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 E xenteration

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 Vol 18 (6): 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