163 BASAL CELL CARCINOMA SECTION 12 SKIN CANCER

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MHBD125-163[704-711].qxd 8/15/08 11:39 AM Page 705BASAL CELL CARCINOMAPART 13DERMATOLOGY705• May ulcerate (Figures 163-12 to 163-15) and can leave a bloodycrust.Superficial BC• Red or pink scaling plaques with a thready border (slightly raisedand pearly) (Figure 163-5).• Found more on the trunk and upper extremities than the face.Sclerosing BCC• Ivory or colorless, fl t or atrophic, indurated, may resemble scars,are easily overlooked (Figures 163-6 and 163-7).• Called morpheaform because of their resemblance to localized scleroderma(morphea).• Called infiltr ting BCCs because the border is not well demarcatedand the tumor can spread out way beyond what is visible (Figure163-16A to C).• These BCCs are the most dangerous and have the worst prognosis.TYPICAL DISTRIBUTIONNinety percent appear on face, ears, and head with some found on thetrunk and upper extremities (especially the superficial type)DERMOSCOPYDermoscopic characteristics of BCCs (Figure 163-17A to B)include (see Dermoscopy Appendix):• Large gray-blue ovoid nests.• Multiple gray-blue globules.• Leafli e areas- that look like maple leaves.• Spoke wheel areas.• Arborizing “tree-like” telangiectasia.• Ulceration.• Shiny white areas/stellate streaks.BIOPSY• A shave biopsy is adequate to diagnose a nodular BCC or a thick superficialBC .• A scoop shave or punch biopsy is preferred for a sclerosing BCC ora very fl t superficial BC .FIGURE 163-3 Nodular BCC on the lower eyelid. Patient referred forMohs surgery. (Courtesy of Richard P. Usatine, MD.)DIFFERENTIAL DIAGNOSISNodular BCC• Intradermal (dermal) nevi often have features in common with aBCC when present on the face.These features include being pearlyand having multiple telangiectasias as seen in Figure 163-18.Theirstable size and symmetry may be helpful in distinguishing themfrom a nodular BCC.A simple shave biopsy is diagnostic andproduces a good cosmetic result.A large excisional biopsy with4-mm margins for a BCC may be cosmetically deforming on theface if it turns out that the lesion was nothing more than a benignintradermal nevus. It is remarkable how similar Figure 163-18FIGURE 163-4 Large nodular BCC with an annular appearance on theface of a homeless woman. (Courtesy of Richard P. Usatine, MD.)
MHBD125-163[704-711].qxd 8/15/08 11:39 AM Page 706PART 13706 CHAPTER 163DERMATOLOGYappears to 163-1 (both biopsies proven to be as labeled) (see Chapter155, Benign Nevi).• Sebaceous hyperplasia is a benign condition commonly seen on theface in older adults and usually occurs with more than one lesionpresent (Figure 163-19).This benign overgrowth of the sebaceousglands produces small papules that have a doughnut shape with frequenttelangiectasias (see Chapter 152, Sebaceous Hyperplasia).• Fibrous papule of the face is a benign condition with small papulesthat can be fi m and pearly.• Trichoepithelioma/trichoblastoma are benign tumors on the facethat can appear around the nose.They may be pearly but usually donot have telangiectasias.These are best diagnosed with a shavebiopsy.• Keratoacanthoma is a type of squamous cell carcinoma that israised, nodular and may be pearly with telangiectasias.A centralkeratin filled cr ter may help to distinguish this from a BCC (seeChapter 160, Keratoacanthoma).Superficial BC• Actinic keratoses are precancers that are fl t, pink and scaly.Theylack the pearly and thready border of the superficial BCC (seChapter 159,Actinic Keratosis/Bowen’s Disease).• Bowen’s disease is an SCC in situ that appears like a larger thickeractinic keratosis with more distinct well-demarcated borders. Italso lacks the pearly and thready border of the superficial BCC (seChapter 159,Actinic Keratosis/Bowen’s Disease).• Nummular eczema can usually be distinguished by its multiplecoin-like shapes, transient nature, and rapid response to topicalsteroids.These lesions are pruritic and most patients will have othersigns and symptoms of atopic disease (see Chapter 139,AtopicDermatitis).FIGURE 163-5 Superficial BCC on the back of a 45-year-old man whoenjoys running in the California sun without his shirt. Note the diffusescaling, thready border (slightly raised and pearly), and spotty hyperpigmentation.(Courtesy of Richard P. Usatine, MD.)Sclerosing BCC• Scars may look like a sclerosing BCC.Ask about previous surgeriesor trauma to the area. If the so-called scar is fl t, shiny, and enlarging,a biopsy still may be needed to rule out a sclerosing BCC.MANAGEMENT• Mohs micrographic surgery (three studies, n 2,660) is the goldstandard but is not needed for all BCCs. Recurrence rate 1 is 0.8%to 1.1%. Mohs micrographic surgery is the removal of tumor byscalpel in sequential horizontal layers in which each tissue sample isfrozen, stained, and microscopically examined.This is repeated untilall the margins are clear (Figure 163-16A to C).This is thetreatment of choice for BCCs with poorly defined mar ins involvingareas of cosmetic or functional importance such as nose oreyelids. 1 SOR• Surgical excision (three studies, n 1303): Recurrence rate 1 was2% to 8%. Mean cumulative 5-year rate 1 (all 3 studies) was 5.3%.Recommended margins are 4 to 5 mm. 1 SOR• Cryosurgery (Four studies, n 796): Recurrence rate was 3.0% to4.3%. Cumulative 5-year rate (three studies) ranged from 0% to16.5%. 1 SOR Recommended freeze times are 30 to 60 secondsFIGURE 163-6 Sclerosing BCC on the forehead of a man resemblinga scar. Note the white color with shiny atrophic skin. (Courtesy of SkinCancer Foundation.)
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163 BASAL CELL CARCINOMA SECTION 12 SKIN CANCER

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