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Basal Cell Carcinoma

  1. Introduction
    Basal cell carcinoma is the most common malignant skin tumour. Three main clinical types of bcc are identifiable:
    1. Superficial BCC
      1. Nodular BCC: This may appears cystic, or may evolve into a "rodent ulcer".
        Infiltrative Form
      2. Infiltrative Morphoea-Form BCC
      3. Infiltrative Non-Morphea-Form BCC
  2. Natural History:
    1. Basal Cell Carcinoma
      1. The natural history of bcc is that of a slowly enlarging, locally invasive neoplasm. 
      2. The degree of local destruction and risk of recurrence vary with the size, duration, is location, and histologic subtype of the tumor; presence of recurrent re disease; and various patient characteristics.
      3. Location on the central n, face, ears, or the scalp may portend a higher risk. Small nodular, pigmented, cystic, or superficial bccs respond well to most treatments. G- large lesions or morpheaform subtype may be more aggressive.
      4. The or metastatic potential of bcc has been estimated to be 0.0028 to 0.1 % of persons with either bcc or scc have an increased risk of developing subsequent skin cancers, estimated to be up to 40% in 5 years.
    2. Treatment
      The Treatment Goals Are:
      1. Common Treatments:
        1. Curettage And Desiccation
          • Surgical Excision
          • Mohs Surgery
          • Cryosurgery
        2. Radiotherapy
        3. Evolving Treatments: Interferon, Photodynamic Therapy, Oral Retinoids, 5-Fluorouracil.
      2. Choosing The Modality Will Depend On:
        1. Tumour Factor: BCC Are Considered To Be High Risk If:
          1. Recurrent,
          2. Size Greater Than 1 To 2 Cm,
          3. Long Duration, Fast Growth,
          4. Indistinct Margins,
          5. Aggressive Histological Pattern.
            High Risk Sites:
            Nose Eyelids, Ears, Medial Canthus, Nasolabial Fold, Scalp, Lip, Fingers, Toes, Genitals.
        2. Patient Factors: Age, Medical Status, Psychological Factors, Concomitant Medications.
        3. Availability Of The Expertise And Facilities.
  3. Treatment
    1. Surgical Treatment
      1. Excision
        1. This is useful for both primary and recurrent lesions, and it enables histological examination of surgical margins. In good hands, cure rates approaches 95%. Cure rate >99% if margins histologically negative.
        2. For lesion size more than 1.5 cm or in critical cosmetic sites, other modalities e.g. Mohs surgery, radiotherapy, or excision by plastic surgeon with frozen-section control are more preferrable.
      2. Curettage And Electrosurgery
        Commonly Used For Tumour Size Less Than 1.5 Cm. Cure Rate Approaches 95% In Good Hands. This Is Not The Appropriate Treatment For Infiltrative Lesion And Recurrent Lesions In Scar Tissue.
      3. Cryosurgery
        Useful In Primary Tumour And Sometimes In Recurrent Lesion, And Especially Useful In Patients With Multiple Small Lesions. Curettage Is Done To Debulk The Lesion Before Freezing. Local Anaesthesia Is Not Needed And There Is No Bleeding And Scarring May Be Less Than It Is With Surgery. No Tissue Is Available For Histological Confirmation And Healing Takes Several Weeks. Tissue Needs To Frozen 4-6 Mm Beyond The Clinical Border . Thermo-Couples Are Necessary For Larger Lesions And This Method Is Not Suitable For Infiltrative Lesions.
      4. Mohs Micrographic Surgery (MMS)
        The Technique Is Recommended For Recurrent, Large, Difficult Tumour, If It Is Available. MMS, A Specialized Type Of Surgical Excision That Permits The Best Histologic Control And Preservation Of Uninvolved Tissue, Is Associated With Cure Rates > 98%.
      5. Laser Surgery
  4. Non-Surgical Treatment
    1. Radiation Therapy
      This is useful for definitive treatment of primary and recurrent tumour and for palliation of inoperable lesions. It is painless, without postoperative scarring. Potentially carcinogenic, it should be reserved for the older patients. It provides no margin control and radiation dermatitis may develop.
    2. Topical 5-fluorouracil therapy should be limited to superficial BCC. New lines of topicals, the immune modulators, show promise in their efficacy at treating superficial and even nodular BCCs.
      (C) Imiquimod, a relatively well-tolerated cream, has successfully undergone phase III clinical trials. (D) Intralesional chemotherapy (5-fluorouracil and interferon) and photodynamic therapy (which employs selective activation of a photoactive drug by visible) have been used successfully.

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