BCC

Question 1

What proportion of basal cell carcinomas occur on the head and neck?

Answer 1

Four in five cutaneous basal cell carcinomas

Question 2

Is upper lip cancer more common in men or

women?

Answer 2

It is more common in women: 21% of lip cancers on the

upper lip versus only 3% of lip cancer in men.

Question 3

What percentage of cutaneous malignancies occur

on the lower lip?

Answer 3

90%

Question 4

What is the significance of basal cell carcinoma

found in the folds of the face?

Answer 4

These tumors develop at the site of embryonic fusion
plates, resulting in more likely recurrence and higher risk of
spread. They therefore require close follow-up.

Question 5

Is basal cell carcinoma more likely on the upper or lower lip?

Answer 5

Upper lip (13% vs. 1% of lower lip cancers)

Question 6

What is the likelihood of regional nodal metastasis

in basal cell carcinoma?

Answer 6

Nodal spread is rare, occurring in fewer than 0.0028 to 0.5%

of patients.

Question 7

What is the mechanism by which ultraviolet (UV)

B-wave light damages skin?

Answer 7

UV light in the B-band (280 to 320 nm), which is the same
wavelength responsible for sunburn, causes direct damage
to DNA by exciting DNA molecules, resulting in covalent
bonds between adjacent cytosine bases. These dimers are
read as “AA” by DNA polymerase, and therefore the
corresponding “TT” is added to the growing strand.

Question 8

What are the risk factors for basal cell carcinoma?

Answer 8

Sun exposure is the most important risk factor, with other
factors including lightly pigmented skin, blue or green eyes,
and white ethnicity. Certain genetic conditions also
predispose individuals to basal cell carcinoma, including
basal cell nevus syndrome (also called Gorlin syndrome) and
xeroderma pigmentosum. Exposure risks include tanning
beds, arsenic, prior trauma, ionizing radiation, and immune
suppressants.

Question 9

What are the so-called high-risk features used in

staging of basal cell carcinoma?

Answer 9

● Poor differentiation
● Perineural spread
● Origination in the ear or the hair-bearing lip
● Depth > 2 mm
● Clark level IV or V invasion

Question 10

What percentage of nonmelanocytic cutaneous

neoplasms are basal cell carcinoma?

Answer 10

80%

Question 11

What are the most commonly described types of

basal cell carcinoma?

Answer 11

There are 26 different subtypes of basal cell. The following
are the most commonly described:
● Nodular is the most common form of basal cell carcinoma
(60 to 80%), often described as pearly with rolled borders
and occasionally central ulceration.
● Morpheaform (or sclerosing or fibrosing) has irregular
borders on yellow plaques and is the most aggressive
type of basal cell carcinoma, with higher recurrence and
worse prognosis.
● Fibroepithelial
● Superficial is most common type on the trunk, irregularly
shaped, waxy, and with an occasionally eczematous or
psoriatic appearance.
● Other commonly described types are pigmented and
micronodular.

Question 12

What percentage of basal cell carcinomas are

nodular?

Answer 12

56 to 78%

Question 13

Which subtype of basal cell carcinoma has the

youngest average age at initial diagnosis?

Answer 13

Superficial, which is more common on the trunk

Question 14

What aspect of morpheaform tumors render them
able to spread along embryogenic fusion planes
and therefore makes them more aggressive with
worse prognosis?

Answer 14

Morpheaform tumors secrete collagenases, enabling

movement between anatomic subsites.

Question 15

Which subtype of basal cell carcinoma is much
more common in patients of African and Chinese
descent than those that are found in white
patients?

Answer 15

Pigmented basal cell carcinoma

Question 16

Describe the clinical constellation known as nevoid

basal cell carcinoma syndrome (or Gorlin syndrome)

Answer 16

Patients are diagnosed at an early age with multifocal basal
cell carcinomas, odontogenic keratocysts, and often also
bifid ribs, scoliosis, developmental delay, and frontal
bossing.

Question 17

Describe the characteristic features of nodular

basal cell carcinoma.

Answer 17

Classically, nodular basal cell carcinoma is described as a
pearly lesion with rolled borders, central ulceration, and
peripheral telangiectasias.

Question 18

Describe the features associated with arsenic

exposure.

Answer 18

● Truncal basal cell carcinoma
● Keratoses of the palms and soles
● Nail changes (Mees lines)

Question 19

What type of biopsy should be performed for a

suspected basal cell carcinoma?

Answer 19

Shave biopsy is appropriate for the vast majority of basal
cell carcinomas. When lesions are pigmented, a punch
biopsy should be performed to assess the depth of the
lesion.

Question 20

When is imaging required in basal cell carcinoma?

Answer 20

Rarely: Large tumors, suspicion of invasion of deeper
structures (e.g., fixation, bone invasion), symptoms of
perineural invasion, palpable lymphadenopathy

Question 21

What parts of the head and neck are at highest
risk of recurrence when affected by cutaneous
malignancies?

Answer 21

The preauricular and postauricular regions, floor of nose/
columella, medial and lateral canthi, nasolabial fold, aka the
so-called H-zone

Question 22

Under what circumstances should cryosurgery
be considered for management of basal cell
carcinoma?

Answer 22

Cryosurgery can be used in small (< 1 cm) nonaggressive

tumors.

Question 23

In the management of basal cell carcinoma, what tumor attributes favor excisional curettage and
electrodessication?

Answer 23

Small (< 2 cm), nonaggressive tumors can be removed with
excisional curettage with 90% success. Excisional curettage
is not optimal for management of functionally and
cosmetically important tumors.

Question 24

What rate of cure can be expected with Mohs

surgery in basal cell carcinoma?

Answer 24

96 to 99% cure rate in recurrent and primary resections,

respectively

Question 25

What are the advantages of Mohs surgery over

simple excision with electrodessication?

Answer 25

Maximal preservation of normal tissue, optimization of
functional/cosmetic outcomes, assessment, and clearing of entire margin, lower recurrence rates, immediate recon-
struction (usually), only one practitioner involved at all phases of management

Question 26

What are the nonsurgical options for management

of basal cell carcinoma?

Answer 26

● Radiation therapy (most commonly used nonsurgical
therapy, although waning in popularity)
● Photodynamic therapy
● Immunotherapy
● Chemotherapy
● Vismodegib, an agent that targets the hedgehog signal-
ing pathway and was approved in 2012 for treatment of basal cell carcinoma

Question 27

In patients with cutaneous basal cell carcinoma,

when should neck dissection be considered?

Answer 27

Neck dissection should be used only in instances when
there is clinical evidence of nodal metastasis because basal
cell carcinoma metastasizes to the lymph nodes in only
0.5% of cases.

Question 28

Why is it best to defer reconstruction in the morpheaform type of basal cell carcinoma?

Answer 28

Morpheaform basal cell carcinoma classically exhibits
subdermal spread that results in more common recurrence
than other variants of basal cell carcinoma. Reconstruction
either with grafting or tissue rearrangement may cover this
subdermal extension and delay diagnosis of recurrence,
sometimes with devastating consequences for the patient.