Basal Cell Carcinoma

Basal cell carcinoma is the most common form of skin cancer. This tumor is not life threatening except in the rarest of circumstances. For most, basal cell carcinoma grows slowly over years, and appears as a pimple-like growth that bleeds, heals, and re-bleeds. If untreated, basal cell carcinoma my penetrate and destroy deeper tissues and can be mutilating.

Most basal cell carcinomas are caused by ultraviolet rays from the sun. It is known that chronic sun exposure, radiation, and tanning bed use can lead to the development of basal cell carcinomas.

Several treatments exist for basal cell carcinoma and include:

Excision. With this procedure, the tumor is cut out and often stitched together. The skin is sent to a laboratory and examined to ensure that the entire tumor has been removed. Sometimes all dissolvable stitches are used, otherwise sutures are generally removed within 7 to 14 days depending upon what area of the body the cancer is. The pathology results may take up to 7 days and rarely longer. This treatment is 95% effective for the treatment of nodular basal cell carcinomas.
ED&C. With this procedure, the tumor is scraped out and the base of the wound is burned using an electric needle or a laser. With this procedure an open sore is left that can take weeks or even months to heal. The final result is often a permanent white depressed scar or pink raised scar that can itch.
Mohs' Micrographic Surgery. This procedure has the highest cure rate (lowest risk of the tumor coming back) of any treatment available. With this procedure, the visible tumor is cut out along with a thin margin of clinically uninvolved skin. While the patient waits, the removed skin is processed and slides are made for the surgeon to read and interpret under the microscope. This processing may take 15 to 60 minutes. If the margins are free of tumor, the wound can be left to heal by itself or can be closed using plastic surgery that is most often done right in the office. If all of the tumor is not removed, the surgeon will go back and try to remove the remaining tumor. This second piece of skin (called a stage) is tested and examined under the microscope. This process will go on until all of the tumor is removed.
Radiation. This treatment is reserved for those who are late-middle aged or elderly who are not good surgical candidates or do not wish to undergo surgery. Healing can be excellent, although 9 or more treatment sessions are needed.
5-Fluorouracil Cream (Efudex®, Carac®). This chemotherapy cream may be used for superficial basal cell carcinomas and results in mild to severe skin irritation. It is 88% effective for the treatment of superficial basal cell carcinomas.
Imiquimod (Aldara®). This cream was FDA-approved for the treatment of superficial basal cell carcinomas in 2004. Clinical studies have proven that this treatment is at least 80% effective for early basal cell carcinomas (superficial type). Skin irritation and crusting is common and expected with the use of this cream.
No treatment. In some circumstances, one may choose not to treat a tumor. This is often done in elderly individuals or those in extremely poor health when the tumor grows in areas of little cosmetic importance and when there is little risk of damaging deeper structures. Delay in treatment can result in enlargement of the tumor, that can bleed and become problematic later.

Dr. Bader was invited to author the chapter regarding basal cell carcinoma on the online medical reference textbook on emedicine.com, a subsidiary of WebMD. To see this article please click here: Basal Cell Carcinoma.

There are different histologic subtypes of basal cell carcinoma. These types are classified based on growth patterns that can be indentified under the microscope. Some types are more difficult to treat and do not respond as well to all treatment options. Therefore, one must take into account several factors when choosing an appropriate treatment or even the option not to treat. Such factors include: the age of the patient, the location of the tumor (i.e. is it close to the eye), the overall health of the patient (i.e. are able to undergo surgery), medications (i.e. are they on blood thinners that they are unable to stop, the histologic subtype of the tumor, the ability and desire of the patient to care for the site after treatment, the importance of a good cosmetic outcome after treatment, and cost.

Nodular Basal Cell Carcinoma is the most common type of basal cell carcinoma. This tumor usually looks like a pimple that bleeds, heals, and then re-bleeds. With time, these tumors enlarge and usually ulcerate (form an open sore) usually in the center. Under the microscope, these tumors grow as large, ball-like collections (or nodules), hence the name nodular basal cell carcinoma. This type of tumor is often treated with excision, electrodesiccation & curettage, Mohs' micrographic surgery, or radiation.

Superficial Basal Cell Carcinoma is common, and looks like a pink patch of skin that may have some scale and may have one or more tiny scabs. This type of basal cell is often misdiagnosed as eczema, ringworm, or psoriasis. The tumor cells are attached to the undersurface of the epidermis, the top layer of skin. Hence, it has been termed a superficial basal cell carcinoma. Treatment for this type of basal cell carcinoma is similar to those listed above for Nodular basal cell carcinoma, although topical creams, such as Aldara or 5-Fluorouracil, can be used.

Infiltrating Basal Cell Carcinoma grows as strands of tumor cells the grow (infiltrate) between the collagen fibers within the dermis. For this reason, it is more difficult to identify the margins of the tumor clinically (by looking). These tumors do not have the typical pimple-like appearance of a nodular basal cell. These tumors are best treated using Mohs' Micrographic Surgery, although wide excision and radiation are often used.

Morpheaform or Sclerosing Basal Cell Carcinoma often appears as a waxy, yellowish area or a scar. As they do not have the typical appearance of a nodular basal cell, typically don't ulcerate, and look rather harmless, they are often not detected by the patient and non-Dermatologists. Often, these tumors are much larger than they appear, making treatment more difficult than other types of basal cell carcinoma. For this reason, Mohs' Micrographic Surgery is the treatment of choice.