Basal cell carcinoma

D: Commonest form of skin malignancy; also known as a'rodent ulcer'. ^^

A: Prolonged sun exposure or UV radiation. ^^

A/R: Multiple basal cell carcinomas are associated with Gorlin's syndrome (naevoid basal cell carcinoma syndrome). Risk factors include photosensitising pitch, tar and oils that act as co-carcinogens to UV radiation; previous treatment with arsenic (once present in many tonics) predisposes to multiple basal cell carcinomas developing even after a lag of many years.

_E Common in geographic areas with high sunlight exposure, especially in those with fair skin, common in the elderly, rare before the age of 40 years.

A chronic slowly progressive skin lesion usually on the face but also on the scalp, ears or trunk.

Nodulo-ulcerative (most common): Small glistening translucent skin over a coloured papule that slowly enlarges (early) or a central ulcer ('rodent ulcer') with raised pearly edges (late). Fine telangiectatic vessels often run over the tumour surface. Cystic change may be seen in larger more protuberant lesions. Morphoeic: Slowly expanding, yellow/white waxy plaque with an ill-defined edge.

Superficial: Most often on trunk, multiple pink/brown scaly plaques with a fine 'whipcord' edge expanding slowly; can grow to more than 10cm in diameter.

Pigmented: Specks of brown or black pigment may be present in any type of basal cell carcinoma in all or part of the tumour.

Small dark blue staining basal cells growing in well-defined aggregates invading the dermis with the outer layer of cells arranged in palisades. Numerous mitotic and apoptotic bodies are seen. Growth rate is usually slow but steady and insidious. It does not metastasise, but has the potential to invade and destroy local tissues.

Biopsy (diagnosis is based mainly on clinical suspicion).

Cryotherapy, curettage, cauterisation and photodynamic therapy are used for small superficial lesions.

Surgical: Excision with a 0.5 cm margin of surrounding normal skin for discrete nodular or cystic nodules in patients under 60 years; Mohs' micrographic surgery, which includes careful review of tissue excised under frozen section, is the treatment of choice for large tumours (1 cm diameter) and lesions near the eyes, nose and ears. Excision and skin flap coverage may be necessary. Radiotherapy: Useful in basal cell carcinomas involving structures that are difficult to surgically reconstruct (e.g. eyelids, tearducts). Repeated treatments may be necessary as there is risk of side-effects such as radiation dermatitis, ulceration, depilation.

The tumour has a slow but relentless course. Can become disfiguring on the face. Has the potential to invade into underlying cartilage and facial or skull bones and damaging important surrounding structures or eroding into blood vessels.

Good with appropriate treatment. If left may continue to grow, invade and ulcerate. Regular follow-up is necessary to detect local recurrence or other lesions.

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