2,3,7]
References
  1. FIRNHABER, J.M. Diagnosis and Treatment of Basal Cell and Squamous Cell Carcinoma, Am Fam Physician [online] . 2012 Jul 15,86(2),161-168. [viewed 23 May 2014] Available from: http://www.aafp.org/afp/2012/0715/p161.html
  2. MACKIEWICZ-WYSOCKA MAłGORZATA, BOWSZYC-DMOCHOWSKA MONIKA, STRZELECKA-WęKLAR DARIA, DAńCZAK-PAZDROWSKA ALEKSANDRA, ADAMSKI ZYGMUNT. Reviews Basal cell carcinoma – diagnosis. wo [online] 2013 December, 4:337-342 [viewed 23 May 2014] Available from: doi:10.5114/wo.2013.35684
  3. KASPER M, JAKS V, HOHL D, TOFTGåRD R. Basal cell carcinoma - molecular biology and potential new therapies. J Clin Invest [online] 2012 Feb 1, 122(2):455-63 [viewed 23 May 2014] Available from: doi:10.1172/JCI58779
  4. JETLEY S, JAIRAJPURI ZS, RANA S, TALIKOTI MA. Adenoid basal cell carcinoma and its mimics. Indian J Dermatol [online] 2013 May, 58(3):244 [viewed 23 May 2014] Available from: doi:10.4103/0019-5154.110874
  5. WATT TC, INSKIP PD, STRATTON K, SMITH SA, KRY SF, SIGURDSON AJ, STOVALL M, LEISENRING W, ROBISON LL, MERTENS AC. Radiation-related risk of basal cell carcinoma: a report from the Childhood Cancer Survivor Study. J Natl Cancer Inst [online] 2012 Aug 22, 104(16):1240-50 [viewed 23 May 2014] Available from: doi:10.1093/jnci/djs298
  6. CHINEM VP, MIOT HA. Epidemiology of basal cell carcinoma. An Bras Dermatol [online] 2011 Mar-Apr, 86(2):292-305 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21603813
  7. TURAN E, YURT N, YEşILOVA Y, TüRKçü G. Early-onset basal cell carcinoma. Turk J Pediatr [online] 2013 May-Jun, 55(3):354-6 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24217088

Examination

Fact Explanation
Skin lesion - Inspection Single or multiple skin lesions usually occurs on hair bearing sun exposed skin of elderly people specially on the head and neck. The examination findings vary with the sub type of the basal cell carcinoma. It may be nodular, micronodular, cystic ,pigmented, sclerosing or infiltrative. [1,2,3,4]
Skin lesion - palpation Fixation of the basal cell carcinoma deep to the skin is indicative of deep local invasion. [1,2]
Facial and trigeminal nerve examination Should be done in Patients with recurrent or deeply infiltrative tumors, to detect nerve involvement. This occurs very rarely. [1,2,3]
Lymphadenopathy Should be examined for lymphadenopathies due to possible regional or distant metastasis that can occur very rarely. (Posterior auricular, Parotid, Suboccipital, and upper cervical groups of lymph nodes)[1,2,4]
Ulceration Basal cell carcinoma ulcerate in the middle. Nodular sub type is more predisposed to ulceration. Ulcer is usually central, bleeds when traumatized and has rolled edges. [1,2,4]
Dermoscopic examination This is an non invasive adjunct to the physical examination that aids the diagnosis. The lesion is magnified 10-20 folds by the dermoscope. The first step is to differentiate the lesion according to the presence or absence of pigmentation. In a non-pigmented Basal Cell Carcinoma lack of pigmentation, arborizing telangiectasias, ulceration and short fine superficial telangiectasia may be observed. In a Pigmented basal cell carcinoma, lack of pigment network, large blue-gray ovoid nests, multiple blue-gray globules, leaf-like areas and spoke wheel areas are commonly evident. Shiny white to red areas are the specific feature of superficial basal cell carcinomas. [3,4,5]
References
  1. MACKIEWICZ-WYSOCKA MAłGORZATA, BOWSZYC-DMOCHOWSKA MONIKA, STRZELECKA-WęKLAR DARIA, DAńCZAK-PAZDROWSKA ALEKSANDRA, ADAMSKI ZYGMUNT. Reviews Basal cell carcinoma – diagnosis. wo [online] 2013 December, 4:337-342 [viewed 23 May 2014] Available from: doi:10.5114/wo.2013.35684
  2. JETLEY S, JAIRAJPURI ZS, RANA S, TALIKOTI MA. Adenoid basal cell carcinoma and its mimics. Indian J Dermatol [online] 2013 May, 58(3):244 [viewed 23 May 2014] Available from: doi:10.4103/0019-5154.110874
  3. PERES LP, FIORENTIN JZ, BAPTISTA TDA S, FUZINA DG, BLANCO LF. Clinical and histopathological profile of basal cell carcinoma in a population from Criciúma, Santa Catarina, Brazil. An Bras Dermatol [online] 2012 Jul-Aug, 87(4):657-9 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22892792
  4. TURAN E, YURT N, YEşILOVA Y, TüRKçü G. Early-onset basal cell carcinoma. Turk J Pediatr [online] 2013 May-Jun, 55(3):354-6 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24217088
  5. KEFEL S, GUVENC P, LEANDER R, STRICKLIN SM, STOECKER WV. Discrimination of basal cell carcinoma from benign lesions based on extraction of ulcer features in polarized-light dermoscopy images. Skin Res Technol [online] 2012 Nov, 18(4):471-5 [viewed 23 May 2014] Available from: doi:10.1111/j.1600-0846.2011.00595.x

Differential Diagnoses

Fact Explanation
Malignant melanoma Malignant melanoma is a neoplasm of melanocytes or their precursor cells. Usually asymmetrical very dark black or blue irregular lesions which can occur anywhere in the body. There is an associated lymphadenopathy. It may be familial and patient may have a past history of similar lesions. Individuals who easily tan are less likely to develop a melanoma. [1]
Melanocytic Nevi Melanocytic nevi are benign hamartomas or neoplasms composed of melanocytes. They may be flat or protruding and vary in color from pink or flesh tones to dark brown or black. They range in size from millimeters to several centimeters and mostly round or oval in shape. [2]
Bowen disease Bowen disease is a neoplastic skin disease which is considered as an early stage of squamous cell carcinoma. It is a gradually enlarging, well-demarcated erythematous plaque with an irregular border. It's surface crusting or scaling. [3]
Actinic Keratosis It a premalignant condition which may progress in to a squamous cell carcinoma. It initiates as a small, rough spots that are easier to palpate than inspect.With time, the lesion enlarges usually becoming red and scaly in appearance. Development of Actinic keratosis is induced by ultraviolet light. [4]
Molluscum contagiosum It is caused by a viral infection of the skin resulting a skin lesion which is flesh-colored, dome-shaped, and pearly in appearance. Molluscum contagiosum is highly prevalent in children, sexually active adults, and those who are immunodeficient. [5]
Dermatophytosis (Ring worm infection) Dermatophytosis is caused by a dermatophyte fungus that affects the stratum corneum and keratinized tissue such as nails and hair. It gives rise to typical enlarging raised red rings of ringworm. Involvement of the nails is termed onychomycosis. [6]
Eczema Eczema is an inflammation of the skin. It is characterized by itchy, erythematous, vesicular, weeping, and crusting patches. [7]
Psoriasis Psoriasis is a common, chronic relapsing/remitting immune-mediated skin disease. The skin lesions are characterised by sharply demarcated erythrosquamous plaque which appears infiltrated and reddened as a clinical correlate of inflammation, and scaly as a sign of hyperparakeratosis. It is itchy in about two-thirds of patients. [8]
References
  1. ROSSETTO ANDRé LUIZ, CRUZ ROSANA Cé BELLA, HADDAD JUNIOR VIDAL. DOUBLE-BLIND STUDY WITH TOPICAL ISOCONAZOLE AND TERBINAFINE FOR THE TREATMENT OF ONE PATIENT WITH BILATERAL Tinea nigra plantaris AND SUGGESTIONS FOR NEW DIFFERENTIAL DIAGNOSIS. Rev. Inst. Med. Trop. Sao Paulo [online] 2013 April, 55(2):125-128 [viewed 18 May 2014] Available from: doi:10.1590/S0036-46652013000200011
  2. ROCHA CR, GRAZZIOTIN TC, REY MC, LUZZATTO L, BONAMIGO RR. Congenital agminated melanocytic nevus--case report. An Bras Dermatol [online] 2013 Nov-Dec, 88(6 Suppl 1):170-2 [viewed 18 May 2014] Available from: doi:10.1590/abd1806-4841.20132137
  3. WILMER EM, LEE KC, HIGGINS II W, CRUZ AP. Hyperpigmented palmar plaque: an unexpected diagnosis of Bowen disease. Dermatol Online J [online] 2013 Jun 15, 19(6):18573 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24011322
  4. IANHEZ M, FLEURY LF JR, MIOT HA, BAGATIN E. Retinoids for prevention and treatment of actinic keratosis. An Bras Dermatol [online] 2013 Jul-Aug, 88(4):585-93 [viewed 23 May 2014] Available from: doi:10.1590/abd1806-4841.20131803
  5. HOYT BS, TSCHEN JA, COHEN PR. Molluscum contagiosum of the areola and nipple: case report and literature review. Dermatol Online J [online] 2013 Jul 14, 19(7):18965 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24010511
  6. SILVEIRA-GOMES F, DE OLIVEIRA EF, NEPOMUCENO LB, PIMENTEL RF, MARQUES-DA-SILVA SH, MESQUITA-DA-COSTA M. Dermatophytosis diagnosed at the Evandro Chagas Institute, Par?, Brazil Braz J Microbiol [online] , 44(2):443-446 [viewed 24 May 2014] Available from: doi:10.1590/S1517-83822013005000049
  7. DARSOW U, RAAP U, STäNDER S, CARSTENS E, AKIYAMA T. Atopic Dermatitis [online] 2014 [viewed 24 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24830009
  8. MROWIETZ U, REICH K. Psoriasis--New Insights Into Pathogenesis and Treatment Dtsch Arztebl Int [online] 2009 Jan, 106(1-2):11-19 [viewed 24 May 2014] Available from: doi:10.3238/arztebl.2009.0011

Investigations - for Diagnosis

Fact Explanation
Skin biopsy Skin biopsy gives the confirmation of the diagnosis. Furthermore it determine the histological subtype which may important in the future management. Skin biopsy can be obtained by several methods and shave biopsy is the simplest. Shave biopsy is the most commonly used technique as it is easy to perform and cosmesis, and cost-effectiveness. A superficial shave removes a thin disk of tissue by a scalpel, a double-edged razor blade, or scissors. [1,2,3] Excisional or punch biopsy is occasionally needed to differentiate pigmented basal cell carcinoma and melanoma. [1,2] Distinguishing histological features of basal cell carcinomas are thinned or ulcerated epidermis, basaloid tumour cells budding from epidermis or follicles, peripheral palisading of nuclei and mucinous stroma. [1,2,3,4]
Cytology It is an alternative diagnostic method for skin biopsy though the sensitivity remains comparatively low. [1,2,3]
Ultrasonography High frequency ultrasonography gives a non-invasive three-dimensional assessment of the basal cell carcinoma. This important in planning the treatment. But it is rarely done.[5]
References
  1. PICKETT H. Shave and punch biopsy for skin lesions. Am Fam Physician [online] 2011 Nov 1, 84(9):995-1002 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22046939
  2. FIRNHABER, J.M. Diagnosis and Treatment of Basal Cell and Squamous Cell Carcinoma, Am Fam Physician [online] . 2012 Jul 15,86(2),161-168. [viewed 23 May 2014] Available from: http://www.aafp.org/afp/2012/0715/p161.html
  3. PERES LP, FIORENTIN JZ, BAPTISTA TDA S, FUZINA DG, BLANCO LF. Clinical and histopathological profile of basal cell carcinoma in a population from Criciúma, Santa Catarina, Brazil. An Bras Dermatol [online] 2012 Jul-Aug, 87(4):657-9 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22892792
  4. MACKIEWICZ-WYSOCKA MAłGORZATA, BOWSZYC-DMOCHOWSKA MONIKA, STRZELECKA-WęKLAR DARIA, DAńCZAK-PAZDROWSKA ALEKSANDRA, ADAMSKI ZYGMUNT. Reviews Basal cell carcinoma – diagnosis. wo [online] 2013 December, 4:337-342 [viewed 23 May 2014] Available from: doi:10.5114/wo.2013.35684
  5. WORTSMAN X. Sonography of facial cutaneous basal cell carcinoma: a first-line imaging technique. J Ultrasound Med [online] 2013 Apr, 32(4):567-72 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23525381

Investigations - Screening/Staging

Fact Explanation
Skin biopsy and ultrasonograpy in suspicion of infiltration. Staging is only done in the rare occasions which the local tumor becomes invasive. Stage 0: Involves only the epidermis (no dermal involvement) Stage I: Less than 2 cm and has not spread to the other organs or lymph nodes. Stage II: More than 2 cm and has not spread to the other organs or lymph nodes. Stage III: Spread to tissues ( muscle, bone, cartilage), and/or regional lymph nodes involvement but not spread to other organs. Stage IV: Cancer of any size and has spread to other organs. [1]
References
  1. DICKSON PV, GERSHENWALD JE. Staging and prognosis of cutaneous melanoma. Surg Oncol Clin N Am [online] 2011 Jan, 20(1):1-17 [viewed 23 May 2014] Available from: doi:10.1016/j.soc.2010.09.007

Management - General Measures

Fact Explanation
Patient education and prevention Excessive sun exposure, Radiation and arsenic exposure are the possible etiologies which should be avoided to prevent of basal cell carcinoma. In patients with recurrence tendency, it is advisable to perform self examination frequently. Wearing sunglasses, applying sun screen before excessive sun exposure, Limiting the time outdoors when the sun is at its peak, Wearing long pants, a shirt with long sleeves are protective measures. [1,2,3]
References
  1. FIRNHABER, J.M. Diagnosis and Treatment of Basal Cell and Squamous Cell Carcinoma, Am Fam Physician [online] . 2012 Jul 15,86(2),161-168. [viewed 23 May 2014] Available from: http://www.aafp.org/afp/2012/0715/p161.html
  2. LAZOVICH D, CHOI K, VOGEL RI. Time to get serious about skin cancer prevention. Cancer Epidemiol Biomarkers Prev [online] 2012 Nov, 21(11):1893-901 [viewed 24 May 2014] Available from: doi:10.1158/1055-9965.EPI-12-0327
  3. AL-NAGGAR RA. Practice of skin cancer prevention among road traffic police officers in Malaysia. Asian Pac J Cancer Prev [online] 2013, 14(8):4577-81 [viewed 24 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24083705

Management - Specific Treatments

Fact Explanation
Curettage and electrodesiccation This method is best suited for nodular, or ulcerative tumors less than 1cm in size, but does not apply for infiltrative lesions. Curet is used to remove tumor and to firm the dermis under anaesthesia. Electrodessication follows and curettage repeated and the cycle is repeated again. Eschar usually separates in 2-3 weeks and healing occurs shortly afterwards. This method does not cause aesthetic impacts. Delayed healing, hypopigmentation and hypertrophic scars are the rare complications. [1,2,3]
Excisional surgery Excisional surgery is appropriate to remove the tumor. A wide excision or the removal of extra normal skin around the tumor may be recommended in some cases. Lack of normal tissue conservation is a disadvantage of this method. Tumors at low or moderate risk of recurrence are preferred to undergo excisional surgery.[1,2]
Mohs surgery Margins are controlled microscopically. It is highly accurate method which conserves normal tissue. [4]
Cryosurgery Cryotherapy is an appropriate treatment for nodular and superficial basal cell carcinoma. Biopsy is essential prior to the procedure as the determination of the depth of the tumor is important. Cryotherapy is not indicated for tumors that are more than 3 mm deep. Liquid nitrogen is used to freeze the tumor and 5 mm area of normal tissue for 30 seconds. It has a high cure rates when used correctly. [1,2,3,5]
Radiotherapy Low penetration irradiation is used to treat basal cell carcinoma in eyelids, nares, mouth, deltoid or sternal or in older patients with large tumors. [1,2,6]
Carbon Dioxide Laser Usually used for superficial tumors. This method is considered when bleeding diathesis is present because bleeding is unusual. Laser therapy is often used for tumors on the lip, face or scalp because it provides surgeons with greater control over the depth of skin that is removed. [1,2,6]
Photodynamic therapy This method is best used for tumors on the face and scalp or if individuals have multiple lesions. A topical treatment is applied on skin. That agent is activated by a strong light. The treatment destroys cancer while sparing surrounding tissue. 5-Aminolevulinic acid is the most used photoactive agent. This therapy can be administered orally or parenterally except for topical application. [1,2,3,5,7]
Biological therapy (Immunotherapy) Topical application of Interferon Alpha has been found effective in smaller lesions. Interferon and interleukin-2 are under study to treat melanoma and non melanoma skin cancers. They stimulate immune system against the tumor cells. Imiquimod is another drug that is for this therapy. [1,2]
5-fluorouracil 5% cream Topical 5-fluorouracil 5% cream is one of␣the treatment modalities for non-melanoma skin cancer. It is used to treat small and superficial lesions. Its use for other sub types is not recommended as it may not penetrate deeply enough. [8]
References
  1. WILLIAMSON GS, JACKSON R. Treatment of Basal Cell Carcinoma by Electrodesiccation and Curettage Can Med Assoc J [online] 1962 May 12, 86(19):855-862 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1849182
  2. FIRNHABER, J.M. Diagnosis and Treatment of Basal Cell and Squamous Cell Carcinoma, Am Fam Physician [online] . 2012 Jul 15,86(2),161-168. [viewed 23 May 2014] Available from: http://www.aafp.org/afp/2012/0715/p161.html
  3. MACKIEWICZ-WYSOCKA MAłGORZATA, BOWSZYC-DMOCHOWSKA MONIKA, STRZELECKA-WęKLAR DARIA, DAńCZAK-PAZDROWSKA ALEKSANDRA, ADAMSKI ZYGMUNT. Reviews Basal cell carcinoma – diagnosis. wo [online] 2013 December, 4:337-342 [viewed 23 May 2014] Available from: doi:10.5114/wo.2013.35684
  4. CHAGAS FS, SANTANA SILVA BD. Mohs micrographic surgery: a study of 83 cases. An Bras Dermatol [online] 2012 Mar-Apr, 87(2):228-34 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22570026
  5. CHIRIAC A, MIHAILA D, FOIA L, SOLOVAN C. Basal cell carcinomas in elderly patients treated by cryotherapy. Clin Interv Aging [online] 2013:341-4 [viewed 23 May 2014] Available from: doi:10.2147/CIA.S42174
  6. SHOKROLLAHI K, MARSDEN NJ, WHITAKER IS, JAMES W, MURISON MS. Basal cell carcinoma treated successfully with combined CO2 laser and photodynamic therapy in a renal transplant patient: a case report. Cases J [online] 2009 Aug 11:7920 [viewed 23 May 2014] Available from: doi:10.4076/1757-1626-2-7920
  7. WILSON BD, MANG TS, STOLL H, JONES C, COOPER M, DOUGHERTY TJ. Photodynamic therapy for the treatment of basal cell carcinoma. Arch Dermatol [online] 1992 Dec, 128(12):1597-601 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1456752
  8. VAN RUTH S, JANSMAN FG, SANDERS CJ. Total body topical 5-fluorouracil for extensive non-melanoma skin cancer Pharm World Sci [online] 2006 Jun, 28(3):159-162 [viewed 24 May 2014] Available from: doi:10.1007/s11096-006-9030-x