Basal cell carcinoma (BCC)

Latest update 16/06/09

This chapter is set out as follows:

• Aetiology
• Key diagnostic features
• Management

Aetiology

• Both environmental and genetic factors are important
• Risk factors include a fair complexion, blue eyes and fair hair
• Although significant sun exposure is important, as with melanoma the body sites on which BCC develop are not always the sites of maximum solar exposure
• Trauma appears to play a part in the development of some BCC and there are reports of tumours arising in sites of traumatic injury or burn

Key diagnostic features

• Age - most arise in patients aged over 40, however the incidence is increasing in younger patients

• History
  • Tend to be slow growing, often increasing in size by 2-3 mm a year
  • Often reported by the patient as never fully healing and either bleeding or producing a crust/scab from time to time

• Distribution
  • The majority occur on the head and neck, although most parts of the body can be affected
  • The incidence of superficial BCC, especially on the trunk appears to be increasing significantly
  • Uncommon on the forearms and hands, and are very rare on non hair-bearing parts of the body
  • BCC can be multiple so a thorough skin examination is needed

• Clinical findings - general
  • Tend to produce a bloody crust as opposed to the scale found in keratinising tumours such as actinic keratoses and SCC
  • Can be pigmented

• The exact appearance (naked-eye and dermoscopic) depends on the type:
  • Solid
  • Superficial
  • Nodulosuperficial or mixed
  • Morphoeic (or infiltrative)
  • Basisquamous (or metatypical)
  • BCC - other e.g. arising from a naevus sebaceous

Management

• General
  • Patients found to have BCC must take care with good UV protection. Patients limiting their recreational UV must have an adequate intake of vitamin D3 (e.g. oily fish, egg yolks, fortified milk, cod liver oil capsules)
  • Beware of multiple lesions arising in younger patients as this may reflect an underlying disorder such as Gorlins Syndrome or Xeroderma Pigmentosum (although the latter is more associated with SCC)

• Place of treatment
  • Recent changes to the NICE guidance now means that BCC can be managed by a greater number of health professionals across primary and secondary care - please refer to 'Improving Outcomes for People with Skin Tumours including Melanoma'

• Referral
  • Basisquamous BCC are best managed as for SCC and referred urgently to secondary care as a two-week wait
  • Other BCC do not come under the two-week wait system. Most patients can be referred routinely, however patients with lesions on or close to important facial structures should be referred as semi-urgent and seen within six weeks

• Treatment
  • Any indiviudal managing BCC should be fully up to speed with the British Association of Dermatologits guidelines 'Guidelines for the Managament of Basal Cell Carcinoma'

Diagnosis - Solid BCC (nodular, nodulo-ulcerative, cystic)

Key diagnostic features

• Bleeds or scabs and 'never heals'
• Distribution
  • Head and neck most common
  • The inner canthus and behind the ears are not uncommon sites so careful examination is needed
• Naked eye appearance
  • Nodule
  • Shiny/translucent, rolled edge, telangiectasia (more peripheral)
  • With time the nodule becomes more irregular and ulcerates
  • Cystic
• Palpation - very firm
• Dermoscopy
  
  • Well-focused arborising vessels
  • Blue-grey globules and ovoid structures
  • Ulceration
  • Leaf-like areas and spoke wheel areas

	Figure 1 - Solid BCC nose
	Figure 2 - Dermoscopic view of 1 Well focused arborising vessels (arrows)
	Figure 3 - Solid BCC nose
	Figure 4 - Dermoscopic view of 3 Blue-gray ovoid bodies (arrows)
	Figure 5 - Solid BCC with crust Lesion had been bleeding intermittently for 6 months
	Figure 6 - Solid BCC forearm An uncommon site
	Figure 7 - Dermoscopic view of 6 Blue-gray ovoid bodies (arrows)
	Figure 8 - Solid BCC behind ear This subtle lesion was found in a patient referred with another BCC
	Figure 9 - Heavily pigmented BCC of left cheek
	Figure 10 - Dermoscopic appearance of figure 9
	Figure 11 - BCC of left shin
	Figure 12 - Dermoscopic appearance of figure 11
	Figure 13 - BCC left medial canthus BCC are relatively common in this area. Given the potential high morbidity caused by BCC around the eyes, this site should always included as part of a thorough skin examination

Diagnosis - Superficial BCC

Key diagnostic features

• Often found in relatively younger patients (mean age 56.8 years) and may be multiple
• Distribution
  • Most often found on the trunk
• Naked eye appearance
  • Expand slowly as a red/pink patch
  • Develop a very fine raised 'whipcord' edge
  • As they enlarge the surface becomes more fragile developing focal areas of scale and crust
• Dermoscopy
  • Ulceration
  • Vessels - in some lesions arborising vessels or peripheral hairpin-like vessels present

	Figure 1 - Superficial BCC on upper back Early lesions can look very innocent
	Figure 2 - Superficial BCC trunk Note focal areas of crust (arrow)
	Figure 3 - Superficial BCC trunk Note raised whipcord edge (arrow)
	Figure 4 - Superficial BCC Even larger lesions can be subtle at first glance
	Figure 5 - The same lesion as 4 Stretching the skin reveals the rolled whipcord edge (arrow)
	Figure 6 - Superficial BCC on back
	Figure 7 - Dermoscopic appearance of figure 6 Superficial BCC can have hairpin-like vessels at the edge. Compared to those found in seborrhoeic keratoses the vessels in superficial BCC are more parallel

Diagnosis - Nodulosuperficial or mixed BCC

Note – Some clinicians use the term 'multifocal BCC'. These lesions were historically thought to arise from more than one abnormal focus. 3D analysis has cast doubt on this and suggests that such lesions originate from only one focus

Key diagnostic features

• May be poorly defined as often have a mixed picture with superficial / solid components, and sometimes an infiltrative pattern

Figure 1 - Nodulosuperficial BCC A biopsy showed evidence of a superficial lesion but excision also revealed solid components

Diagnosis - Morphoeic BCC

Key diagnostic features

• Distribution
  • Predominantly facial, especially central face
• Appearance
  • Slowly expanding yellow/ white, waxy patches with a very ill defined edge. Can be depressed
  • Surface telangiectasia
  • More advanced lesions show ulceration, crusting and fibrosis
• The lesion is firm on palpation

	Figure 1 - Morphoeic BCC
	Figure 2 - Morphoeic BCC cheek A very subtle, depressed and firm area with ill-defined edges (arrow)

Diagnosis - Basisquamous BCC (syn. metatypical BCC)

These lesions have components of both BCC and SCC

Key diagnostic features

• Appearance
  • Can become sizeable
  • More in keeping with an SCC. Thick crust/scale not uncommon
• Management
  • As per SCC - any lesion suspected or confirmed as being basisquamous should be referred urgently to secondary care as a 2-week wait

Figure 1 - Basisquamous BCC of the face Histology showed features of both a BCC and SCC

Diagnosis - BCC Other

	Figure 1 - Beware the non-healing / atypical 'leg ulcer' The patient gave a 2-year history of a non-healing ulcer on the upper shin. The lesion turned out to be a BCC with a squamous component
	Figure 2 - Naevus sebaceous and BCC A BCC can occasionally arise from a naevus sebaceous (see chapter on appendage tumours). In the past it was believd that this happened in 4% of such lesions, however it is now believed that many of the lesions previously diagnosed as BCC were instead trichoblastoma's, which are benign. Accordingly there is a move away from excising all naevus sebaceous lesions and instead offering a watch and wait policy if the patient chooses to do so This patient had the naevus sebaceous from birth (black arrow). Excision of the lesion revealed early transformation in to a BCC (purple arrow). On reflection could this have been a trichoblastoma?
	Figure 3 - BCC arising from a naevus sebaceous