Basal Cell Carcinoma


Basal Cell Carcinoma Is Very Common

There’s a reason people aren’t too scared when they hear the words basal cell carcinoma. Basal cell carcinoma is the least deadly type of skin cancer. It’s also the most common type. If you’ve heard about basal cell carcinoma before (possibly from reading this blog), you may know that basal cell carcinoma is the least aggressive of the skin cancer types. However, it’s not entirely benign. It can lead to serious disfigurement if you let it progress. Basal cell carcinoma can be very destructive.

Need to know only the basics about basal cell before going back to watching TV? Here are some quick stats and facts that you should know.

basal-cell-carcinoma-infographic-epidemiology-treatment-prevention

How is basal cell carcinoma different from melanoma?

Basal cell carcinoma originates from the basal cells of the epidermis. The epidermis is the top layer of the skin. The epidermis is further divided from top to the bottom into the stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and lastly the stratum basale. Within the basal layer, there exists a type of cell called the keratinocyte. The keratinocytes that live in the bottom of the epidermis in the basal layer are stem cells. They are able to regenerate almost indefinitely to make more of the skin cells of the upper layers. When these basal cells undergo mutation, cancers can develop. Mutations can be caused by UV light exposure or the normal process of cell division. Melanoma is a different type of skin cancer. Melanoma originates from a different cell type called the melanocyte. Melanocytes are also located in the stratum basal. Melanocytes lie sandwiched between keratinocytes.

How do you get basal cell carcinoma?

Basal cell carcinoma is linked to UV light exposure history. The most common sites for basal cell carcinoma to develop are those exposed to the sun. Unexposed areas of the body can also develop basal cell carcinoma, but this is rare.

If you have fair skin, light hair, light eyes, and a long history of sun exposure, chances are you may develop a basal cell carcinoma later in life. The cumulative sun exposure of a lifetime is the greatest risk factor. Unlike with melanoma, scientists believe that intense burns (like the ones we would get during childhood summers) do not increase the risk for basal cell carcinoma. It’s the cumulative dose of sun exposure that increases the risk.

Rare Causes of Basal Cell Carcinoma

There is also a very rare genetic condition that predisposes people to develop basal cell carcinomas. It is called Nevoid basal-cell carcinoma syndrome or Gorlin syndrome. This is caused by a mutated version of a gene. This mutated gene makes sufferers incredibly susceptible to developing basal cell carcinomas.

I have a spot on my skin that looks like the pictures you posted. Do I have basal cell carcinoma?

I can’t tell you whether your skin lesion is skin cancer or not. You should consult with your dermatologist anytime you are worried about something on your skin.  They can check your skin lesion for any of the classic signs of basal cell carcinoma.

What are these signs you may be wondering? When looking at a basal cell carcinoma, your doctor will look for small blood vessels we call telangiectasias. They are also generally pearly in nature and pink. The most classic description is that of the pearly pink nodule, but there are many histologic subtypes of basal cell that can present in different ways. Your dermatologist may use a special magnifying lens called a dermatoscope to decide whether your skin lesion looks suspicious or not. This is why it’s important to visit your dermatologist regularly and monitor your own lesions at home. Any changes can be signs of early skin cancer.

I made an appointment with my dermatologist. What should I expect?

If your doctor thinks your skin lesion is suspicious enough, he or she will perform a biopsy. If your lesion looks like a little ball sticking out of your skin (we call this a nodule), the doctor will use a scalpel to perform a shave biopsy. If the lesion is ulcerated or flat, the doctor will instead perform a punch biopsy. You can learn more about the different types of biopsies here.

The Procedure

In order to start any procedure, the doctor has to wipe the area with alcohol first. Then he or she will inject a local anesthetic such as lidocaine. The doctor will let the lidocaine take effect. This is almost immediate. Next, he or she either removes the skin lesion entirely (as in a shave biopsy) or punches into the skin with a biopsy tool to get a full thickness skin sample.

Depending on the type of biopsy, you may or may not need stitches. Punch biopsies generally require 1-2 stitches. Bleeding from a shave biopsy can be controlled with a special solution such as aluminum chloride. Your dermatologist will dab this on to decrease the bleeding. A simple band-aid will usually suffice.

You will then go home and recover from the procedure. Feel free to tell your loved ones it was a traumatic experience and demand that they bend to your will as you “recover.”

You can expect the pathologist to send a report to your dermatologist in 7-10 days with the results. If you haven’t gotten the results back from your doctor, call their office.

If I definitely have basal cell carcinoma, how will my doctor treat it?

There are many options when treating basal cell carcinoma. The option your doctor chooses will depend on the extent of invasion of your cancer, the size, the location on your body, and your preferences as a patient. (1,2) A good dermatologist will always take the time to talk to you about possible complications and describe the procedure.

Here are the possible ways to treat basal cell carcinoma:

Electrodesiccation and Curettage:

This is a fancy way of saying your doctor scrapes the skin cancer off and uses electricity to burn it. This can only be done on small cancers. The scraping is done with a curette tool. A curette is a metal tool with a sharp loop at the end. There will be 2-3 rounds of scraping and burning. The room will be saturated by the smell of burning human flesh, but if you can get through this very minor procedure you have a greater than 95% chance of being cured. You won’t need stitches, and the wound can be covered with a simple bandage.

curette

Curette tools.

Mohs Micrographic Surgery:

This method requires more time and labor for your dermatologic surgeon to complete. Not every dermatologist is also a Mohs surgeon, but all Mohs surgeons are also dermatologists. This is indicated when the cancer is located in a cosmetically sensitive area.

Mohs surgery has very high cure rates because the doctor is checking all the borders of the tumor to see if you are cured. You can read all about Mohs surgery here, or continue reading this page for a synopsis.

The Steps in Mohs Surgery

Like most procedures, it begins with the injection of local anesthesia. The doctor will remove the skin cancer as close to the outwardly visible margins as possible. The site where the cancer was removed is covered and bleeding is minimized.

You head back to the waiting room until it’s your turn again. The doctor takes that sample that’s just been removed to a back room where a technician will prepare the sample to be seen under the microscope. The sample has been marked in a certain way so the orientation (up, down, left, or right) is known. When the sample is ready, the doctor will look at it under the microscope to see if the edges are clear of cancer.

If the margins are not clear, let’s say there is still a bit of cancer at the 9 o’clock position and the 5 o’clock position, then the dermatologic surgeon knows that he or she must cut further into those 2 sides. This goes on for as many rounds as necessary until you’re cured based on what is seen under the microscope.

Once you’re cured, the doctor decides on the best way to close the surgical site back up with the best possible cosmetic result. This will involve stitches. The stitches and the extent of the defect may look very big at first. Don’t be scared! Mohs surgery patients tend to heal well, and the scar is much smaller in a few months.

It’s called micrographic surgery because the greatest amount of healthy tissue is spared due to the fact that you’re using the microscope to check the sample every time.

Simple excision:

This is the same procedure used to remove suspicious pigmented lesions that may be melanoma. The doctor applies anesthesia. Instead of cutting very close to the skin cancer, the doctor will cut with a margin of 2-3 millimeters in the shape of an ellipse. Then, the doctor closes the ellipse with stitches.

Simple excision is used when there isn’t a clear necessity for Mohs surgery. Why doesn’t my doctor go with Mohs every single time? Mohs surgery is expensive. Can you imagine how much more money it costs the healthcare system to check every piece of tissue removed? Plus the time the doctor has to spend going back and forth to check it. Seeing as we have limited healthcare resources, if you have a well-demarcated skin cancer on your leg. the dermatologist we can simply cut it off at a fraction of the cost and time. You do not want to be the patient in the waiting room for 5 rounds of Mohs.

Topical Medications:

The options for topical medications are imiquimod or 5-fluorouracil. These can be used for 3-6 weeks if the surface area of the cancer is large to reduce the size. These are only indicated for very superficial skin cancers. One major drawback is that since there is no removal of tissue, there is nothing to examine under the microscope by the pathologist. If the pathologist can’t examine the margins, you can’t be sure that you cured the skin cancer. These medicines can be irritating. This is the most common side effect that causes patients to stop the treatment.

Cryosurgery:

Cryosurgery is the medical term for freezing something off with liquid nitrogen. This can be done with or without local anesthesia. The pain of the anesthesia is often worse than the liquid nitrogen. The doctor will spray liquid nitrogen about 3 times over the cancer spot. It will feel painful like a burn because it gets insanely cold. The skin will blister like a burn, and the skin will crust over and fall off. This is good for superficial basal cells. People with bleeding problems or intolerance to local anesthesia can be good candidates for cryosurgery. Cure rates aren’t as good compared to techniques that remove the skin cancer.

molluscum-freezing-cryotherapy

Liquid nitrogen delivery device.

Radiation:

Radiation is only used when surgery is not an option. It may require 15-30 treatments.

Photodynamic Therapy:

Photodynamic therapy, commonly referred to as PDT, is not commonly used for skin cancer. In this procedure, the doctor applies a photosensitizing agent like 5-aminolevulinic acid to the skin cancer.

A photosensitizing agent makes the cancer cells sensitive to light exposure. The cancer is then exposed to blue light. The cancer cells are selected by the medicine so only the cancer cells die. You can expect some redness and swelling. You have to avoid UV exposure for 2 days after this because the photosensitizing medicine may still be active.

Oral Medications:

There are currently 2 medications on the market that are FDA approved to treat basal cell carcinoma. They’re called Erivedge (generic: vismodegib) and Odomzo (generic: sonidegib). They’re only indicated for the rare cases of a metastatic basal cell or advanced cancer where radiation and surgery are contraindicated. The most common side effect of Erivedge is a loss of sense of taste. This can lead to weight loss.

Have you or a friend ever been diagnosed with a skin cancer? What technique did your doctor use to treat it?

References:

  1. American Academy of Dermatology. Basal Cell Carcinoma. https://www.aad.org/public/diseases/skin-cancer/basal-cell-carcinoma
  2. Skin Cancer Foundation. Basal Cell Carcinoma Treatment Options. http://www.skincancer.org/skin-cancer-information/basal-cell-carcinoma/bcc-treatment-options

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