Nodular basal cell carcinoma
See also in: External and Internal Eye,Anogenital,Hair and ScalpAlerts and Notices
Synopsis
There are many subtypes of BCC, including nodular, superficial, infundibulocystic, fibroepithelial, morpheaform (sclerosing, desmoplastic), infiltrative, micronodular, and basosquamous. Nodular BCC is the most common subtype overall and accounts for half of all lesions. In Black and Hispanic patients, BCCs are more often pigmented.
Nodular BCC is typically seen on the face, most commonly on the cheeks, nose, melolabial fold, forehead, and eyelids. Although BCCs typically arise in hair-bearing areas, they can rarely be seen in hairless genital mucosa for an unknown reason.
The greatest risk factor contributing to the development of BCCs is sun exposure, and people with light skin phototypes are at higher risk. Intermittent sun exposure is more associated with the development of BCCs than cumulative ultraviolet (UV) exposure. Other risk factors for BCCs include environmental exposure (ie, ionizing radiation, indoor tanning, chemicals such as arsenic, psoralen plus UVA, and coal tar), phenotype (freckling, red hair, light skin that always burns and never tans), immunosuppression such as organ transplantation (which results in a 5-10 times higher risk of BCCs than the general population), and various genetic syndromes including xeroderma pigmentosum, oculocutaneous albinism, Muir-Torre syndrome, basal cell nevus syndrome (Gorlin syndrome), Rombo syndrome, and Bazex-Dupré-Christol syndrome. The gene most frequently altered in BCCs is the PTCH1 gene, followed by the TP53 gene.
Although BCCs are almost never fatal, local tissue destruction and disfiguration occur. The metastasis rate of BCCs is approximately 1 in 35 000. Metastasis is rare and typically occurs through perineural spread, lymph node metastasis, and then lung / bone metastasis.
Codes
ICD10CM:C44.91 – Basal cell carcinoma of skin, unspecified
SNOMEDCT:
403911008 – Nodulo-ulcerative basal cell carcinoma
Look For
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Squamous cell carcinoma
- Keratoacanthoma
- Sebaceous hyperplasia
- Molluscum contagiosum
- Squamous cell carcinoma in situ (Bowen disease)
- Trichoblastoma
- Trichoepithelioma
- Fibrous papule
- Intradermal nevus
- Lichen planus-like keratosis
- Dermatofibroma
- Dermatofibrosarcoma protuberans
- Atypical fibroxanthoma
- Adenoid cystic carcinoma (see adenoid cystic carcinoma of ear)
- Merkel cell carcinoma
- Eccrine carcinoma
- Microcystic adnexal carcinoma
- Basosquamous carcinoma
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Management Pearls
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
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Last Reviewed:11/07/2021
Last Updated:01/29/2023
Last Updated:01/29/2023
Patient Information for Nodular basal cell carcinoma
Overview
Basal cell carcinoma (BCC), also known as basal cell epithelioma, is the most common form of skin cancer. BCC usually occurs on sun-damaged skin, especially in light-skinned individuals with a long history of chronic sun exposure. Although it requires treatment to prevent it from becoming too invasive, BCC typically does not spread to lymph nodes or other parts of the body.There are several subtypes of BCC, including:
- Nodular BCC
- Infiltrating BCC
- Superficial BCC
Who’s At Risk
Although anyone of any ethnic background or any age can develop BCC, the most people with this type of skin cancer are white and middle-aged or elderly. In fact, more than 99% of people with BCC are white, and more than 95% are between the ages of 40 and 80. Men and women seem to get BCC at equal rates.Sun exposure also can cause BCC. People who live in sunnier areas or who spend time outdoors because of work or hobbies are more likely to develop BCC.
Signs & Symptoms
The most common location for BCC is on sun-damaged skin, especially the following areas:- Face
- Head
- Neck
- Chest
- Upper back
Nodular BCCs are described as "pearly" in appearance. They are usually skin-colored or pink bumps, and tiny blood vessels can frequently be seen on their surface. As a BCC grows, it can develop a shallow hole in its center, and bleeding with minor trauma can occur.
Self-Care Guidelines
Preventing sun damage is important to avoid the development of a BCC. Wearing a broad-spectrum sunscreen with SPF 30 or higher and wearing big hats and long-sleeved shirts can help prevent some sun exposure. In addition, staying out of the sun in the middle of the day (between 10:00 AM and 3:00 PM) can be helpful.If you think that you may have a BCC, you should see your primary care provider or a dermatologist as soon as possible. There are no effective self-care treatment options.
Once a month, you should do a self-exam to look for signs of skin cancer. It is best to do the exam in a well-lit area after a shower or bath. Use a full-length mirror and a hand mirror when necessary. Using a hair dryer can help you look at any areas of skin covered by hair, such as your scalp.
- In front of a full-length mirror, look at the front of your body making sure to examine the front of your neck, chest (including under breasts), legs, and genitals.
- With your arms raised, look at both sides of your body making sure to look at your underarms.
- With your elbows bent, look at the front and back of your arms as well as your elbows, hands, fingers, areas between your fingers, and fingernails.
- Look at the tops and bottoms of your feet, the areas between your toes, and toenails.
- With your back to the mirror and holding a hand mirror, look at the back of your body, including the back of your neck, shoulders, legs, and buttocks.
- Using a hand mirror, look at your scalp and face.
When to Seek Medical Care
If you have developed a new bump on sun-exposed skin, or if you have a spot that bleeds easily or does not seem to be healing, then you should make an appointment with your primary care physician or with a dermatologist.Try to remember to tell your doctor when you first noticed the spot and what symptoms, if any, it may have (such as easy bleeding or itching). Also, be sure to ask your parents, siblings, and adult children whether they have ever been diagnosed with a skin cancer, and tell this information to your physician.
Treatments
If your physician thinks you have a BCC, he or she will want to make sure they have the correct diagnosis by doing a biopsy of the spot. The procedure involves:- Numbing the skin with an injectable anesthetic (numbing medicine or procaine hydrochloride [Novocain]).
- Sampling a small piece of skin by using a flexible razor blade, a scalpel, or a tiny cookie cutter (called a "punch biopsy"). If a punch biopsy is taken, stitches (sutures) may be placed and will need to be removed 6-14 days later.
- Having the skin sample tested under the microscope by a specially trained physician (dermatopathologist).
Nodular BCCs:
- Freezing (cryosurgery) with liquid nitrogen – Very cold liquid nitrogen is sprayed onto the BCC, freezing it and destroying it in the process. This technique is not used very often.
- Curettage, also known as "scrape and burn" – After numbing the lesion, the doctor uses a curette to "scrape" the skin cancer cells away, followed by an electric needle to "burn," or cauterize, the tissue. The cauterizing helps to kill the cancer cells and also to stop any bleeding of the site.
- Excision – The BCC is cut out with a scalpel, and sutures are usually placed to bring the wound edges together.
- Mohs micrographic surgery – In this technique, the physician takes tiny slivers of skin from the cancer site until it is completely removed. This technique is particularly useful for BCCs located on the nose, the ears, and the lips.
- Radiation treatment – X-ray therapy is often useful for patients who are not good surgical candidates because of other health issues.
Nodular basal cell carcinoma
See also in: External and Internal Eye,Anogenital,Hair and Scalp