BCC Flashcards
What is basal cell carcinoma?
Basal cell carcinomas (BCCs) are slow growing, locally invasive malignant epidermal skin tumours which are thought to arise from hair follicles.
The tumour infiltrates local tissues through the slow irregular growth of subclinical finger-like outgrowths and morbidity results from local tissue invasion and destruction, especially on areas of chronic sun exposure, such as the face, head and neck
Metastasis is relatively rare with a metastasis rate of 0.0028% to 0.5%.
Does BCC a affect dark skinned races?
BCC predominantly affects Caucasians and is very uncommon in dark-skinned races.
BCC is the most common cancer in Europe, Australia and the USA and is showing a worldwide increase in incidence
Risk factors for BCC
The most significant aetiological factors appear to be genetic predisposition and exposure to ultraviolet (UV) radiation.
The sun-exposed areas of the head and neck are the most commonly involved sites. Sun exposure in childhood may be especially important.
Increasing age, male sex, skin types I and II (skin that always burns and never/only sometimes tans), immunosuppression and arsenic exposure are other recognised risk factors. A high dietary fat intake may also be relevant.
People diagnosed with one BCC are at increased risk of developing further BCCs. The risk of developing a second BCC within three years of the first presentation is approximately 44%.
Gorlin’s syndrome
What is Gorlin’s syndrome?
Gorlin’s Syndrome is a genetic condition resulting in the mutation of the Tumour Suppressor Gene PTCH 1.
It results in the development of multiple early onset BCCs.
How does Gorlin’s syndrome present?
Gorlin’s syndrome: This is also called naevoid BCC syndrome and It presents with: Autosomal dominant inheritance. Multiple BCCs. Pitting of the palms and soles. Jaw cysts. Spine and rib anomalies. Calcification of the falx cerebri. Cataracts. Usually treated with imiquimod cream, chemotherapy and photodynamic therapy.
Presentation of BCC
The sun-exposed areas of the head and neck are the most commonly involved sites. Approximately 80% occur on the head and neck, with the rest mainly on the trunk and lower limbs.
Early lesions are often small, translucent or pearly and have raised areas with telangiectasia.
The classic rodent ulcer has an indurated edge and ulcerated centre. It is slow-growing but can spread deeply to cause considerable destruction.
What is nodular BCC?
Solitary, shiny, red nodule with large telangiectatic vessels.
Commonly on the face.
Cystic, pearly, telangiectasia.
May be ulcerated.
Micronodular and microcystic types may infiltrate deeply.
What is superficial BCC?
Often multiple, usually on the upper trunk and shoulders.
Equal distribution over the face, trunk and limbs, although the site of predilection seems to vary according to sex (the head in women, the trunk in men).
Erythematous well-demarcated scaly plaques, often larger than 20 mm at presentation. Central clearing and a thread-like border. A rolled edge can be seen if stretched. The lesion may bleed or weep.
Slow growth over months or years; usually not aggressive, rarely become invasive and extremely rarely metastasise. Less likely to erode and ulcerate than nodular BCCs.
May be confused with Bowen’s disease or inflammatory dermatoses.
Particularly responsive to medical rather than surgical treatment.
What is morphoeic BCC?
Also known as sclerosing or infiltrative BCC.
Usually found in mid-facial sites.
More aggressive and have poorly defined borders.
Characterised by thickened yellowish plaques.
Often present late and may become very large and then require extensive plastic surgical reconstruction. May infiltrate cutaneous nerves (perineural spread).
Prone to recurrence after treatment.
What is pigmented BCC?
Brown, blue or greyish lesion.
Nodular or superficial histology.
Seen more often in individuals with dark skin.
May resemble malignant melanoma.
What is basosquamous BCC?
Mixed BCC and SCC
Potentially more aggressive than other forms of BCC.
What is periocular BCC?
This is a usually slow developing, usually painless and non-resolving lesion.
The most usual form and location is a small hard whitish nodule that appears on the lower eyelid.
Periocular BCC can also present in the medial canthus, upper lid, and lateral canthus.
It can present as nodular (hard nodule, pearly appearance, abnormal [telangiectatic] vessels), nodulo-ulcerative (as nodular but with raised rolled border surrounding central ulcer, may bleed), or morphoeic or sclerosing (flat hardened plaque of thickened skin, without surface vascularisation, ill-defined border making it difficult to determine area of involvement).
Differentials for nodular BCC
Intradermal naevus
Sebaceous hyperplasia
Fibrous papule
Molluscum contagiosum
Keratoacanthoma
Differentials for superficial BCC
Discoid eczema Psoriasis Actinic keratosis Lichen simplex Bowen’s disease SCC Seborrhoeic wart
Referral of BCC to secondary care
• NICE recommends:
Consider routine referral for people if they have a skin lesion that raises the suspicion of a BCC.
Only consider a suspected cancer pathway referral (for an appointment within two weeks) for people with a skin lesion that raises the 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.
