Infiltrating Basal Cell Carcinoma

Maysoon ALGain

Dermatology Demonstrator

KAAU

Case Presentation

• CC: growth on right side of nose• HPI: 81 yo HF who first noted growth on

right side of nose “last December”, progressively growing.

• PMH: arthritis• SH: ½ ppd smoker X 25 years• ROS: denies F/C, significant weight loss• FH: non-contributory

Physical Exam

• General: AAO, VSS and good• VA: 20/80 OD, 20/50 OS• Pupils: 3mm OU, no APD• External: extensive ulcerative lesion from

bridge of nose to RLL and R cheek, with almost complete destruction of RLL and nearly complete ptosis of RUL

• IOP, CVF, DFE normal OS, unobtainable OD

Differential Diagnosis

• Malignant melanoma

• Squamous cell carcinoma

• Basal cell carcinoma, infiltrative

• Infectious

Basics of BCC• Background– Most common cutaneous malignancy (~80-

90%)– Typically slow-growing, rarely metastasizes– Sun-exposed skin, mostly face and scalp, esp

nose, cheek, and periorbital regions (~80%)• Frequency– 900,000 Dx in US/year– estimated lifetime risk of 33-39% for

men and 23-28% for women• Sex– Men 2X over women

Basics of BCC• Mortality/Morbidity– <0.1% metastasize– Very low mortality– Significant morbidity with direct invasion of

adjacent tissues, especially when on face or near an eye

• Age – Likelihood increases with age– Rare in <40 yo

• Race– Most often in light-skinned, rare in dark-

skinned races

Variants of Basal Cell Carcinoma

• Superficial• Nodular

• Micronodular• Infiltrating (5%)• Sclerosing/

morpheaform (5%)• Metatypical• Infundibulocystic

• Nodulocystic • Adenoid• Clear cell• Follicular• Sebaceous

• Perineurally invasive

Perineural Invasion

• May be seen in 3% of pts with infiltrating and morpheaform types

–Most often infiltrating type, which has highest rate of local recurrence

• Requires CT scan for full work-up

• Causes? inherently aggressive behavior vs inadequate early management?

Treatment Options

• Electrodessication and curettage• Curettage alone

• Surgical excision• Mohs micrographically controlled

surgery• Cryosurgery• Ionizing radiation• Surgical excision plus radiation

• Exenteration

Factors Considered in Treatment Planning

• Pt preference to keep eye• Pt age• Surgical excision-considered definitive tx• “Careful frozen section controlled excision of

periocular BCCs yields cure rates comparable to Mohs micrographic surgery at 5-year follow-up”– 5 year recurrence of 2.2% in one study– Wong, et al. “Management of Periocular Basal Cell

Carcinoma with Modified En Face Frozen Section Controlled Excision.” Ophthalmic and Plastic Reconstructive Surgery. 2002. Vol 18 (6): 430-435.

• Therefore, avoiding exenteration was considered a good possibility

Conclusion

• Basal cell carcinomas are not always as innocent as we tend to believe

• In formulating treatment course:– Strong pt preference and

other pt factors– Current research