Basal cell carcinoma (BCC), previously known as basal cell epithelioma, is the most common cancer in Humans. BCC mostly arises on sun-damaged skin and rarely develops on the mucous membranes or palms and soles. Basal cell carcinoma is usually a slow-growing tumor for which metastases are rare. Although rarely fatal, BCC can be highly destructive and disfigure local tissues when treatment is inadequate or delayed. On clinical examination, BCC usually appears as flesh- or pink-colored, pearly papules with overlying ulceration or telangiectatic vessels. BCC occurs on the head or neck in the majority of cases.
More than 26 different subtypes of BCC are described in the literature, but most dermatologists agree on four major, distinctive, clinicopathologic types: (1) nodular, (2) superficial, (3) morpheaform, and (4) fibroepithelial (also known as fibroepithelioma of Pinkus). Combinations of the these four types with nodular BCC can occur as well. The majority of BCCs are amelanotic, but variable amounts of melanin may be present within these tumors.
The current mainstay of BCC treatment involves surgical modalities such as excision, electrodesiccation and curettage (EDC), cryosurgery, and Mohs micrographic surgery. Such methods are typically reserved for localized BCC and offer high 5-year cure rates, generally over 95%.
The prime etiological factor in the development of basal cell carcinoma is exposure to UV light, particularly the UVB wavelengths but also the UVA wavelengths. A detailed review of the literature with meta-analysis and sensitivity analysis show a significantly higher risk for outdoor workers, with an inverse relationship between occupational UV exposure and BCC risk with latitude. The Fitzpatrick skin type is a good predictor of relative risk of BCC among whites.
Cumulative UV dose and skin type are not sole predictors; exposure duration and intensity, particularly in early childhood and adolescence, also plays a role in BCC development. Recreational sunlight exposure and the use of indoor tanning salons is a contributing factor for the development of BCCs. UV light therapy may also lead to BCC occurrence. Intermittent intense sun exposure, as identified by prior sunburns; a positive family history of BCC; a fair complexion, especially red hair; easy sunburning (skin types I or II); and blistering sunburns in childhood are also risk factors for the development of BCC.
Ultraviolet light exposure is not the only risk factor as 20% of BCC arise on non–sun-exposed skin. BCCs occur also due to a variety of other factors such as ionizing radiation exposure, arsenic exposure, immunosuppression, and genetic predisposition. Some genetic syndromes associated with an increased risk of BCCs are xeroderma pigmentosum, basal cell nevus syndrome (also known as Gorlin syndrome), Bazex–Dupre–Christol syndrome, and Rombo syndrome.
There is no association with diet, but smoking also appears to be a risk factor in females.
BCC is the most common skin cancer in humans, with increasing incidence rates worldwide. Men generally have higher rates of BCC than women. BCC is more frequent in geographic locations with greater UV exposure such as those at higher or lower latitudes. The most common predictor of BCC development is a history of squamous cell carcinoma (SCC) or BCC. Patients are at least ten times more likely to develop a second BCC if they have a BCC history compared to patients without a history of non-melanoma skin cancer.
Over the last 30 years, estimated incidence rates have risen between 20% and 80%. Incidence rates for BCC also increase with age, with the median age of diagnosis being 68 years. Mortality from BCC is uncommon and occurs primarily in immunocompromised patients. Metastatic BCC (1%) is more likely attributed to tumors with aggressive histopathologic patterns (morpheaform, metatypical, basosquamous, infiltrating,). If a BCC does metastasize, it often involves regional lymph nodes, bone, lungs, and skin. The mean age at the time of death is higher than with SCC, and the age-adjusted mortality rate for BCC has been estimated at 0.12 per 100 000. Mortality risk is related to increasing age, male gender (greater than twice the rate of occurrence when compared with women), and Caucasian phenotype.
Chronic sun exposure is one of the most important risk factors for the development of BCC. BCCs typically have a delay of diagnosis of about 15 to 20 years between the time of UV damage and clinical onset. 
The mechanism of BCC formation via ultraviolet radiation is by direct DNA damage, indirect DNA damage through reactive oxygen species, and immune suppression. Melanin absorbs UVA and indirectly damages DNA through free radicals. UVB directly damages DNA and RNA with a characteristic C/T or CC/TT transition. Ultraviolet exposure also causes dose-dependent suppression of the cutaneous immune system, impairing immune surveillance of skin cancer.
Literature suggests that the cell of origin from which BCC arises are immature, pluripotent cells associated with the hair follicle. Of note, the gene most often altered in BCCs is the PTCH1 gene. PTCH1 gene mutations occur in 70% of people with sporadic BCC. Ten percent to 20% of people with sporadic BCC have smoothened (SMO) mutations. Literature suggests that a sufficiently elevated expression level of Gli, by activating mutations of SMO or by homozygous inactivation of PTCH1 in a responding cell is sufficient to drive the formation of BCC. The second most common mutation found in BCCs are in the P53 gene. Mutations in CDKN2A locus also have been detected in a smaller number of sporadic BCCs.
The characteristic feature seen in BCCs is islands or nests of basaloid cells, with cells palisading at the periphery in a haphazard arrangement in the centers of the islands. Each of these small pleomorphic cells is composed of a basophilic nucleus without a discernible nucleolus and scanty cytoplasm. Retraction artifact, also referred to as clefting, usually is seen between the tumor and its surrounding stroma on paraffin-embedded sections. Mucin deposition may be present within the tumor and in the stroma around the tumor. Mitotic figures also may be present. Perineural growth, also known to as perineural invasion, can be an indicator of aggressive disease.
The histologic differential diagnosis may include trichoepithelioma or trichoblastoma. Various morphological subtypes have been defined, including nodular (solid), micronodular, superficial, cystic, infiltrating, infundibulocystic, pigmented, adenoid, sclerosing, metatypical, basosquamous, and fibroepitheliomatous. Mixed patterns of the above listed types are also common.
Many clinical variants of BCC exist, but the most recognized types are superficial, nodular, and morphea-like BCC. Nodular BCC is the most common.
BCC typically presents as a shiny, pink- or flesh-colored papule or nodule with surface telangiectasia. The tumor may enlarge and ulcerate, giving the borders a rolled or rodent ulcer appearance. The most common sites for nodular basal cells are the face, especially the nose, cheeks, forehead, nasolabial folds, and eyelids. Patients often give a history of crusting and recurrent bleeding, causing them to seek evaluation. Pigmented nodular BCCs are more common in dark-skinned individuals.
Superficial BCCs present as a pink-red, scaly, macule or patch, which may contain telangiectasia. They have a predilection for the shoulders, chest, or back, and multiple lesions may be present. There are also pigmented variants of superficial BCC. Clinically, superficial BCC can appear similar to inflammatory dermatoses such as eczema or psoriasis, so one should consider the diagnosis of superficial BCC when faced with a persistent, erythematous, scaly plaque. Portions of superficial basal cell carcinomas can evolve into nodular BCC over time.
The other common clinical variant of BCCs is the morpheaform subtype. This tumor frequently presents as white- or flesh-colored and is slightly elevated to the even, depressed area of induration with ill-defined borders. Morpheaform BCCs may resemble a scar or plaque of morphea. The lesion's surface is typically smooth, although crusts with underlying erosions or ulcerations as well as superimposed papules may be observed. Telangiectasias also may be present. The biologic behavior is usually more aggressive, with extensive local destruction.
A skin biopsy is needed for clinical confirmation of BCC. A shave, punch, or excisional biopsy may be performed, taking care to include some portion of the dermis in the specimen to differentiate between superficial and other invasive histologic subtypes of BCC. It should be noted that punch and shave biopsy techniques are about 80% accurate in diagnosing the various subtypes of basal cell carcinoma.
A qualified practitioner should perform a complete skin examination is since individuals with one finding of skin cancer often have additional cancers or pre-cancers at other sites and have an increased risk of developing malignant melanoma. Documentation of the location of the lesions with photographs or digital images is recommended. There is a low threshold for obtaining skin biopsies in these patients. Preoperative imaging studies may be obtained when there is suspicion of the parotid gland, muscle, deep soft tissue, orbital, bone involvement, or perineural invasion. Patients with a history of BCC should have long-term, even lifetime, follow-up, particularly those with multiple or high-risk tumors.
Dermoscopy can be beneficial to the experienced clinician, aiding in the diagnosis of non-pigmented and pigmented BCCs. The hallmark of BCC on dermoscopy is the presence of well-focused arborizing vessels. Additional findings include multiple blue-gray globules, leaf-like structures, large blue-gray ovoid nests, and spoke-wheel areas. There is no pigment network, as one would see with dermoscopy of pigmented lesion.
Therapy selection depends on the patient's age and gender as well as the site, size, and type of lesion. No single treatment method is ideal for all lesions or all patients. A biopsy should be performed in all patients with suspected BCC to determine the histologic subtype and confirm the diagnosis. The main goals of BCC treatment are (1) to completely remove the tumor to prevent recurrence at a later date, (2) to correct any functional impairment resulting from the tumor, and (3) to give the best cosmetic result to the patient, especially because most BCCs are on the face.
Treatment of BCC is usually surgical, but some forms of BCC are amenable to medical treatment or radiation therapy. The various types of therapy include Mohs micrographic surgery (MMS), standard surgical excision, EDC, radiation, photodynamic therapy, cryosurgery, topical therapies, and systemic medications such as Vismodegib. The recurrence rates for primary BCC are as follows: Mohs surgery, 1.0%; surgical excision, 10.1%; EDC, 7.7%; radiation therapy, 8.7%; and cryosurgery, 7.5%.
Mohs surgery provides the best long-term cure rate of any treatment modality for BCC. MMS is the gold standard for treatment of high-risk BCCs and recurrent BCCs because of its high cure rate and tissue-sparing benefit. The high cure rate is attributed to an examination of all the tissue margins when compared with standard vertical sectioning, with an examination of less than 1% of the outer peripheral and deep margins. By only taking thin tissue layers from the areas with positive tumor margins, the wound size is minimized and a superior cosmetic outcome can be expected.
Postoperative pathologic analysis with permanent sections follows standard surgical excision. Four-millimeter margins are typically adequate for well-circumscribed tumors that are less than 2 centimeters in diameter. For facial lesions, simple excision with narrow margins is often not adequate for effective removal. EDC is frequently used to treat low-risk BCCs. Cure rates as high as 97% to 98% have been reported, but the clinician should be cautious to select the appropriate cases (those without extension into the deep dermis). BCCs treated with EDC is the least expensive and fastest treatment method, but because they are left to heal by second intention the procedure commonly results in a white atrophic scar that can be cosmetically disfiguring.
Radiation therapy is a primary option for treating BCC or SCC if surgery is contraindicated. It also can be used as an adjuvant treatment for basal cell carcinoma when further surgery could sacrifice major nerves or other vital structures or there is a perineural invasion by cancer cells. The disadvantages to radiation therapy are the cost, poor cosmesis in some patients, a prolonged course of therapy (15 to 30 visits), and increased risk for future skin cancers. Scars from radiation therapy tend to worsen with time, while surgical scars improve over time.
Cryosurgery is another treatment option for low-risk BCCs and involves the controlled application of liquid nitrogen to the clinically visible tumor and a small surrounding margin of normal-appearing skin for margin control. A temperature probe is inserted at the lateral tumor margin and the tip is positioned position the tip just below the tumor by pushing it obliquely. Next, liquid nitrogen is applied and continued until a temperature of -60°C is reached. The procedure is advantageous for those wishing to avoid invasive surgery, and it is also a relatively quick. The treated area may be painful and swollen after it thaws. Cryosurgery also can cause hypertrophic scarring and permanent pigment alteration.
Topical therapy is another treatment for basal cell carcinoma. Topical 5-fluorouracil (5-FU) and Imiquimod 5% cream are approved by the Food and Drug Administration (FDA) for treatment of superficial BCC. Both topical therapies are good options in patients with multiple superficial BCCs and in patients who are poor surgical candidates. Application site reactions are common and include erythema, pruritus, pain, edema, hypopigmentation, hyperpigmentation, crusting, bleeding, and erosions. Another disadvantage is there no histologic confirmation of complete tumor clearance.
A more recent treatment for patients with advanced or metastatic BCC that cannot be treated with conventional therapeutic methods is the use of Hedgehog pathway inhibitors. Vismodegib was approved by the FDA in 2012. A second inhibitor, sonidegib, was also approved. The side effects of vismodegib and sonidegib can lead to discontinuation in up to 55% of patients. The most commonly reported adverse effects included nausea, dysgeusia, muscle spasm, alopecia, weight loss, diarrhea, and fatigue.
In certain populations, such as the immune suppressed, the elderly, and those with poor baseline functional status as well as cases of metastatic, advanced, recalcitrant, or cosmetically sensitive disease, nonsurgical management may be a desirable alternative.
The differential diagnosis of BCC includes adnexal tumors with follicular, sweat gland, or sebaceous differentiation as well as certain types of SCC. Nodular BCC may be confused with trichoblastoma or trichoepithelioma. Superficial BCC may mimick some inflammatory dermatoses such as psoriasis and eczema. Morphea-like BCC may be confused with a plaque of morphea or a scar. In these cases, histopathological helps establishing the diagnosis of BCC.
BCC is rarely associated with a fatal outcome. Its prognosis is mainly related to its potential risk of recurrence after initial therapy. The risk of recurrence depends on BCC location and BCC clinical and histopathological features.
BCC clinical and histopathological features
Include: the size, the histopathological type, and the fact that the tumor is primary or recurrent.
An evidence-based approach to basal cell cancer
Basal cell cancer is relatively common. Patients often first present to the primary care provider with complaints of an abnormal skin lesion. When diagnosed early, it has an excellent prognosis but if the diagnosis is delayed, the tumor can advance and lead to significant morbidity. Basal cell cancer is best managed by an interprofessional team that includes a dermatologist, plastic surgeon, nurse practitioner, primary care provider, and a dermatopathologist. Basal cells typically have a slow growth rate and tend to be locally invasive. Tumors around the nose and eye can lead to vision loss. In most cases, surgical excision is curative. However, because recurrences can occur, these patients need long-term follow up.
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