Principles of Basal Cell Carcinoma Management
The histologic subtype and anatomic location are important considerations in the management of BCCs, thus a biopsy is necessary to guide optimal treatment choice. Although most subtypes are amenable to standard surgical excision, some (such as morpheaform or micronodular) are best treated with Mohs micrographic surgery. Superficial BCCs can be treated with cryosurgery, curettage and electrodesiccation, topical imiquimod or 5-fluorouracil therapy, or photodynamic therapy (PDT).
First-line therapy: Surgical excision
- Surgical excision with a 3 to 5 mm margin of normal tissue is usually optimal. Send the specimen for pathologic evaluation to assure adequacy of excision.
- In cases when surgery is not possible (i.e., elderly persons and/or in the debilitated, clinically indistinct borders or extensive area) or contraindicated, radiation therapy provides excellent results. It is also excellent for surgically complex lesions.
- For superficial or small (under 1 cm) lesions of the trunk, cryosurgery or curettage and electrodesiccation (C & E) provide an acceptable cure rate and good cosmetic outcome. C & E scars may be unsightly, and so this is not the preferred treatment for facial lesions, and is not recommended for large primary BCC, morpheiform or recurrent BCC. Complications of cryosurgery include scarring and postinflammatory pigmentary changes.
- Indications for Mohs micrographic surgery: refer to a dermatologist
- Facial lesions over 1 cm in diameter that have been present for more than 2 years and lesions located on the temple, eyelid, medial canthus, nose, and nasolabial fold, as they are more likely to recur
- Recurrent BCCs
- Lesions with clinically indistinct margins
- Histopathology is morpheaform or micronodular pattern
- Tumors greater than 2 cm in diameter on the body
- Tumors that will require extensive reconstruction to repair the surgical defect
- Topical imiquimod 5% cream (such as Aldara)
- Photodynamic therapy (PDT). Referral to dermatologist is strongly recommended
- Patient education with respect to pathogenesis and natural history of basal cell carcinomas is essential. Sun protection must be stressed.
- Perform a complete examination of all sun exposed skin on the initial visit and then quarterly following definitive treatment for the first year. Annual full-body skin examination thereafter is indicated to identify future development of tumor recurrence and new skin cancers.