bcc- by ajmal rashid

8/3/2019 BCC- By Ajmal Rashid

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By:- Dr.Ajmal Rashid

BASAL CELL CARCINOMA

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BASAL CELL CARCINOMA

A group of malignant cutaneous

tumors characterized by thepresence of lobules, columns,bands or cords of basaloid cells

(germinative cells).

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1. BASAL CELL CARCINOMA

Slow growing

At least 75% tumours areon face

locally invasive, aggressive,and destructive

there is a limited capacityto metastasize.


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EPIDEMIOLOGY

Most common skin cancer

More in fair skinMore common in males

On the lower leg, three timesmore common in women


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AETIOLOGY The most important risk factor is solar ultraviolet

radiation acute episodes of intense burning sun exposure are

a greater risk factor than cumulative lifetime sunexposure

Other factors

Arsenic exposure Ionizing radiation

air pollutants

burns


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Mutations in the PTCH1 gene

In Naevoid basal cell carcinoma syndrome and

in sporadic BCC tumour

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Types

Nodular

Ulcerated Superficial

Morpheic

Pigmented

Fibroepithelioma of Pinkus (FEP)

Naevoid basal cell carcinoma syndrome7

Nodular

Ulcerated

Superficial

Morpheic

Pigmented


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Nodular Ulcerated

Superficial

Pigmented

Morpheic


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Sites

Majority on the head and neck

predilection for the upper central part ofthe face

Morphoeic type - almost exclusively

on face.Superficial type - mainly on the

trunk.

Palms and soles - rarely affected9

may be multiple


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Characteristic Features

Translucency

UlcerationTelangiectasias

Rolled border

10 Characteristics may vary for different clinical sub-types


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1. BASAL CELL CARCINOMA

NODULAR TYPE

most commonly on thesun-exposed areas ofthe head and neck

translucent papule or

nodule usually telangiectasias often a rolled border

Differential diagnosis

traumatized dermal nevusAmelanotic melanoma


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Basal cell carcinoma, nodular type

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BCC nodular type

A solitary, shiny, red nodule with large

telangiectatic vessels on the ala nasi, arising

on skin with dermatoheliosis (solar elastosis).

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Nodular basal cell carcinoma in danger

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TYPES OF BCC (Ulcerated)NODULAR Usually begin as a small

pink pearly papule

Develop a depression inthe centre

Rolled edge


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BCC (Ulcerated)

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Basal cell carcinoma: ulcer type

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BCC(SUPERFICIAL)

Erythematous patch(often well demarcated)

that resembles eczema Usually found on the

trunk

May be multiple

Usually have typicalbeaded edge

D/DEczemaPsoriasisPagets diseaseBowens disease


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Superficial basal cell carcinoma

An isolated patch of eczema that does notrespond to treatment should raise suspicion

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Superficial basal cell carcinoma

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BCC (MORPHOEIC) orsclerodermiform

Ivory White or waxy

Always on face

Presents as aspontaneous scar

Margins are usuallymuch wider than what isclinically visible

dense fibrosis of the stroma

produces a thickened plaque rather

than a tumourpalpation reveals a firm skin texture

that extends irregularly beyond the

visible changes


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Basal cell carcinoma: MORPHOEIC

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Basal cell carcinoma: MORPHOEIC

D/D morphoea

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Basal cell carcinoma: MORPHOEICappearance of scar tissue in the absence of trauma orprevious surgical procedure or the appearance of atypical-appearing scar tissue at the site of a previously treated skinlesion should alert the clinician to the possibility ofmorpheaform BCC and the need for biopsy.

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BCC (PIGMENTED)

exhibits increasedmelanization

hyperpigmented,translucent papule

may also be eroded

D/D- nodularmelanoma.


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Basal cell carcinoma,pigmented

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Basal cell carcinomapigmented

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FIBROEPITHELIOMA OF PINKUS

Clinically, the lesion is a benign-appearing,pedunculated, pink tumor that may resemblean acrochordon

H/P - atypical basaloid cells

in fibrotic and mucinous stroma


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BCC (Multifocal)

Bowenoid usually found on lower legs ofwomen with sun damaged skin.

Diagnosis by biopsy

Poorly differentiated


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Multiple superficialbasal cell carcinomas

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Naevoid basal cell carcinoma

syndrome

Autosomal dominant

Skinmultiple BCCspalmoplantar pits

skin tags

milia

epidermoid cysts

Characteristic faciesFrontal bossing

broad nasal root

hypertelorism.

Other systems skeletal malformations

(mandibular keratocysts), soft tissue

Eyes Strabismus, hypertelorism,

dystopia canthorum, congenitalblindness

CNS endocrine organs

Internal Neoplasms Fibrosarcoma of the jaw,ovarian

fibromas, teratomas, andcystadenomas

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Basal cell naevus syndrome

Gorlins syndrome


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Basal cell nevus syndrome: basal cellcarcinomas

Multiple nodular BCCs on the right side of the face, frontalbossing, and a large scar on the right cheek at the site ofexcision of an odontogenic cyst.

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Naevoid basal cell carcinoma syndrome:

palmar pits

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Naevoid basal cell carcinoma

syndrome

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Follicular atrophoderma and basal

cell carcinoma

Rare genodermatosis (X-linked inheritance)

Predisposition to multiple BCCs Follicular atrophoderma

ice-pick marks, enlarged follicular ostia on thedorsa of hands,elbows, feet and face

HypotrichosisHypohidrosis

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BazexDuprChristol syndrome


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H/P Of BCC

Basaloid tumor cells

Budding from epidermis or follicle or within thedermis

Peripheral Palisading of nuclei

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well-circumscribed nodule

made up of islands of

basaloid cells

Peripheral palisading (arrowheads)

Clefting (arrows)


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A solid group of atypical basaloid cells is

present at the dermo-epidermal junctionshowing peripheral palisading and cleft

formation between tumour nest and dermis


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BCC

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Basal cell carcinoma, nodular type,


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pigmented

typical nodular basal cell carcinoma with the additionalfeature of melanin pigmentation of the tumour nests

BCC


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BCC


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Basisquamous or metatypical BCC

Tumours that on pathological study appear tohave features of both BCC and SCC

Significantly higher incidence of metastaticspread

small aggregates of cells lacking classic

palisading

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Course BCC slow progressive course of peripheral

extension, which producing thread-likemargin

doubling time is estimated to be between 6months and 1 year

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S d


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Spread Local

Periorbital tissues; bones of the face, skull ,meninges

Perineural Invasion - Uncommon

most often in histologically aggressive or recurrent lesions

may manifest as pain, paraesthesia, weakness, or paralysisDissemination - Rare

Inhalation

ulceration involves the airway inhaled and become

implanted in the lungs bloodstream metastasis

deposits in the viscera or spinal column

spread via lymphatics47


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Factors influencing prognosis in

basal cell carcinoma

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TREATMENT

Destructive therapies

Surgical excisionMohs micrographic surgery Photodynamic therapyRadiation therapy

Topical therapy Imiquimod 5-FU

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Destructive therapies

INDICATION

small primary tumors atnon-critical sites

MODALITIES

curettage and cautery

cryotherapy

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Disadvantages

risk of recurrencemorbidity associated with cryotherapy


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Surgical excision

3- 4 mm margin Tumor less than 2 cm in diameter

3-mm margin clear the tumour in 85% of cases and a 45-mm margin in 95% of cases

5-mm marginmorphoeic BCC

large BCCs (more than2 cm in diameter)

smaller nodular BCCs with poorly defined clinicalmargins

recurrent BCCs

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Mohs surgery offers superior histologic analysis of tumor

margins

while permitting maximal conservation oftissue compared with standard excisionalsurgery

Usually reserved for high risk lesions eyelids, nose, lips, ears

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Repeated cycles of surgeryand

intraoperative microscopicexamination of the entire surgical margin ofthe excised tissues

allows accurate and dependable identification

and removal of all residual invasive tumour

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Indications for Mohs Surgery for

Basal Cell Carcinoma

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Recurrence rate after MMS

Primary 1 percent

Recurrent 5.6 percent

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excision (10 percent)curettage and desiccation (7.7percent)XRT (8.7 percent)cryotherapy (7.5 percent)

superior to the rate for other modalities


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Radiation Therapy

Advantagesminimal patient discomfort

avoidance of an invasive procedure for a patientunwilling or unable to undergo surgery

Disadvantages lack of histologic verification of tumor removal

prolonged treatment course cosmetic result that may worsen over time

predisposition to aggressive and extensive recurrences

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IMIQUIMOD (5 percent cream)

Imiquimod is a Toll-like receptor 7 agonist

believed to induce interferon- and othercytokines to boost T helper 1 type immunity.

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Photodynamic Therapy

involves the activation of a photosensitizingdrug (-aminolevulinic acid) by visible light toproduce activated oxygen species that destroythe constituent cancer cells

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Flow chart BCC treatment

59 ED&C = electrodesiccation and curettage


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FOLLOW UP

Counseling about sun

protectionPeriodic full-body skin

examinationsA patient who has had one BCC should undergo

periodic full-body skin examinations for :- local recurrence

to detect fresh tumors arising elsewhere


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bcc- by ajmal rashid

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