BCC- By Ajmal Rashid
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Transcript of BCC- By Ajmal Rashid
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By:- Dr.Ajmal Rashid
BASAL CELL CARCINOMA
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BASAL CELL CARCINOMA
A group of malignant cutaneous
tumors characterized by thepresence of lobules, columns,bands or cords of basaloid cells
(germinative cells).
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1. BASAL CELL CARCINOMA
Slow growing
At least 75% tumours areon face
locally invasive, aggressive,and destructive
there is a limited capacityto metastasize.
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EPIDEMIOLOGY
Most common skin cancer
More in fair skinMore common in males
On the lower leg, three timesmore common in women
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AETIOLOGY The most important risk factor is solar ultraviolet
radiation acute episodes of intense burning sun exposure are
a greater risk factor than cumulative lifetime sunexposure
Other factors
Arsenic exposure Ionizing radiation
air pollutants
burns
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Mutations in the PTCH1 gene
In Naevoid basal cell carcinoma syndrome and
in sporadic BCC tumour
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Types
Nodular
Ulcerated Superficial
Morpheic
Pigmented
Fibroepithelioma of Pinkus (FEP)
Naevoid basal cell carcinoma syndrome7
Nodular
Ulcerated
Superficial
Morpheic
Pigmented
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Nodular Ulcerated
Superficial
Pigmented
Morpheic
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Sites
Majority on the head and neck
predilection for the upper central part ofthe face
Morphoeic type - almost exclusively
on face.Superficial type - mainly on the
trunk.
Palms and soles - rarely affected9
may be multiple
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Characteristic Features
Translucency
UlcerationTelangiectasias
Rolled border
10 Characteristics may vary for different clinical sub-types
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1. BASAL CELL CARCINOMA
NODULAR TYPE
most commonly on thesun-exposed areas ofthe head and neck
translucent papule or
nodule usually telangiectasias often a rolled border
Differential diagnosis
traumatized dermal nevusAmelanotic melanoma
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Basal cell carcinoma, nodular type
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BCC nodular type
A solitary, shiny, red nodule with large
telangiectatic vessels on the ala nasi, arising
on skin with dermatoheliosis (solar elastosis).
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Nodular basal cell carcinoma in danger
zone14
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TYPES OF BCC (Ulcerated)NODULAR Usually begin as a small
pink pearly papule
Develop a depression inthe centre
Rolled edge
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BCC (Ulcerated)
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Basal cell carcinoma: ulcer type
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BCC(SUPERFICIAL)
Erythematous patch(often well demarcated)
that resembles eczema Usually found on the
trunk
May be multiple
Usually have typicalbeaded edge
D/DEczemaPsoriasisPagets diseaseBowens disease
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Superficial basal cell carcinoma
An isolated patch of eczema that does notrespond to treatment should raise suspicion
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Superficial basal cell carcinoma
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BCC (MORPHOEIC) orsclerodermiform
Ivory White or waxy
Always on face
Presents as aspontaneous scar
Margins are usuallymuch wider than what isclinically visible
dense fibrosis of the stroma
produces a thickened plaque rather
than a tumourpalpation reveals a firm skin texture
that extends irregularly beyond the
visible changes
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Basal cell carcinoma: MORPHOEIC
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Basal cell carcinoma: MORPHOEIC
D/D morphoea
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Basal cell carcinoma: MORPHOEICappearance of scar tissue in the absence of trauma orprevious surgical procedure or the appearance of atypical-appearing scar tissue at the site of a previously treated skinlesion should alert the clinician to the possibility ofmorpheaform BCC and the need for biopsy.
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BCC (PIGMENTED)
exhibits increasedmelanization
hyperpigmented,translucent papule
may also be eroded
D/D- nodularmelanoma.
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Basal cell carcinoma,pigmented
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Basal cell carcinomapigmented
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FIBROEPITHELIOMA OF PINKUS
Clinically, the lesion is a benign-appearing,pedunculated, pink tumor that may resemblean acrochordon
H/P - atypical basaloid cells
in fibrotic and mucinous stroma
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BCC (Multifocal)
Bowenoid usually found on lower legs ofwomen with sun damaged skin.
Diagnosis by biopsy
Poorly differentiated
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Multiple superficialbasal cell carcinomas
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Naevoid basal cell carcinoma
syndrome
Autosomal dominant
Skinmultiple BCCspalmoplantar pits
skin tags
milia
epidermoid cysts
Characteristic faciesFrontal bossing
broad nasal root
hypertelorism.
Other systems skeletal malformations
(mandibular keratocysts), soft tissue
Eyes Strabismus, hypertelorism,
dystopia canthorum, congenitalblindness
CNS endocrine organs
Internal Neoplasms Fibrosarcoma of the jaw,ovarian
fibromas, teratomas, andcystadenomas
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Basal cell naevus syndrome
Gorlins syndrome
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Basal cell nevus syndrome: basal cellcarcinomas
Multiple nodular BCCs on the right side of the face, frontalbossing, and a large scar on the right cheek at the site ofexcision of an odontogenic cyst.
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Naevoid basal cell carcinoma syndrome:
palmar pits
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Naevoid basal cell carcinoma
syndrome
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Follicular atrophoderma and basal
cell carcinoma
Rare genodermatosis (X-linked inheritance)
Predisposition to multiple BCCs Follicular atrophoderma
ice-pick marks, enlarged follicular ostia on thedorsa of hands,elbows, feet and face
HypotrichosisHypohidrosis
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BazexDuprChristol syndrome
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H/P Of BCC
Basaloid tumor cells
Budding from epidermis or follicle or within thedermis
Peripheral Palisading of nuclei
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well-circumscribed nodule
made up of islands of
basaloid cells
Peripheral palisading (arrowheads)
Clefting (arrows)
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A solid group of atypical basaloid cells is
present at the dermo-epidermal junctionshowing peripheral palisading and cleft
formation between tumour nest and dermis
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BCC
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Basal cell carcinoma, nodular type,
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pigmented
typical nodular basal cell carcinoma with the additionalfeature of melanin pigmentation of the tumour nests
BCC
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BCC
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Basisquamous or metatypical BCC
Tumours that on pathological study appear tohave features of both BCC and SCC
Significantly higher incidence of metastaticspread
small aggregates of cells lacking classic
palisading
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Course BCC slow progressive course of peripheral
extension, which producing thread-likemargin
doubling time is estimated to be between 6months and 1 year
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Spread Local
Periorbital tissues; bones of the face, skull ,meninges
Perineural Invasion - Uncommon
most often in histologically aggressive or recurrent lesions
may manifest as pain, paraesthesia, weakness, or paralysisDissemination - Rare
Inhalation
ulceration involves the airway inhaled and become
implanted in the lungs bloodstream metastasis
deposits in the viscera or spinal column
spread via lymphatics47
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Factors influencing prognosis in
basal cell carcinoma
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TREATMENT
Destructive therapies
Surgical excisionMohs micrographic surgery Photodynamic therapyRadiation therapy
Topical therapy Imiquimod 5-FU
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Destructive therapies
INDICATION
small primary tumors atnon-critical sites
MODALITIES
curettage and cautery
cryotherapy
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Disadvantages
risk of recurrencemorbidity associated with cryotherapy
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Surgical excision
3- 4 mm margin Tumor less than 2 cm in diameter
3-mm margin clear the tumour in 85% of cases and a 45-mm margin in 95% of cases
5-mm marginmorphoeic BCC
large BCCs (more than2 cm in diameter)
smaller nodular BCCs with poorly defined clinicalmargins
recurrent BCCs
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Mohs surgery offers superior histologic analysis of tumor
margins
while permitting maximal conservation oftissue compared with standard excisionalsurgery
Usually reserved for high risk lesions eyelids, nose, lips, ears
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Repeated cycles of surgeryand
intraoperative microscopicexamination of the entire surgical margin ofthe excised tissues
allows accurate and dependable identification
and removal of all residual invasive tumour
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Indications for Mohs Surgery for
Basal Cell Carcinoma
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Recurrence rate after MMS
Primary 1 percent
Recurrent 5.6 percent
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excision (10 percent)curettage and desiccation (7.7percent)XRT (8.7 percent)cryotherapy (7.5 percent)
superior to the rate for other modalities
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Radiation Therapy
Advantagesminimal patient discomfort
avoidance of an invasive procedure for a patientunwilling or unable to undergo surgery
Disadvantages lack of histologic verification of tumor removal
prolonged treatment course cosmetic result that may worsen over time
predisposition to aggressive and extensive recurrences
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IMIQUIMOD (5 percent cream)
Imiquimod is a Toll-like receptor 7 agonist
believed to induce interferon- and othercytokines to boost T helper 1 type immunity.
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Photodynamic Therapy
involves the activation of a photosensitizingdrug (-aminolevulinic acid) by visible light toproduce activated oxygen species that destroythe constituent cancer cells
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Flow chart BCC treatment
59 ED&C = electrodesiccation and curettage
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FOLLOW UP
Counseling about sun
protectionPeriodic full-body skin
examinationsA patient who has had one BCC should undergo
periodic full-body skin examinations for :- local recurrence
to detect fresh tumors arising elsewhere
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