Basal cell carcinoma ( BCC )

Definition –BCC is a slow growing , locally invasive malignant epidermal skin
 tumour predominantly affecting Caucasians

Epidemiology

Most common cancer in Europe , Australia and US Incidence increasing worldwide & shows marked geographical variation
Accurate incidence figures difficult to obtain ( under-reported )
Reflects effects of UVB radiation and ethnicity ( on BCC pathogenesis ) Non-melanoma skin cancer NMSC
Together with cutaneous squamous cell carcinoma form the bulk of NMSCs Rarely metastisizes Men generally have higher rates Uncommon in dark-skinned people and rare before age 20 Typically a neoplasm of the elderly ( median age 68 yrs )

Risk factors

Tends to arise in sun exposed areas of the head and neck
Commonest peri-ocular malignancy Sun exposure in childhood may be important Positive family history Increasing age Male sex Fair skin types I and II ( Fitzpatrick skin type ) Immunosuppression History of previous BCC Arsenic exposure Individual suffering from haematological diseases Hereditary conditions as 
○ nevoid basal cell nevus ( Gorlin-Goltz syndrome )
○ Bazex- Spiegler syndrome
○ abinism High dietary fat intake Smoking also appears to be a risk factor

Aetiology

Multifactorial UV radiation- direct DNA damage , indirect DNA damage through reactive oxygen species and immune suppression DNA mutations in the patched ( PTCH ) tumour suppressor gene – part of hedgehog signaling pathway Complex interaction between duration and intensity of exposure to UV radiation and polymorphic genes

Presentation

Slow growth 80 % occur in head and neck- rest in trunk and lower limbs Intermittent bleeding and scab formation Does not cause pain or itching Skin coloured , pink or pigmented , translucent or pearly – dilated vessels telengiectasis may be seen Size can vary from fe millimeters to several centimeters Classical- rodent ulcer – indurated edges and ulcerated centre

Differentials

Squamous cell carcinoma Malignant melanoma Melanocytic naevi Bowen’s disease Psoriasis Eczema Sebaceous hyperplasia Molluscum contagiosum Chalazion Keratoacanthoma Papilloma

Nodular BCC

Most common type Shiny pearly nodule with a smooth surface Slow growing Progressively ulcerates Prominent telengiectasia Classically described as rodent ulcer Aggressive subtypes
○ micronodular
○ microcystic
○ infiltrative

Superficial BCC

Well defined patch or plaque but can be ill defined Upper trunk and limbs Slowly enlarging scaly red plaque with central erosion and delicate thin rolled borders Multiple microerosions

Morpheic /Infiltrative

More aggressive natural history Ill defined borders Waxy , scar-like plaque with indistinct borders Diagnosis not always clinically evident Usually found in head and neck region High recurrence rate

Fibroepithelial

Mixed BCC and SC Infiltrative growth pattern – more aggressive than BCC May metastasize Also known as Fibroepithelioma of Pinkus

Prognostic factors

Tumour size Tumour site Definition of clinical margin Histological subtype Histological features Failure of previous treatment Immunosuppression

National Comprehensive Cancer Network ( NCCN ) stratifies BCCs into low and high risk subtypes based on location , size, borders , recurrence , immunosuppression , site of prior radiation treatment , pathological subtype and evidence of perineural involvement 
( A suture-reinforced scleral sling. Technique for suspension of the ptotic upper lid. Helveston EM , Wislon DL Arch Ophthalmol . 1975 Aug;93(8):643-5 )

Management

Surgical –Curettage + electrodessication (EDC) Cautery Cryosurgery Standard excision Moh’s microsurgery ( MMS )

High 5 yr cure rate of over 95 %

Non-surgical –Radiation therapy Photodynamic therapy Topical immunotherapy
Imiquimod 5 % cream
5-Fluorouracil Smoothened inhibitors e.g Vismodegib

NICE guidance BCC

Consider routine referral for people if they have
 skin lesion that raises 
the suspicion of BCC

Only consider a suspected cancer pathway referral for people with a skin lesion that raises suspicion of a BCC if there is particular concern that a delay may have a significant impact because of factors such as lesion site or size

LINKS AND RESOURCES

PATIENT INFORMATION

British Association of Dermatologists http://www.bad.org.uk/for-the-public/patient-information-leaflets/basal-cell-carcinoma

Skin Cancer Foundation on BCC https://www.skincancer.org/skin-cancer-information/basal-cell-carcinoma/

A valuable patient resource from the British Skin Foundation https://www.britishskinfoundation.org.uk/bcc

Cancer Org – excellent work on BCC treatment https://www.cancer.org/cancer/basal-and-squamous-cell-skin-cancer/treating/basal-cell-carcinoma.html

Cancer Council Australia poster on skin cancers https://www.cancer.org.au/content/pdf/Factsheets/MS%20214%20CCA%20MELANOMA%20POSTER%20V4%20.pdf

American Society of Clinical Oncology 2 page PIL on BCC https://www.cancer.net/sites/cancer.net/files/asco_answers_basal_cell_carcinoma.pdf

National Cancer Institute a complete guide to treatment of BCC for the patient https://www.cancer.gov/types/skin/patient/skin-treatment-pdq

A comprehensive patient resource on skin cancer https://www.skcin.org/

INFORMATION FOR CLINICIANS

Dermnetz BCC is an important resource with images https://dermnetnz.org/topics/basal-cell-carcinoma/

A short but very useful differential diagnosis – from GP Online https://www.gponline.com/differential-diagnosis-examine-pictures-bcc-bowens-disease-actinic-keratosis-psoriasis/dermatology/article/1190506

 

BCC Learning module from the American Academy of Dermatology https://www.aad.org/member/education/residents/bdc/bcc

Wish to know more?  Read the full guideline on BCC management from the Journal of American Academy of Dermatology https://www.jaad.org/article/S0190-9622(17)32529-X/fulltext

Diagnosis and treatment of basal cell carcinoma: European consensus–based interdisciplinary guidelines Peris, Ketty et al. European Journal of Cancer, Volume 118, 10 – 34 https://www.ejcancer.com/article/S0959-8049(19)30362-4/abstract

Guidelines of care for the management of basal cell carcinoma J Am Acad Dermatology https://www.ncbi.nlm.nih.gov/pubmed/29331385#

 

References

1. Basal cell carcinoma: Epidemiology, clinical and histologic features, and basic science overview.Prieto-Granada C, Rodriguez-Waitkus P. Curr Probl Cancer. 2015 Jul-Aug;39(4):198-205. doi: 10.1016/j.currproblcancer.2015.07.004. Epub 2015 Jul 8 https://www.ncbi.nlm.nih.gov/pubmed/26239203 
2. Clinical Review – Basal cell carcinoma BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7418.794 (Published 02 October 2003)
3. Guidelines for the management of basal cell carcinoma N.R. Telfer, G.B. Colver* and C.A. British Journal of Dermatology 2008 159, pp35–48 https://www.bad.org.uk/library-media/documents/BCC_2008.pdf
4. British Association of Dermatologists The Collge of Optometrists Basal Cell carcinoma ( BCC ) Periocular BCC Module ELFH https://www.college-optometrists.org/guidance/clinical-management-guidelines/basal-cell-carcinoma-bcc-periocular-.html
5. DermNet New Zealand Basal Cell Carcinoma McDaniel B, Badri T.
6. Basal Cell Carcinoma. [Updated 2018 Nov 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan- https://www.ncbi.nlm.nih.gov/books/NBK482439/
7. Lewin, Jesse M, and John A Carucci. “Advances in the management of basal cell carcinoma.” F1000prime reports vol. 7 53. 12 May. 2015, doi:10.12703/P7-53 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4447055/
8. Skin cancers – recognition and referral- NICE CKS
9. Mackiewicz-Wysocka, Małgorzata et al. “Basal cell carcinoma – diagnosis.” Contemporary oncology (Poznan, Poland) vol. 17,4 (2013): 337-42. doi:10.5114/wo.2013.35684 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934050/
10. Reinau, D., Surber, C., Jick, S. et al. Epidemiology of basal cell carcinoma in the United Kingdom: incidence, lifestyle factors, and comorbidities. Br J Cancer 111, 203–206 (2014). https://doi.org/10.1038/bjc.2014.265 ( Abstract )
11. Chinem VP, Miot HA. Epidemiology of basal cell carcinoma. An Bras Dermatol. 2011;86(2):292‐305. doi:10.1590/s0365-05962011000200013
12. Tanese K. Diagnosis and Management of Basal Cell Carcinoma. Curr Treat Options Oncol. 2019;20(2):13. Published 2019 Feb 11. doi:10.1007/s11864-019-0610-0 ( Abstract )
13. Marzuka AG, Book SE. Basal cell carcinoma: pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management. The Yale Journal of Biology and Medicine. 2015 Jun;88(2):167-179. ( Abstract )

14. Common skin lesions Basal cell carcinoma CME DermNet NZ https://dermnetnz.org/cme/lesions/basal-cell-carcinoma-cme