| Basal Cell Skin Cancer Nonmelanoma skin cancer primarily comprises basal cell carcinoma and squamous cell carcinoma. Rates of skin cancer have been described as epidemic, with the incidence of all skin cancers rising at 4% to 5% each year. Frequency United States The annual incidence of basal cell carcinoma (BCC) is approximately 900,000 cases (550,000 in men, 350,000 in women). The age-adjusted incidence per 100,000 white individuals is 475 cases in men and 250 cases in women. The estimated lifetime risk of BCC in the white population is 33-39% in men and 23-28% in women. International Prevalence rates of basal cell carcinoma vary in different countries. The highest incidence occurs in Australia, where the age-adjusted incidence has been calculated to be 1332 cases per 100,000 population for men and 755 cases per 100,000 population for women. Mortality/Morbidity Basal cell carcinoma (BCC) can cause clinically significant morbidity if allowed to progress. Because this cancer most commonly affects the head and neck, cosmetic disfigurement is not uncommon. Loss of vision or the eye may occur with orbital involvement. Perineural spread can result in loss of nerve function and in deep and extensive invasion of the tumor. These neoplasms are often friable and prone to ulceration; thus, they provide a nidus for infection. Death from BCC is extremely rare. Race Basal cell carcinoma (BCC) is generally a disorder of white individuals, especially those with fair skin. It is rare in dark-skinned individuals. Sex The male-to-female ratio for basal cell carcinoma (BCC) is approximately 3:2. Age Basal cell carcinoma (BCC) most commonly occurs in adulthood, especially in elderly persons. Clinical History Basal cell carcinoma (BCC) patients often present with a nonhealing sore of varying duration. The lesions are typically seen on the face, ears, scalp, neck, or upper trunk. Mild trauma, such as face washing or drying with a towel, initially may cause bleeding. A history of chronic recreational or occupational sun exposure is commonly elicited. Intense sun exposure often occurred in childhood or young adulthood. Physical Findings Several clinical and histologic subtypes of basal cell carcinoma (BCC) may exhibit different patterns of behavior. Recognizing the various types is important because aggressive therapy is often necessary for variants such as micronodular, infiltrating, or morpheaform BCC. When one examines possible skin cancers, the best plan is to use good lighting and magnification. The affected skin should be stretched, squeezed, and palpated to best estimate the size and depth of the tumor. Oblique illumination of the tumor can highlight surface changes, such as a rolled border. Nodular BCC: This is the most common variety of BCC. Nodular BCCs most commonly occur on the head, neck, and upper back. They may have some of the following features:
Cystic BCC: Lesions of cystic BCC are translucent blue-gray cystic nodules that may mimic benign cystic lesions. Superficial BCC: This variety appears as scaly patches or papules that are pink to red- brown, often with central clearing. A threadlike border is common. Erosion is less common in superficial BCC than in nodular BCC. Superficial BCC is common on the trunk and has little tendency to become invasive. The papules may mimic psoriasis or eczema, but they are slowly progressive and not prone to fluctuate in appearance. Numerous superficial BCCs may indicate arsenic exposure. Micronodular BCC: This aggressive BCC subtype has the typical BCC distribution. It is not prone to ulceration, it may appear yellow-white when stretched, and it is firm to the touch. It may have a seemingly well-defined border. Morpheaform and infiltrating BCC: These are aggressive BCC subtypes with sclerotic (scarlike) plaques or papules. The border is usually ill defined and often extends well beyond clinical margins. Ulceration, bleeding, and crusting are uncommon. It may be mistaken for scar tissue. Causes UV radiation: This is the most important and common cause of basal cell carcinoma (BCC). Short-wavelength UV radiation (290-320 nm, sunburn rays) is believed to play a greater role in BCC formation than long-wavelength UVA radiation (320-400 nm, tanning rays). In addition, chronic sun exposure appears to be important in the development of BCC. A latency period of 20-50 years is typical between the time of UV damage and the clinical onset of BCC. Arsenic exposure: Chronic exposure to arsenic is associated with BCC development. Exposure may be medicinal, occupational, or dietary. A contaminated water supply is most commonly implicated. Immunosuppression: Immunosuppression is associated with a modest increase in the risk of BCC. History of nonmelanoma skin cancer (BCC or squamous cell carcinoma): Persons with one nonmelanoma skin cancer are at increased risk of developing others in the future. The rate of new nonmelanoma skin cancer is 35% at 3 years and 50% at 5 years after an initial diagnosis of skin cancer. One reason for the rising incidence of skin cancer is an increase in sun exposure in the general population. Some postulate that ozone depletion may be intensifying UV exposure. Other contributing factors for the increased incidence of skin cancer include the advancing age of the US and world population, earlier and more frequent diagnosis due to enhanced public awareness of skin cancer, and more frequent skin examinations by physicians and patients. The definitive treatment for most skin cancers involves the complete surgical removal of the lesion, ensuring that the margins are free of tumor cells. Other treatment options include curettage and electrodessication, excision, Erbium laser, and phototherapy; and postoperative margin assessment, radiation therapy, and superficial therapies. Medical Care Local therapy with chemotherapeutic and immune-modulating agents is useful in some cases of basal cell carcinoma (BCC). In particular, small and superficial BCC may respond to these compounds. In addition, they may be used for prophylaxis or maintenance in patients who are prone to having many BCCs, such as those with basal cell nevus syndrome. Surgical Care The goal of surgical treatment of basal cell carcinoma (BCC) is to destroy or remove the tumor so that no malignant tissue is allowed to proliferate further. Factors to consider when choosing therapy include the the location and size of tumors, the age of the patient, and the patient's ability to tolerate surgery. The most common surgical methods are curettage, wide excision, Mohs micrographic surgery, and radiotherapy. Additionally, cryotherapy is sometimes used to treat these tumors. Prognosis Individuals with BCC have a 30% greater risk of having another BCC unrelated to the previous lesion compared with the risk in the general population. References |
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