1. Basal Cell Carcinoma Presented by: Bill V. Way, D.O. AOCD Board Certified Dermatologist Residency in US Army at Walter Reed Consultant for Charlton Methodist Hosp for past 19 years

2. Epidemiology and Etiology Incidence US 500-1000 per 100,000 >400,000 new patients annually Age usually over age 40 Sex Males >Females Race rare in brown and black skinned pt

3. Diagnosis High index of suspicion Onset Prior treatment

4. Types of BCC Supeficial BCC Nodular BCC Pigmented BCC Cystic BCC Sclerosing or Morpheaform BCC Recurrent BCC

23. Biopsy Biopsy: Shave, Punch,Excision Specimen to reliable dermatopathologist or pathologist

24. What to Biopsy Select a good representation of the lesion for biopsy If small lesion, biopsy the entire lesion Final treatment code is dependent on actual size of lesion at time of biopsy Get exact measurements of lesion, digital photo if possible

25. When should you do a biopsy? If you are unsure of diagnosis of lesion and have in the differential a skin cancer, basal cell carcinoma, squamous cell carcinoma or melanoma, then do a biopsy List your differential in the order which you think the lesion is. Learn from your errors.

26. Methods of Biopsy Shave Biopsy: easiest and fastest Punch Biopsy: depth of lesion Excisional Biopsy: > time, > expense, complete removal of tumor Incisional Biopsy: partial removal of tumor, >time, > expense

27. Shave Biopsy Xylocaine 2% with epi 1cc tuberculin syringe, 30g needle Non-sterile gloves #15 sterile blade Bard Parker Specimen bottle, labeled correctly Drysol solution Bacitracin Ointment, Bandaid

29. Punch Biopsy Xylocaine 2% with epi 1cc tuberculin syringe, 30g needle Sterile gloves Punch : 2mm, 3mm, 4mm, 6mm Minor surgery tray, suture size for area Specimen bottle labeled correctly Bacitracin Ointment and bandaid

37. Excision or Incisional Biopsy Xylocaine 2% with epi 3-5cc syringe, 30g needle, sterile gloves #15 or #11 sterile blade, surgery tray Suture for area, absorbable, non-absorbable Specimen bottle labeled correctly Bacitracin Ointment and sterile dressing

38. Treatment of BCC Electrodesiccation and curettage Excision Cryosurgery Moh’s Surgery Radiation 5-Fluorouracil Aldara (Imiquimod)

39. Electrodesiccation & Curettage Hyfrecator Curettes: 2mm, 3mm, 4mm EDC times 3 Expect scar formation 85-90% cure rate Check for Pacemaker, Defribralator

45. Excision Adequate outline of tumor margin Adequate margins 3-5mm Surgery Tray, Hyfrecator Suture: absorbable, non-absorbable Tag tip, specimen labeled correctly Pressure dressing, antibiotic ointment

46. Cryosurgery Used only for superficial and small nodular BCC Not indicated for deeper BCC High morbidity, very painful

47. Moh’s Surgery Can be used on all BCC Difficult lesions: sclerosing or recurrent, poorly defined borders, tumors of nose, eyelids Recurrent lesions Lesions over 25mm dia 98% cure rate Expensive, > time Few Moh’s Surgeons, Dermatologist

57. Radiation therapy For elderly pt who can not tolerate surgery Useful for eyelids and lips Requires several outpt visits If used in young pt can lead to development of SCC or recurrent BCC later in life at same site

58. 5-Fluorouracil Should not be used today Can destroy surface without affecting deeper bcc cells

59. Prevention Frequent skin examination q 3 months Yearly by PCP or Dermatologist Sunscreens SPF 15 or higher Protective clothing, hats, sunglasses Team approach: Patient, Family, Doctor

60. Remember Look at all the patient’s skin, especially the sun exposed skin. Biopsy ?? Lesions Treat if trained and comfortable Otherwise refer to a more qualified physician: Dermatologist, Moh’s Surgeon, Plastic Surgeon Follow patients frequently

61. Thank you We look forward to future lectures and having you each do rotations in dermatology if possible.