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Basal Cell Carcinoma

Overview
Basal cell carcinoma (BCC) is the most common type of skin cancer in the United States. It accounts for approximately 75% of non-melanoma skin cancers. This type of skin cancer originates in basal cells, which are located in the bottom layer of the epidermis.

Incidence of basal cell cancer increases with age. BCC may spread to nearby tissue, but usually does not metastasize (spread) to distant sites. The prognosis is good, in most cases, and follow-up examinations are important because recurrences may occur.

Risk Factors and Causes
Exposure to ultraviolet radiation (e.g., sunlight, tanning beds) is the main risk factor for developing BCC. While it occurs more often in older adults, it is becoming more common in younger people, even people in their 20s and 30s. Fair-skinned people have a much greater risk for BCC. Radiation treatments, as well as immune suppression, also increase the risk.

Inherited disorders that manifest a greater sensitivity to ultraviolet radiation also increase the risk for BCC. For example, nevoid basal cell carcinoma syndrome (also called the basal cell nevus syndrome) causes multiple tumors to develop at a young age.

Signs and Symptoms
Basal cell carcinoma occurs most often on the head and neck, but it can affect any area. The most common sign is a pink, translucent, and/or pearly looking papule that frequently has small blood vessels running through it. These lesions bleed and scab easily, and as they grow larger, they do not "heal."

BCC can be pigmented (dark), particularly in darker-skinned individuals. In these cases, the tumors resemble non-pigmented lesions, except they are brown instead of pink.

A fairly common BCC variant is superficial BCC. As its name suggests, it rarely invades and is typically confined to the epidermis. It usually develops on the trunk and extremities and appears as a red, scaly plaque, with crusting. Its appearance and slow growth are similar to that of eczema or psoriasis, so careful diagnosis is extremely important to exclude these conditions and determine proper treatment.

A form of BCC known as morpheaform or sclerosing BCC causes a more aggressive lesion. It appears whitish, without a defined edge, and is firm to the touch. It may look like a scar and can blend in fairly well with the surrounding skin, thus escaping detection for years, while continuing to spread. When these tumors are excised (cut out), they are surprisingly larger than expected.

Diagnosis
A physician can often diagnose basal cell carcinoma on sight; however, definitive diagnosis is essential, especially given the possibility of morpheaform BCC. A skin biopsy is performed to confirm the diagnosis and to guide treatment options. A biopsy also may be used to rule out a more aggressive form of skin cancer (e.g., malignant melanoma).

Treatment
Treatment for basal cell carcinoma depends on the stage of the disease (i.e., whether it has spread to surrounding tissue), the size and location of the tumor, and the patient's overall health. Standard treatment may include surgery, radiation therapy, and chemotherapy. In some cases, more than one treatment is used.

Types of surgery include the following:

• Cryosurgery or cryotherapy (an instrument is used to freeze and destroy cancer cells)
• Curettage and electrodessication (a sharp instrument [curette] is used to remove cancer cells and then electric current is applied to control bleeding and destroy remaining cancer cells)
• Dermabrasion (a rotating instrument is used to remove cancer cells)
• Laser surgery (a laser is used to remove cancer cells)
• Mohs micrographic surgery (often used to treat skin cancer on the face because it removes little normal tissue; the lesion is removed in layers and each layer is examined under a microscope for cancer cells)
• Shave excision (cancer cells are shaved off the skin surface)
• Simple excision (cancer cells and surrounding normal tissue is removed)

In some cases, primary superficial BCC that is less than 2 cm in diameter may be treated using imiquimod (Aldara®) cream. This treatment may be used in adults on the trunk, neck, arms, or legs. The cream is applied 5 times per week for 6 weeks, usually during regular sleeping hours, and is left on the skin for 8 hours before being washed off with mild soap and water. Common side effects include redness, swelling, flaking, scabbing, itching, and burning at application site.

Radiation therapy uses high-energy x-rays to destroy cancer cells. External beam radiation uses a machine outside the body to direct radiation to the cancer cells and internal radiation (also called brachytherapy or "seed therapy") uses wires, needles, "seeds", or catheters that are placed into or near the cancer to deliver the radiation. The type of radiation used depends on the stage of the BCC.

Chemotherapy, which uses drugs to destroy cancer cells, may be used to treat basal cell carcinoma. In most cases, the chemotherapy drugs are applied directly to the skin in a cream or a lotion (called topical treatment).

Photodynamic therapy also may be used to treat basal cell carcinoma. In this treatment, a drug that is activated by light (called a photosensitizer or a photosensitizing agent) is injected into a vein. This drug is absorbed by all cells in the body, but collects at a higher concentration and remains longer in cancer cells. One to three days after the injection, when most of the drug no longer remains in normal cells, a laser is focused on the lesion, activating the drug and destroying cancer cells.

Prevention
Regular self-examination is essential to prevent basal cell carcinoma. It is recommended that all individuals, regardless of risk factors, examine their skin regularly for suspicious growths to provide early detection and improve the outcome. Sun protection, including minimizing overall exposure, regular use of sunscreen, wearing hats and protective clothing, and avoiding tanning beds decreases the risk for developing BCC.

Patients who are at increased risk for developing the disease should be regularly examined by a dermatologist, perhaps using photographs to help assess skin changes. After treatment, patients should be examined every 6 months for 5 years, and then once a year.

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