BCC
Friday, January 12, 2024 1:12 PM
Basal cell carcinoma
• Originate in keratinocytes in the stratum Basale where the cells are dividing
• Locally invasive
• Most common malignant skin tumour
• Very slow growing (develop over months/years)
• Most common over the head and neck (80%)
• Rarely metastasise
• Main risk factor -
○ UV light exposure
○ Many foreign holidays or living abroad
○ History of frequent or serious sun burn
○ Outdoor occupations and/or hobbies
○ Excess use of sun beds
• Specific risk factors for BCC: age (most common in elderly/middle aged)
○ Male sex
○ Age - very common in older people
○ Genetic - albinism, xeroderma pigmentosa, certain mutations
○ Immunosuppression - AIDS and transplant patients
○ Previous skin cancers
○ Fitzpatrick skin types 1 and 2
○ Gorlin's syndrome - aka nevoid basal cell carcinoma syndrome (NBCCS)- increases risk of
deveoping BCCS.
▪ Rare autosomal dominant condtion.
▪ Normally begin to develop BCC in early adulthood or adolescence
▪ Has many other clinical features e.g. Broad nasal root
○ Carcinogens - ionising radiation, arsenic (especially multiple superficial BCC),
hydrocarbons
Presentation:
• Painless lesion with many different morphologies:
○ Nodular - most common (60-80%)
▪ Generally small and skin coloured or pinkish
▪ Dome shaped nodules
▪ Central depression
▪ Most common on the forehead, temples, nose and upper lip (sun exposed areas)
▪ Telangiectasia - surface telangiectasia
□ Especially on the rolled edges
▪ Ulceration - if they develop an ulcerated or necrotic centre, they are called Rodent
ulcers
□ Common if older
□ Can become necrotic
▪ Rolled edges - characteristic pearly rolled edges
▪ Pearlescent appearance or sheen (pearly edges)
○ Superficial - scaly irregular erythematous plaque with clear rolled border. May have
micro erosions. Slightly raised. Most common in younger people. 10%-20% of BCC
○ Basosquamous - more aggressive.
▪ Bit of a combination of BCC and SCC (5%).
▪ Quick growing
▪ Potentially metastatic so needs to be removed
▪ Can bleed and ulcerate
Lesions Page 1
, ▪ Can bleed and ulcerate
▪
○ Morphoeic - rare and normally more invasive (5%).
▪ Poorly demarcated thickened patch of skin
▪ Irregular borders, waxy scar like plaque
○ Pigmented - blue/black very rare (5%).
▪ Difficult to distinguish from melanoma so excised like a melanom
○ Cystic
○ Keratotic
• Bleeding and ulceration is rare and indicates more severe lesion
• Very slow growing lesion
There is a very low metastatic potential but there is a risk of local invasion
Very slow development and increase in size
Management of BCC
• Conservative - watch and wait
Lesions Page 2
, • Conservative - watch and wait
○ Very low risk of local invasion so low metastatic potential
○ Conservative is common in older people because BCCs rarely become malignant
• Wide local excision with biopsy - gold standard investigation/diagnosis and management.
• For tumours/lesions <2cm in size
▪ Larger lesions require Moh's micographic surgery to ensure you have removed the
entire lesion
• Need at least 3-5mm margins
• Need to excise deep enough through the skin to see the hypodermis
▪ Cancerous cells are in the basal layer
▪ Take a small cuff of ft
• Curettage +/- cautery - scraping away the surface, cauterise, scrape etc. Done 3 times.
• Normally only for really superficial low risk lesions becuse there is no sample to
examine to ensure you have clear margins
• Imiquimod is a topical agent which is sometimes used for very superfiial lesions
• Not commonly used
• Cryotherapy - used for superficial lesions
• Using liquid nitrogen to "burn off" the BCC
• MOHs micrographic surgery
• Used in cosmetically sensitive location (e.g. Ears, faces)
• Excise lesion -> send for examination under microscopy -> see if there are clear
margins -> keep excising until there are clear margins
• After you have excised the whole tumour, surgical reconstruction of the region
• Can also be used in very large ill defined lesion where you can't be sure you have
excised it all
• Not done in every centre though
• Radiotherapy - normally just for adjuvant therapy to prevent recurrence, in recurrent BCC or
in high risk patients or areas where surgery isn't appropriate (e.g. Too large to be resected)
Features of a high risk BCC
○ >2cm
○ Around the eyes, nose lips or ears
○ Poorly defined margins
○ Morphoeic, basosquamous or highly infiltrative
○ Patient is immunosuppressed
○ Previous treatment failure
○ Perivascular or perineural invasion
Lesions Page 3
Friday, January 12, 2024 1:12 PM
Basal cell carcinoma
• Originate in keratinocytes in the stratum Basale where the cells are dividing
• Locally invasive
• Most common malignant skin tumour
• Very slow growing (develop over months/years)
• Most common over the head and neck (80%)
• Rarely metastasise
• Main risk factor -
○ UV light exposure
○ Many foreign holidays or living abroad
○ History of frequent or serious sun burn
○ Outdoor occupations and/or hobbies
○ Excess use of sun beds
• Specific risk factors for BCC: age (most common in elderly/middle aged)
○ Male sex
○ Age - very common in older people
○ Genetic - albinism, xeroderma pigmentosa, certain mutations
○ Immunosuppression - AIDS and transplant patients
○ Previous skin cancers
○ Fitzpatrick skin types 1 and 2
○ Gorlin's syndrome - aka nevoid basal cell carcinoma syndrome (NBCCS)- increases risk of
deveoping BCCS.
▪ Rare autosomal dominant condtion.
▪ Normally begin to develop BCC in early adulthood or adolescence
▪ Has many other clinical features e.g. Broad nasal root
○ Carcinogens - ionising radiation, arsenic (especially multiple superficial BCC),
hydrocarbons
Presentation:
• Painless lesion with many different morphologies:
○ Nodular - most common (60-80%)
▪ Generally small and skin coloured or pinkish
▪ Dome shaped nodules
▪ Central depression
▪ Most common on the forehead, temples, nose and upper lip (sun exposed areas)
▪ Telangiectasia - surface telangiectasia
□ Especially on the rolled edges
▪ Ulceration - if they develop an ulcerated or necrotic centre, they are called Rodent
ulcers
□ Common if older
□ Can become necrotic
▪ Rolled edges - characteristic pearly rolled edges
▪ Pearlescent appearance or sheen (pearly edges)
○ Superficial - scaly irregular erythematous plaque with clear rolled border. May have
micro erosions. Slightly raised. Most common in younger people. 10%-20% of BCC
○ Basosquamous - more aggressive.
▪ Bit of a combination of BCC and SCC (5%).
▪ Quick growing
▪ Potentially metastatic so needs to be removed
▪ Can bleed and ulcerate
Lesions Page 1
, ▪ Can bleed and ulcerate
▪
○ Morphoeic - rare and normally more invasive (5%).
▪ Poorly demarcated thickened patch of skin
▪ Irregular borders, waxy scar like plaque
○ Pigmented - blue/black very rare (5%).
▪ Difficult to distinguish from melanoma so excised like a melanom
○ Cystic
○ Keratotic
• Bleeding and ulceration is rare and indicates more severe lesion
• Very slow growing lesion
There is a very low metastatic potential but there is a risk of local invasion
Very slow development and increase in size
Management of BCC
• Conservative - watch and wait
Lesions Page 2
, • Conservative - watch and wait
○ Very low risk of local invasion so low metastatic potential
○ Conservative is common in older people because BCCs rarely become malignant
• Wide local excision with biopsy - gold standard investigation/diagnosis and management.
• For tumours/lesions <2cm in size
▪ Larger lesions require Moh's micographic surgery to ensure you have removed the
entire lesion
• Need at least 3-5mm margins
• Need to excise deep enough through the skin to see the hypodermis
▪ Cancerous cells are in the basal layer
▪ Take a small cuff of ft
• Curettage +/- cautery - scraping away the surface, cauterise, scrape etc. Done 3 times.
• Normally only for really superficial low risk lesions becuse there is no sample to
examine to ensure you have clear margins
• Imiquimod is a topical agent which is sometimes used for very superfiial lesions
• Not commonly used
• Cryotherapy - used for superficial lesions
• Using liquid nitrogen to "burn off" the BCC
• MOHs micrographic surgery
• Used in cosmetically sensitive location (e.g. Ears, faces)
• Excise lesion -> send for examination under microscopy -> see if there are clear
margins -> keep excising until there are clear margins
• After you have excised the whole tumour, surgical reconstruction of the region
• Can also be used in very large ill defined lesion where you can't be sure you have
excised it all
• Not done in every centre though
• Radiotherapy - normally just for adjuvant therapy to prevent recurrence, in recurrent BCC or
in high risk patients or areas where surgery isn't appropriate (e.g. Too large to be resected)
Features of a high risk BCC
○ >2cm
○ Around the eyes, nose lips or ears
○ Poorly defined margins
○ Morphoeic, basosquamous or highly infiltrative
○ Patient is immunosuppressed
○ Previous treatment failure
○ Perivascular or perineural invasion
Lesions Page 3
