1' BASAL CELL CARCINOMA

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1. 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

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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

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TYPES OF BCC (1)

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

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TYPES OF BCC (2)

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

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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

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TYPES OF BCC (4)

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

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DIFFERENTIAL DIAGNOSIS

• Cyst
• Infected spot
• Sebaceous hyperplasia
• Naevus
• Molluscum contagiosum
• Wart

• Bowens disease
• Tinea
• Eczema/psoriasis
• Malignant melanoma
• Seborrhoeic keratosis
• Erosions and leg ulcers

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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

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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

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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

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AETIOLOGY

• Sunlight exposure
• Therapeutic radiation
• Chemical carcinogens arsenic
• Immunosuppression
• Viral infection
• Scars and chronic inflammation
• Premalignant lesions
• Genetic syndromes

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CLINICAL FEATURES

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

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• SCC on lower leg - Marjolins ulcer
• Failure to respond to nursing care
• Heaped up margin

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METASTASES

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

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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
• gt2cm
• poorly differentiated
• scars and ulcers
• immunosuppression
• perineural invasion
• recurrent lesions

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DIFFERENTIAL DIAGNOSIS

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

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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

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TREATMENT METHODS

• Excision margins 2-10mm
• Mohs micrographic surgery
• Curretage and cautery
• Cryotherapy
• Laser
• Photodynamic therapy
• Retinoids
• Radiation therapy

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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