BASAL CELL CARCINOMA
A skin tumor originating in the basal layer of the epidermis, basal cell carcinoma is the most common skin neoplasm, aggressive due to its potential to invade tissues both deeply and superficially, and due to its high rate of local recurrence, but it rarely metastasizes to distant sites (0.5%).
In 86% of cases, the preferred location is the face. The incidence of basal cell carcinoma has also been steadily increasing in recent decades, affecting 10% of the Caucasian population, mainly older adults.
Factors involved in the development of basal cell carcinoma include primarily UV radiation exposure, followed by ionizing radiation, arsenic ingestion, immunosuppression due to prolonged corticosteroid therapy, presence of precursor lesions (actinic keratosis), and genetic factors (xeroderma pigmentosum).
CLINICAL FORMS OF BASAL CELL CARCINOMA
The typical clinical appearance is the nodular ulcerative form (rodent ulcer), which appears as a single, well-defined lesion. Initially, it presents as a translucent papule, primarily located on the face and neck (80% of cases).
Superficial basal cell carcinoma is a flat, erythematous lesion with multiple crusts, slightly pigmented, that develops slowly, predominantly on the upper trunk, especially on the shoulders.
The nodulocystic clinical form appears as a single red nodule with a network of dilated vessels, primarily on the face. The cystic structure may rupture at the skin surface, releasing fluid spontaneously.
Morfeoform (sclerosing) basal cell carcinoma is considered the most aggressive clinical form, characterized by a flat, indurated lesion with poorly defined, ‘scar-like’ margins, making excision difficult as invasion has been observed up to 7mm beyond the apparent edges.
Pigmented basal cell carcinoma can pose significant differential diagnosis challenges with cutaneous melanoma. It may combine an ulcerated nodule with dark brown pigmentation.
The diagnosis of basal cell carcinoma is based on clinical examination, with biopsy necessary in doubtful cases. For a definitive diagnosis, excisional biopsy and histopathological examination of the lesion are required.
TREATMENT OF BASAL CELL CARCINOMA
Biopsy of the tumor formation is performed to obtain a positive diagnosis. The main biopsy types used are:
- lesion curettage
- core needle biopsy
Excisional biopsy is, in the opinion of plastic surgeons, the most accurate method to obtain a histopathological diagnosis, and also serves a curative purpose. This avoids an additional surgical intervention.
Excision of the tumor is performed with oncological safety margins (5–10mm), followed by intraoperative examination of the tumor, including its superficial and deep margins. Unlike the techniques mentioned above, this method ensures assessment of tumor invasion in depth.
TREATMENT GOALS
The treatment of basal cell carcinoma must achieve three objectives:
- complete excision of the tumor;
- preservation of function, especially in tumors located on the eyelids, nose, perioral area, or ears;
- achieving an acceptable cosmetic outcome, considering that most basal cell carcinomas occur on the face. However, this goal must be secondary to the first objective, due to the high recurrence rate of basal cell carcinoma caused by the tendency to preserve as much apparently healthy tissue as possible, which may still harbor microscopic invasion.
Treatment of basal cell carcinoma is primarily surgical. Surgical techniques used include:
- surgical excision
- Mohs micrographic surgery
- cryosurgery
- curettage
- cauterization
Surgical Excision
In our clinic, we consider the best therapeutic option to be surgical excision, followed by intraoperative margin examination. Post-excisional defects are managed using plastic surgery techniques: direct suturing, full-thickness skin grafts (if the tumor was on the face or hand), split-thickness skin grafts, or local flaps. Statistically, postoperative results are positive, with 90% of interventions being curative.
Preoperatively, the excision margins and the flap needed to cover large defects are marked. Surgical excision is recommended under general or regional anesthesia.
Mohs Micrographic Surgery
This surgical technique, developed by Frederick Mohs in 1930, involves obtaining frozen sections of the tumor margins, which are then microscopically analyzed by a pathologist. The entire circumference of the section is examined. If results are positive, re-excision is performed with further microscopic analysis of frozen sections. The curative success rates of Mohs micrographic surgery are 99% for primary basal cell carcinomas and 95% for recurrent tumors.
The high cost of this technique, combined with similar results achieved by an experienced surgeon, limits its widespread use.
FOLLOW-UP OF PATIENTS WITH BASAL CELL CARCINOMA
Post-treatment follow-up for patients with primary basal cell carcinoma includes examining the scar for early detection of local recurrence, as well as clinical examination of the entire skin for the development of new basal cell carcinoma lesions.
Multiple studies have shown a high risk of basal cell carcinoma recurrence: 44% within 3 years of the first treated lesion. Additionally, in a significant number of cases, the risk of developing a new tumor at a different site is 30% within the first year.
The risk of basal cell carcinoma recurrence is high, which necessitates close monitoring during the first 5 years.
Factors increasing risk of recurrence include:
- large tumors
- poorly defined tumor margins
- tumors that exceeded therapeutic limits, invading deep planes (orbit, sinuses)
- aggressive clinical forms (morpheiform)
- tumors located in surgically difficult areas of the face
- where achieving safe excision margins is challenging
- histopathological indicators of tumor invasiveness: vascular or neural involvement
- failure of initial treatment (much higher risk after first recurrence)
- immunosuppression
Clinical signs of tumor recurrence, subtle at onset, appear around the scar and include telangiectasia, pearly tumor formations, erythema, ulceration, or scar enlargement.
Patient monitoring after basal cell carcinoma treatment should also include preventive measures against recurrence: use of sunscreen, avoidance of sun exposure, and self-examination, considering that 80% of basal cell carcinomas occur on the face.
CUTANEOUS MELANOMA
Among skin neoplasms, melanoma is the most aggressive tumor once it breaches the skin barrier, as malignant melanocytes spread to lymph nodes and distant organs, leading to rapid progression towards fatal outcomes.
In recent decades, melanoma incidence has steadily increased.
Malignant melanoma results from the malignant transformation of melanocytes, cells primarily responsible for producing melanin, a pigment that absorbs UV rays and protects the body from their harmful effects.
Adults are affected, mostly over 40 years old, with both sexes equally. Early-stage diagnosis, when melanoma is curable, remains a major challenge.
The etiology of cutaneous melanoma is not yet fully understood. Certain risk factors have been identified:
- high number of pigmented nevi
- presence of dysplastic nevi
- primarily affecting individuals of Caucasian descent
- adult age
- family history of melanoma
- environmental factors: history of UVB exposure during childhood and adolescence
- use of artificial tanning devices
The most important clinical features suggesting malignant melanoma are summarized under the ABCDE acronym:
- Asymmetry of a skin lesion
- Irregular borders
- Color variation, including red, white, and, in brown or black lesions, blue tones
- Diameter greater than 6 mm
- Elevation of the surface
WHAT TO DO IF CUTANEOUS MELANOMA IS SUSPECTED?
After consultation with a specialist plastic surgeon or dermatologist, dermatoscopy must be performed.
Dermatoscopy and computer-assisted dermatoscopy are non-invasive imaging techniques using optical systems that provide 10–20x magnification, enabling early detection of cutaneous melanoma.
