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BASAL CELL CARCINOMA

The most common cancer


affecting humans

Slow growing

At least 75% first tumours are


on the face

Relatively benign in most


cases but if left untreated can
be disfiguring and life
threatening

AETIOLOGY AND
EPIDEMIOLOGY

The most important risk factor is solar ultraviolet radiation

Type 1 skin

Episodes of painful sunburn in early life

Mechanism of injury by UV radiation is complex:


direct DNA damage
damage to repair mechanisms
immune dysregulation
mutations in p53 suppressor genes

TYPES OF BCC (1)


NODULAR
Usually begin as a small
pink pearly papule
Develop a depression in
the centre
Rolled edge
Overlying telangiectasia

TYPES OF BCC (2)


SUPERFICIAL
Usually found on the trunk
May be multiple
Flat red patches
Usually have typical
beaded edge

TYPES OF BCC (3)


MORPHOEIC
White or waxy
Always on face
Presents as a spontaneous
scar
Margins are usually much
wider than what is clinically
visible

TYPES OF BCC (4)


Multifocal
Bowenoid usually found on lower legs of
women with sun damaged skin. Diagnosis
by biopsy
Poorly differentiated

DIFFERENTIAL DIAGNOSIS
Cyst

Bowens disease

Infected spot

Tinea

Sebaceous hyperplasia

Eczema/psoriasis

Naevus

Malignant melanoma

Molluscum contagiosum

Seborrhoeic keratosis

Wart

Erosions and leg ulcers

MANAGEMENT

Surgical excision with 4mm margins complete excision of 98%


tumours less than 2cm in diameter

Mohs micrographic surgery immediate histological analysis. If


residual tumour further surgery. Ensures precise and conservative
tumour removal. Usually reserved for high risk lesions eyelids, nose,
lips, ears. 5 year cure rate 99%

Photodynamic therapy

Radiation therapy

Topical therapy imiquimod (aldara) immune modulator

FOLLOW UP POLICY
Overall recurrence rate for BCC is around
5%
Thus patients are followed up for 2 years
at least 6 monthly
However risk of second primary 5 years
after excision 36% patients develop a
second primary and 20% develop multiple
new BCCs

2.SQUAMOUS
CELLCARCINOMA
Less common than
BCC but more
aggressive
The incidence is rising
Most important
aetiological agent is
UV radiation total
life time exposure

AETIOLOGY

Sunlight exposure

Therapeutic radiation

Chemical carcinogens arsenic

Immunosuppression

Viral infection

Scars and chronic inflammation

Premalignant lesions

Genetic syndromes

CLINICAL FEATURES
May be seen at any body
site
Disorganised keratin
Keratin horn on a fleshy
tumourous base
Surface tends to ulcerate

SCC on lower leg Marjolins ulcer


Failure to respond to
nursing care
Heaped up margin

METASTASES
SCC may spread in several ways:
Local invasion
Along tissue plains, between muscles, over
periosteum
Along nerves and blood vessels
Distant mets

RISK FACTORS FOR


METASTASES

Most SCCs behave in a relatively benign fashion

SCC arising from sun-damages skin has a low propensity to


metastasize 0.5% compared to 2% of all SCCs

SCCs arising in certain situations have a much higher rate of spread:


>2cm
poorly differentiated
scars and ulcers
immunosuppression
perineural invasion
recurrent lesions

DIFFERENTIAL DIAGNOSIS
Solar keratosis
Bowens disease
Viral warts
Cutaneous horn
Keratoacanthoma
Basal cell carcinoma
Leg ulcers

MANAGEMENT
Intention to cure primary lesion and prevent recurrences
No one treatment has been shown to be effective in all
patients
Thus treatment should be tailored to the individual as
much as possible
Ideally multidisciplinary oncology team clinical
oncologist, dermatologist, pathologist, appropriate surgeon

TREATMENT METHODS

Excision margins 2-10mm

Mohs micrographic surgery

Curretage and cautery

Cryotherapy

Laser

Photodynamic therapy

Retinoids

Radiation therapy

FOLLOW UP POLICIES
75% SCCs recur within 2 years
95% recurrences are within 5 years
Most clinicians follow up for at least 4 years
3 monthly for first year then every 6 months
Close examination of the scar site and draining lymph
node areas is recommended

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