BAD BCC Flashcards
What is the maximum clinical diameter for low risk Area Lb?
≤ 20 mm
This is the threshold for categorizing a lesion as low risk based on its size.
What is the maximum clinical diameter for high risk Area (trunk and extermities - excluding hands/nail units/genitals/pre-tibia/ankles and feet?
> 20 mm
Lesions exceeding this size are categorized as high risk.
What is the maximum clinical diameter for low risk Area Mc?
≤ 10 mm
This size indicates a low risk classification.
What is the maximum clinical diameter for high risk Area Mc?
> 10 mm
Lesions larger than this are classified as high risk.
How are borders classified for low risk lesions?
Well defined
The clarity of borders influences the risk classification.
How are borders classified for high risk lesions?
Poorly defined
Poorly defined borders contribute to a higher risk classification.
What distinguishes primary from recurrent lesions?
Primary vs. recurrent
Primary lesions are the initial occurrences, while recurrent lesions appear after treatment.
What is the immunosuppression status for low risk lesions?
No
Absence of immunosuppression is a factor in determining lower risk.
What is the immunosuppression status for high risk lesions?
Yes
Immunosuppression increases the risk associated with the lesion.
What is the site of prior radiotherapy for low risk lesions?
No
Prior radiotherapy at the site indicates a higher risk.
What is the site of prior radiotherapy for high risk lesions?
Yes
The presence of prior radiotherapy increases the risk classification.
What growth pattern is associated with low risk BCC?
Nodular or superficial
These growth patterns are less aggressive.
What growth pattern is associated with high risk BCC?
Infiltrative (infiltrating, morphoeic, micronodular)
These patterns are more aggressive and invasive.
What is the differentiation status of basosquamous for low risk BCC?
Absent
Lack of differentiation indicates a lower risk.
What is the differentiation status of basosquamous for high risk BCC?
Present (with or without lymphovascular invasion)
Presence of differentiation or invasion indicates higher risk.
What is the level of invasion for low risk lesions?
Dermis, subcutaneous fat
Limited invasion corresponds to lower risk classification.
What is the level of invasion for high risk lesions?
Beyond subcutaneous fat
Deeper invasion increases the risk classification.
What is the thickness threshold for low risk lesions?
≤ 6 mm
Thickness is a critical factor in risk assessment.
What is the thickness threshold for high risk lesions?
> 6 mm
Greater thickness correlates with higher risk.
What is the perineural invasion status for low risk lesions?
Absent
Absence of perineural invasion indicates lower risk.
What is the perineural invasion status for high risk lesions?
Present
Presence of perineural invasion elevates the risk classification.
What is the pathological TNM stage for low risk lesions?
pT1 ≤ 20 mm (maximum diameter)
This classification indicates lower risk based on size.
What is the pathological TNM stage for high risk lesions?
pT2 > 20 mm but ≤ 40 mm, pT3 > 40 mm, or upstaged pT1 or pT2, or minor bone invasion, pT4 major bone invasion
Higher stages indicate increased risk.
What are the histological margins for low risk lesions?
Not involved (≥ 1 mm)
Adequate margins are crucial for lower risk classification.
What are the histological margins for high risk lesions?
Involved (0 mm) or histologically close (< 1 mm)
Involvement of margins signifies higher risk.
What is the first-line treatment option for adults with low-risk BCC?
Standard surgical excision
Low-risk BCC refers to basal cell carcinoma with a lower likelihood of recurrence or metastasis.
What should be offered as a first-line treatment for adults with primary BCC and high-risk factors?
Standard surgical excision with immediate reconstruction
This applies if the BCC has well-defined clinical margins under bright lighting and magnification or dermoscopy.
What is the first-line treatment option for adults with high-risk BCC and poorly defined clinical margins?
Standard surgical excision with delayed definitive reconstruction or Mohs micrographic surgery
This is applicable within a high-risk anatomical site.
What is the required peripheral clinical surgical margin for excising low-risk BCC?
4 mm
This margin ensures adequate removal of the carcinoma.
What is the minimum peripheral clinical surgical margin for excising primary BCC with a high-risk factor?
5 mm
This margin is necessary to ensure complete excision of high-risk lesions.
What should be ensured at the deep margin when excising BCC?
Adequate excision to a clear plane, including a fat layer where present
This may involve deeper structures if needed.
When should Mohs micrographic surgery be considered for adults with primary BCC?
In adults with at least one high-risk factor
Mohs surgery is a precise surgical technique that minimizes the risk of recurrence.
What is the first-line treatment option for recurrent BCC with at least one high-risk factor?
Mohs micrographic surgery
Especially important if the tumour is at a high-risk site.
What treatment option may be considered for recurrent BCC after discussion at an MDT?
Standard surgical excision with at least a 5 mm margin and delayed definitive reconstruction
MDT stands for multidisciplinary team, which collaborates on patient treatment plans.
What treatment options should be offered to adults with advanced BCC?
Standard surgical excision or radiotherapy
These options are considered for advanced cases where surgical intervention is needed.
What is another treatment option for adults with advanced BCC?
Mohs micrographic surgery
This technique is particularly useful in advanced cases to ensure complete removal.
Who do you offer systemic therpay to
Offer* vismodegib, subject to availability, as a treatment option to adults with advanced¶ BCC who are unsuitable
for Mohs micrographic surgery, standard surgical excision or
radiotherapy, including patients with Gorlin syndrome, following discussion at an MDT
What is the recommendation for offering radiotherapy to adults aged ≥ 60 years with low-risk BCC?
Offer radiotherapy as a treatment option if they are unsuitable for or decline Mohs micrographic surgery or standard surgical excision and express a preference for radiotherapy.
This applies to nodular BCC, infiltrative subtype of BCC with sufficient planning margin, or excised BCC with involved margins.
In which situations should radiotherapy not be offered to adults with BCC?
Do not offer radiotherapy if the lesion is:
* a recurrent BCC following previous radiotherapy
* associated with certain genetic syndromes (e.g., Gorlin syndrome, xeroderma pigmentosum)
This is for adults who are unsuitable for or decline Mohs micrographic surgery or standard surgical excision.
What factors should be considered when discussing alternative treatment modalities for BCC?
Alternative treatment modalities should be discussed at an MDT.
Refer to guidelines R1, R3–5, R9–14, and R18–23.
What are the recommendations against offering radiotherapy to adults with BCC on areas of poor blood supply?
Do not routinely offer radiotherapy if the lesion is on areas of poor blood supply (e.g., lower limbs).
This is especially relevant for patients unsuitable for or who decline Mohs micrographic surgery or standard surgical excision.
What is the suggested age below which radiotherapy should not be offered to younger patients?
Suggested age < 60 years.
Late effects of radiotherapy could be an issue for younger patients.
What type of BCC lesion should not be treated with radiotherapy if it invades bone or cartilage?
A BCC invading bone or cartilage.
This recommendation applies to adults unsuitable for or who decline Mohs micrographic surgery or standard surgical excision.
What treatment options are offered to adults with low-risk BCC who are unsuitable for or decline standard surgical excision?
Topical imiquimod, topical 5-fluorouracil, cryosurgery, topical PDT
PDT refers to photodynamic therapy.
What treatments should not be offered to adults with high-risk BCC who are unsuitable for or decline Mohs micrographic surgery?
Topical imiquimod, topical 5-fluorouracil, cryosurgery, curettage and cautery, topical PDT
Mohs micrographic surgery is a precise surgical technique for removing skin cancer.
Under what condition should topical imiquimod, topical 5-fluorouracil, cryosurgery, or topical PDT be offered to adults with advanced BCC?
For palliation of symptoms, following discussion at an MDT
MDT refers to a multidisciplinary team.
What should be advised to adults with BCC who decline all treatments?
The risk of significant progression of the tumour is at least 25% over 2–5 years.
What interventions lack sufficient evidence for low-risk BCC?
- Mohs micrographic surgery
- Vismodegib
Vismodegib is a drug used to treat basal cell carcinoma.
What interventions lack sufficient evidence for BCC?
- Topical ingenol mebutate gel
- Topical Curaderm-BEC5 cream
- Electrochemotherapy (ECT)
- CO2 laser
- Pulsed-dye laser
- Combinations of various treatments.
Draw out the algorithm for BCC
What is the pathophysiology and aetiology of BCC
What type of cell is BCC?
BCC is an epidermal KC
From which cells is BCC believed to originate?
Pluripotent cells in the interfollicular epidermis and infundibulum of the hair follicle
What factors are believed to contribute to the development of BCC?
Genetic predisposition and exposure to ultraviolet radiation
How does immunosuppression affect the risk of developing BCC?
It increases the risk of BCC
What are examples of conditions that can lead to immunosuppression?
- Organ transplantation
- HIV
- Haematological malignancy
Which signaling pathway is critical for the regulation of cell growth and differentiation in embryonic development?
Hedgehog intracellular signalling pathway
What is associated with the development of BCC in most cases?
Loss of inhibition of hedgehog signalling
What percentage of sporadic BCC cases involve inactivating mutations in the PTCH1 gene?
90%
What type of mutations are found in 10% of BCC cases?
Activating mutations in the SMO gene
What are the germline mutations associated with Gorlin syndrome?
- PTCH1
- PTCH2
- SMO
- SUFU
