Basal Cell Carcinoma: Basal Cell Carcinoma 整形外科 周治剛 醫師 Common Skin Cancers: Common Skin Cancers Basal cell carcinoma Squamous cell carcinoma Malignant melanoma Malignant Melanoma: Malignant Melanoma Superficial spreading melanoma (70%) Nodular melanoma (15%) Acral lentiginous melanoma (10%) Lentigo maligna melanoma (5%) Malignant melanoma: Malignant melanoma Squamous Cell Carcinoma: Squamous Cell Carcinoma Squamous Cell Carcinoma: Squamous Cell Carcinoma Basal Cell Carcinoma (BCC): Basal Cell Carcinoma (BCC) The most common skin cancer. On sun-exposed skin, slow growing, and rarely metastasize. Neglected tumors can lead to significant local destruction and even disfigurement. Basal Cell Carcinoma: Basal Cell Carcinoma Pathophysiology: Pathophysiology Arise from pluripotent cells (which have the capacity to form hair), sebaceous glands, and apocrine glands. Usually arise from the epidermis or the outer root sheath of a hair follicle. Frequency: Frequency Each year in USA 900,000 people are diagnosed with basal cell carcinoma 550,000 male; 350,000 female The estimated lifetime risk of basal cell carcinoma in the white population 33-39% for men 23-28% for women Mortality/Morbidity: Mortality/Morbidity Rarely metastasizes. The incidence of metastatic BCC is estimated at less than 0.1%. The most common sites of metastasis lymph nodes, the lungs, and the bones. Typically, tumors enlarge slowly and relentlessly and tend to be locally destructive. Periorbital tumors can invade the orbit, leading to blindness, if diagnosis and treatment are delayed. Perineural invasion can occur, leading to loss of nerve function. Race, Sex & Age: Race, Sex & Age Race Most often found in light-skinned individuals. dark-skinned individuals rarely affected. Sex Men are affected twice as often as women. Probably due to increased recreational and occupational exposure to the sun in men. Age The likelihood of developing basal cell carcinoma increases with age. Rarely found in patients younger than 40 years. History: History A slowly enlarging lesion that does not heal and that bleeds when traumatized. A history of chronic sun exposure. Recreational sun exposure (eg, sunbathing, outdoor sports, fishing, boating) Occupational sun exposure (eg, farming, construction) Occasionally, a history of exposure to ionizing radiation. Occasionally, a history of arsenic intake arsenic is found in well water in some parts of the United States. Types: Types Nodular basal cell carcinoma Cystic basal cell carcinoma Pigmented basal cell carcinoma Morpheaform (sclerosing) basal cell carcinoma Superficial basal cell carcinoma Nodular basal cell carcinoma: Nodular basal cell carcinoma The most common type. Usually round, pearly, flesh-colored papule with telangiectases. Frequently ulcerates centrally, leaving a raised, pearly border with telangiectases, which aids in making the diagnosis. Most tumors are observed on the face, although the trunk and extremities also are affected. Large Scalp Nodular BCC: Large Scalp Nodular BCC Cystic basal cell carcinoma: Cystic basal cell carcinoma An uncommon variant of nodular basal cell carcinoma Often indistinguishable from nodular basal cell carcinoma clinically, although it might have a polypoid appearance. Typically, a bluish-gray cyst-like lesion is observed. The cystic center of these tumors is filled with clear mucin that has a gelatin-like consistency. Nasal Cystic BCC: Nasal Cystic BCC Pigmented basal cell carcinoma: Pigmented basal cell carcinoma An uncommon variant of nodular basal cell carcinoma Brown-black macules in some or all areas Difficult to differentiate from melanoma. Some areas do not retain pigment. Pearly, raised borders with telangiectases that are typical of a nodular basal cell carcinoma can be observed. This aids clinically in differentiating this tumor from a melanoma. Very Small Pigmented BCC: Very Small Pigmented BCC Lower Eyelid BCC: Lower Eyelid BCC Nasal BCC: Nasal BCC Morpheaform (sclerosing) basal cell carcinoma: Morpheaform (sclerosing) basal cell carcinoma An uncommon variant tumor cells induce a proliferation of fibroblasts within the dermis and an increased collagen deposition (sclerosis) that clinically resembles a scar. Appears as a white or yellow, waxy, sclerotic plaque that rarely ulcerates. The tumor infiltrates in thin strands between collagen fibers Treatment is difficult The clinical margins are difficult to distinguish. Mohs micrographic surgery is the treatment of choice. Superficial basal cell circinoma: Superficial basal cell circinoma Clinically appears as an erythematous, well-circumscribed patch or plaque, often with a whitish scale. Minute eschars may appear within the patch or plaque. Multicentric, with areas of clinically normal skin intervening among clinically involved areas. Advanced Basal Cell Carcinoma: Advanced Basal Cell Carcinoma Causes: Causes Sunlight (UVB, 290-320 nm) Artificial UV light (eg, tanning booths, UV light therapy) Ionizing radiation exposure (eg, x-ray therapy for acne) Arsenic exposure through ingestion, contaminated water source. Immunosuppression Nevoid basal cell carcinoma syndrome basal cell nevus syndrome, Gorlin syndrome autosomal dominant disorder multiple odontogenic keratocysts, palmoplantar pitting, intracranial calcification, and rib anomalies. Various tumors such as medulloblastomas, meningioma, fetal rhabdomyoma, and ameloblastoma also can occur. Bazex syndrome: follicular atrophoderma, multiple basal cell carcinomas, and local anhidrosis. History of previous nonmelanoma skin cancer 35% at 3 years and 50% at 5 years after an initial skin cancer diagnosis. The ABCDE of Malignant Melanoma: The ABCDE of Malignant Melanoma A symmetric B order irregularity C olor variability D iameter greater than 0.6 cm E levation irregularity Nevi 人皆有痣: Nevi 人皆有痣 Melanocytic nevi: Melanocytic nevi Small Nasal BCC: Small Nasal BCC Differential Diagnosis: Differential Diagnosis Staging (TNM): Staging (TNM) Primary tumor (T) TX: Primary tumor cannot be assessed. T0 - No evidence of primary tumor T1 - Tumor 2 cm or less in greatest dimension T2 - Tumor more than 2 cm but not more than 5 cm in greatest dimension T3 - Tumor more than 5 cm in greatest dimension T4 - Tumor invading deep extradermal structures Regional lymph node (N) NX: Regional lymph node cannot be assessed. N0 - No regional lymph node metastasis N1 - Regional lymph node metastasis Distant metastasis (M) MX: Presence of distant metastasis cannot be assessed. M0 - No distant metastasis M1 - Distant metastasis Stage I: T1; Stage II: T2, T3; Stage III: T4, N1; Stage IV: M1 Treatment: Treatment The treatment of BCC is surgical. Chemotherapy does not play a role. In patients with unresectable tumors, radiotherapy may be attempted as palliative treatment. Radiotherapy may be considered as an adjuvant to surgery in patients with advanced tumors or as a definitive treatment in selected patients with early tumors. Medical Care: Medical Care 5% 5-fluorouracil (Efudex), applied twice daily for 2-12 weeks effective in treating superficial basal cell carcinoma Irritation and crusting is common interferon alfa-2b, 1.5 million IU injected intralesionally 3 times per week for 3 weeks In a study, clearing 3 cases of primary basal cell carcinoma and 5 cases of primary superficial basal cell carcinoma. larger studies are needed. Imiquimod cream (Aldara), FDA approved for the treatment of superficial basal cell carcinoma. cure rates of up to 88% for superficial basal cell carcinoma. 3 times per week and advanced as tolerated to once daily and even twice daily for a 12-week course. GDC-0449 At the 2008 meeting of the American Association for Cancer Research, a preliminary report was presented on very promising results in locally advanced, multifocal, and metastatic basal cell carcinoma. Electrodesiccation and curettage: Electrodesiccation and curettage Advantages: A short procedure (<5 min) Eeffective in treating primary nodular and superficial basal cell carcinoma. Cure rates are as high as 95%. Disadvantages: Operator-dependent, often leaves a white atrophic scar. Less effective on the nose, and the tumor often tracks down pilosebaceous units. Less effective in treating infiltrating basal cell carcinoma, micronodular basal cell carcinoma, morpheaform (sclerosing) basal cell carcinoma, and recurrent basal cell carcinoma. Erbium: YAG laser ablation: Erbium: YAG laser ablation Advantages: A short procedure (<5 min) Effective in treating primary nodular and superficial basal cell carcinoma. Cure rates may be as high as 95%. A better cosmetic outcome than electrodesiccation and curettage. Disadvantages: Less commonly performed than electrodesiccation and curettage. Operator-dependent and may leave a white atrophic scar. Less effective in treating infiltrating basal cell carcinoma, micronodular basal cell carcinoma, morpheaform (sclerosing) basal cell carcinoma, and recurrent basal cell carcinoma. Cryosurgery: Cryosurgery Liquid nitrogen Advantages: good cosmetic results and good cure rates when treating tumors with well-defined clinical margins (eg, nodular basal cell carcinoma). a good option for patients who are not surgical candidates. Disadvantages: Operator-dependent, as accurate clinical detection of tumor margins increases the effectiveness of treatment. Ionizing radiation: Ionizing radiation Superficial x-ray 10 treatments of 4 gray (Gy) (400 rad). Electrons (electron beam) can be used and has gained favor over superficial x-rays by many radiation oncologists. Advantages: A good treatment option for patients who are not surgical candidates. Disadvantages: Requires multiple visits. Radiation damage and should be reserved for older patients. Less effective for nonfacial tumors. Surgical Excision: Surgical Excision Free margin excision: One must remove a margin of normal-appearing skin in order to remove all clinically invisible tumor extension. In most circumstances, a 3- to 4-mm margin of normal, clinically uninvolved skin is removed. Advantages: Usually produces good-to-excellent cosmetic results and cure rates as high as 95%. Disadvantages: Operator-dependent. Less effective in treating tumors without clearly defined clinical margins (eg, infiltrating basal cell carcinoma, micronodular basal cell carcinoma, morpheaform [sclerosing] basal cell carcinoma) Far less effective in treating recurrent basal cell carcinoma. Excision & Local Flap: Excision & Local Flap Lower Eyelid BCC: Lower Eyelid BCC Ear BCC Excision and Skin Graft: Ear BCC Excision and Skin Graft Mohs Surgery: Mohs Surgery Mohs micrographically controlled surgery Removed by excision. Removes a thin layer of tissue of surrounding skin, which then is examined under the microscope. The tumor is removed and processed to allow for localization of any tumor that might persist. Advantages: The highest cure rate (99% for primary basal cell carcinoma, 90-95% for recurrent basal cell carcinoma) The treatment of choice for infiltrating basal cell carcinoma, micronodular basal cell carcinoma, morpheaform (sclerosing) basal cell carcinoma, and recurrent basal cell carcinoma. Disadvantages: Time consuming Patients might require additional anesthesia before each stage. Complications: Complications Early postoperative complications Bleeding Infection Loss of skin graft Late postoperative complications Facial scar Ectropion Epiphora Tumor recurrence Prognosis: Prognosis Incidence of recurrence following surgical excision 30% in patients with a positive margin 12% in patients with a close margin less than 5% in patients with a complete excision. With adequate treatment, a cure rate of more than 95% can be expected. Recurrent tumors following radiotherapy have a low tumor control rate. Further Outpatient Care: Further Outpatient Care Regular skin screenings are recommended. A 35% chance of developing another tumor within 3 years. A 50% chance of developing another (not recurrent) BCC within 5 years. Avoid possible potentiating factors eg, sun exposure, ionizing radiation, arsenic ingestion, tanning beds sun-protecting clothing (ie, wide-brimmed hat and long-sleeved shirts) sunscreen is recommended prior to sun exposure.