What is basal cell carcinoma?
Basal cell carcinoma, also called basal cell epithelioma or basalioma, is the most common malignant tumour in humans. It consists of an abnormal proliferation of basal keratinocytes of the epidermis (the cells that make up the settlement of the outermost layer of the skin).
What is your prognosis?
Although it is considered a cancer, its prognosis is excellent and its ability to spread to other organs beyond the skin (metastasis) is minimal – up to 1 in 35,000 cases – being an exceptionally rare cause of death. However, it does have a locally aggressive behavior, with a tendency to progressive growth in the area where it appears, so early diagnosis is the key to its prognosis. The vast majority of cases, with treatment, complete cure occurs.
How does basal cell carcinoma manifest?
It is expressed in different ways, although the most common consists of a small papule (a palpable lesion), which increases in size and occasionally bleeds without fully healing. The appearance of the lesion is variable, although the nodular shape often stands out: translucent pink coloration, with a certain pearly shine, and with small capillaries and/or dark spots inside. It usually appears in areas exposed to the sun: the face, scalp, thorax and back.
Why does basal cell carcinoma appear?
The main risk factor for basal cell carcinoma is chronic sun exposure , typical of sunny Mediterranean countries. For this reason, it appears in the most exposed areas: the face, scalp, chest and upper back.
How is basal cell carcinoma diagnosed?
The doctor in charge of the diagnosis is the dermatologist. This is done by examining the lesion, visually or by dermoscopy (epiluminescence). Currently, knowledge in dermoscopy allows an early diagnosis of the lesion (as small as 1 or 2 millimeters), thus improving the prognosis of the tumor and the effectiveness of the treatment.
The subspecialization in Dermoscopy facilitates the detection of the earliest signs of basal cell carcinoma: telangiectasias focused on all planes, bluish ovoid blood cells, maple leaf or cart wheel structures, ulcers on its surface… These points allow the dermatologist to issue an accurate and rapid diagnosis.
If there is diagnostic doubt, it is possible to perform a skin biopsy using local anthesis, an expeditious procedure that is practically painless.
How is basal cell carcinoma treated?
Treatment depends on the type of basal cell carcinoma, its depth, the area where it sits, and the patient’s general conditions.
If it is a superficial basal cell carcinoma, surgical methods (electrocoagulation or excision) or non-surgical methods can be used. In the latter case, the destruction of the lesion by applying liquid nitrogen (cryotherapy), the use of an immunostimulatory cream (imiquimod) or photodynamic therapy (PDT) are included. PDT consists of the application of a cream on the lesion, which is left on for a period of 2-3 hours and then illuminated with a lamp of special wavelength. Its main advantage is comfort and harmlessness for the patient.
The treatment of the other variants of basal cell carcinoma (nodular, pigmented, morphiform, infiltrating) requires treatment by surgery. This is performed in the vast majority of cases under local anesthesia and on an outpatient basis, without requiring the patient to be admitted. In general, most basal cell carcinomas can be treated conventionally with a simple excision and reconstruction of the defect with direct closure or using a simple reconstruction technique (flap).
In certain cases, when the basal cell carcinoma is located in a noble area (nose, eyes, eyebrows, around the lips), when it is a lesion that has recurred after treatment or when it is a multifocal or morphiform basal cell carcinoma, it is recommended to use a special surgical technique called Mohs micrographic surgery. This technique is not performed routinely, but in the cases described.
Mohs micrographic surgery consists, in the same surgical act performed under local anesthesia, microscopically and serially exploring the skin removed by the surgical dermatologist to confirm that the carcinoma has been completely removed. In short, the tumor is completely removed and the minimum of surrounding healthy skin is removed to preserve the structure of the skin where the lesion was located. This saves an unnecessarily wide excision and is as conservative as possible with a high probability of cure. This technique requires surgical subspecialization on the part of the dermatologist, since it involves remarkable surgical expertise and histological (microscopic) knowledge of the lesion. It is not a standard procedure for the treatment of all basal cell carcinomas.
Exceptionally, in very complex cases or in certain general conditions of the patient, basal cell carcinoma can be treated by radiotherapy (with the exception of the morphiform variant, which is resistant).
FREQUENTLY ASKED QUESTIONS
When should I suspect that a lesion may be basal cell carcinoma?
When a lesion appears on your skin that does not go away, bleeds or grows progressively, it is reason enough to consult your dermatologist without delay.
Which doctor diagnoses and treats basal cell carcinoma?
The specialist in charge of the diagnosis and treatment of basal cell carcinoma is the dermatologist. The greater the dermatoscopic and surgical knowledge the professional has, the earlier and more effective the diagnosis and therapy become.
Can basal cell carcinoma be diagnosed without a biopsy?
Yes. The dermatologist can reach the diagnosis only by observing the lesion, although it is always recommended to perform an examination with Dermoscopy (epiluminescence), which increases the sensitivity of the diagnosis and guides on the best treatment option. This examination is immediate, harmless to the patient and consists of observing the lesion through an image amplification system with polarized light. In cases of diagnostic doubt, a skin biopsy is performed.
Can basal cell carcinoma only be treated with surgery?
No, it depends on the type of basal cell carcinoma, its depth, its location and the patient’s conditions. Your dermatologist will advise you on the best treatment method for you.
How is basal cell carcinoma surgery performed?
The vast majority of cases can be performed under local anaesthesia and without the need for hospital admission. The standard procedure consists of anaesthesia, excision of the lesion using a scalpel (or laser) and direct closure of the resulting defect by suturing (stitches). It is usually a simple procedure with a low complication rate.
Does the treatment of basal cell carcinoma leave a scar?
Generally, yes. If non-aggressive methods such as imiquimod or photodynamic therapy are used, the probability of scarring is lower, but any treatment performed with cryotherapy, electroscalpel or surgery can leave some scarring.
The vast majority of cases the scar is very aesthetic and does not usually cause any noticeable sequelae, especially if the diagnosis is early and the initial lesion is small. In addition, the resulting scar can improve if a non-ablative fractional laser is subsequently applied.
Can basal cell carcinoma be cured without treatment?
No. It is a skin cancer and if it is not treated, it progressively increases in size. The key point of basal cell carcinoma is early diagnosis and treatment.
Is the best treatment for skin cancer by laser?
No. Laser is just one more tool for treatment. In fact, it is exceptional to treat skin cancer with laser, since it does not offer more advantages than other methods and does make therapy more expensive.
Can I suffer from basal cell carcinoma without having had the habit of going to the beach?
Yes. The main risk factor is chronic sun exposure, which can be passive (walking on the street).
Does sunbathing or UVA rays increase the risk of basal cell carcinoma?
Yes. They increase the risk of the most common skin cancers: basal cell carcinoma, squamous cell carcinoma and melanoma.
I’ve been diagnosed with basal cell carcinoma. Is it serious or deadly?
The vast majority of cases, no. The probability of it spreading to other organs beyond the skin is exceptional, and it is also the cause of death. In general, treatment produces complete healing.
Can you only have basal cell carcinoma?
No. In fact, having suffered one increases the likelihood of suffering from others, which is why routine check-ups with your dermatologist have to be followed to examine your skin periodically.
KEY POINTS ABOUT BASAL CELL CARCINOMA
→ In the event of any skin lesion that appears newly, grows progressively or bleeds, you should consult your dermatologist.
→ Basal cell carcinoma is the most common cancer in humans. Its prognosis is usually excellent and complete cure occurs if diagnosis and treatment are early.
→ The diagnosis is made by the dermatologist through clinical examination, dermoscopy (epiluminescence) and, in cases of doubt, skin biopsy .
→ Dermoscopy or epiluminescence is an immediate and harmless test that is performed using an image magnification system with polarized light. This simple test improves the sensitivity of the diagnosis and favors it to be early, favoring optimal treatment.
→ Most of the time it is treated by surgery with local anesthesia and without hospital admission, but each case must be evaluated by your dermatologist, who will advise you on the best option.
REFERENCES
• Daniëlle I.M. Kuijpers, Monique R.T.M. Thissen and Martino H.A. Neumann. Treatment Options and Prognosis, a Scientific Approach to a Common Malignancy: Basal Cell Carcinoma. Am J Clin Dermatol 2002; 3 (4): 247-259.
• N.R.Telfer, G.B.Colver and P.W.Bowers. Guidelines for the management of basal cell carcinoma. British Journal of Dermatology 1999; 141: 415-423.
Acknowledgements
To Dr. Leo Barco for giving us his images. Consult the Dermatology atlas on-line Dermafoto.