Infiltrating Basal Cell Carcinoma
Maysoon ALGain
Dermatology Demonstrator
KAAU
Case Presentation
• CC: growth on right side of nose• HPI: 81 yo HF who first noted growth on
right side of nose “last December”, progressively growing.
• PMH: arthritis• SH: ½ ppd smoker X 25 years• ROS: denies F/C, significant weight loss• FH: non-contributory
Physical Exam
• General: AAO, VSS and good• VA: 20/80 OD, 20/50 OS• Pupils: 3mm OU, no APD• External: extensive ulcerative lesion from
bridge of nose to RLL and R cheek, with almost complete destruction of RLL and nearly complete ptosis of RUL
• IOP, CVF, DFE normal OS, unobtainable OD
Differential Diagnosis
• Malignant melanoma
• Squamous cell carcinoma
• Basal cell carcinoma, infiltrative
• Infectious
Basics of BCC• Background– Most common cutaneous malignancy (~80-
90%)– Typically slow-growing, rarely metastasizes– Sun-exposed skin, mostly face and scalp, esp
nose, cheek, and periorbital regions (~80%)• Frequency– 900,000 Dx in US/year– estimated lifetime risk of 33-39% for
men and 23-28% for women• Sex– Men 2X over women
Basics of BCC• Mortality/Morbidity– <0.1% metastasize– Very low mortality– Significant morbidity with direct invasion of
adjacent tissues, especially when on face or near an eye
• Age – Likelihood increases with age– Rare in <40 yo
• Race– Most often in light-skinned, rare in dark-
skinned races
Variants of Basal Cell Carcinoma
• Superficial• Nodular
• Micronodular• Infiltrating (5%)• Sclerosing/
morpheaform (5%)• Metatypical• Infundibulocystic
• Nodulocystic • Adenoid• Clear cell• Follicular• Sebaceous
• Perineurally invasive
Perineural Invasion
• May be seen in 3% of pts with infiltrating and morpheaform types
–Most often infiltrating type, which has highest rate of local recurrence
• Requires CT scan for full work-up
• Causes? inherently aggressive behavior vs inadequate early management?
Treatment Options
• Electrodessication and curettage• Curettage alone
• Surgical excision• Mohs micrographically controlled
surgery• Cryosurgery• Ionizing radiation• Surgical excision plus radiation
• Exenteration
Factors Considered in Treatment Planning
• Pt preference to keep eye• Pt age• Surgical excision-considered definitive tx• “Careful frozen section controlled excision of
periocular BCCs yields cure rates comparable to Mohs micrographic surgery at 5-year follow-up”– 5 year recurrence of 2.2% in one study– Wong, et al. “Management of Periocular Basal Cell
Carcinoma with Modified En Face Frozen Section Controlled Excision.” Ophthalmic and Plastic Reconstructive Surgery. 2002. Vol 18 (6): 430-435.
• Therefore, avoiding exenteration was considered a good possibility
Conclusion
• Basal cell carcinomas are not always as innocent as we tend to believe
• In formulating treatment course:– Strong pt preference and
other pt factors– Current research