A Pearly-pink Lesion on a 68-year-old Woman

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A 68-year-old woman with a history of basal cell carcinoma (BCC) presents to your office concerned about a new facial lesion she noticed about 6 months ago. There is a 6-mm shiny, skin-colored-to-pink nodule with central ulceration and a rolled border on the right malar cheek, temporal area (Figure 1). Her skin color is fair and she has moderate-to-severe photo damage.

Question 1.      

Answer and Question #2 on Next Page »

The correct answer is D. Nodular basal cell carcinoma

Question 2.

Answer and Question #3 on Next Page »

The correct answer is D. Biopsy

Question 3.

Answer and Discussion on Next Page »

The correct answer is A. Moh’s micrographic surgery

Discussion

The lesion described and seen in the Figure is a nodular basal cell carcinoma (BCC), a tumor found on sun-damaged skin that is relatively easily recognized during routine skin examination. BCC is more common than all other human malignancies combined and its incidence continues to rise, with more than 2.8 million new cases of BCC diagnosed annually in the United States.¹ The main clinical subtypes of BCC include nodular BCC, 50-79%; followed by superficial BCC, up to 15%; and morpheaform BCC, approximately 5-10% of BCC cases.² Nodular BCC presents as pink-to-pearly shiny papules or nodules often with telangiectasia and ulceration.³ Initially the lesions have a smooth surface, but with time they enlarge and ulcerate to form an elevated, rolled border.³

[[{"type":"media","view_mode":"media_crop","fid":"56572","attributes":{"alt":"","class":"media-image media-image-right","height":"217","id":"media_crop_5809649073390","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7111","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Figure. Basal cell carcinoma","typeof":"foaf:Image","width":"207"}}]]Risk factors for BCC include those of other skin cancers, namely sun exposure, fair complexion, light eyes, and increasing age.⁴ Intermittent, intense UVB exposure is the greatest risk factor, but other risk factors include chronic immunosuppression, radiation therapy, and arsenic exposure.⁵ BCC can appear on any part of the body. Mainly it is found in areas with extensive sun exposure, with about 80% located on the head and neck.⁶ Clinical diagnosis can be quite sensitive and specific for BCC, however a biopsy is required for confirmation and classification of histologic subtype, which predicts behavior and has implications for therapeutic decision making.⁵

Metastases of BCC are rare, but treatment is indicated because of the destruction of local tissue and locally invasive activity.⁴ Multiple treatment modalities are available including Moh’s micrographic surgery (MMS), simple excision, electrodessication and curettage, cryosurgery, and topical therapy. MMS is a dermatologic surgery technique that optimizes margin control and tissue conservation; MMS is the first line treatment of BCC that is assessed to be high risk for recurrence or for optimal preservation of function and cosmesis.⁷ A combination of factors including anatomic location, histologic features, primary or recurrent tumors, and patient characteristics influence the choice of treatment.⁷

Criteria for appropriate use of MMS were established by the American Academy of Dermatology in 2012 and are available as a free algorithmic mobile application to help guide clinical practice.⁸ The algorithm, which includes area of the body affected, primary or recurrent occurrence, subtype, lesion size, patient health, and presence of aggressive features indicating high risk for recurrence, is used to rate the indication of MMS for treatment of BCC.⁹ Affected areas are divided into 3 risk groups⁹:

 â–º High-risk area H (mask area of the face, eyebrow, nose, lips, chin, ear, genitalia, hands, feet and nipples/areola)

 â–º Medium-risk area M (cheeks, forehead, scalp, neck, jawline, pretibial surface)

 â–º Low-risk area L (trunk and extremities unless otherwise specified)

Importantly, MMS is appropriate for any BCC located in area H, as is the lesion of the patient pictured in the present case, and for any BCC in area M that is not a primary superficial BCC less than or equal to 0.5 cm.⁹ In area L, MMS is appropriate for treatment of nodular or aggressive recurrent lesions, primary aggressive lesions greater or equal to 0.6-cm, and primary nodular lesions greater than 2.2-cm in healthy patients.⁹

It is important to remember that appropriate use criteria do not compare the merits of MMS to other modalities and clinical judgment is necessary to optimize treatment for each individual patient.

Part 3: Three Suspicious Lesions on an Elderly Woman's Face>>

Click on links below for other sections of this Special Report, Non-melanoma Skin Cancer: A Primer for Primary Care

Part 1: Introduction and Pre-test

References:

1. Mohan SV, Chang ALS. Advanced basal cell carcinoma: epidemiology and therapeutic innovations. Curr Dermatol Rep. 2014;3:40-45.

2. Marzuka AG, Book SE. Basal cell carcinoma: pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management. Yale J Biol Med.  2015;88:167-179.

3. Bolognia J, Jorizzo JL, Schaffer JV. Dermatology. [Philadelphia]: Elsevier Saunders; 2012.

4. Linares MA, Zakaria A, Nizran P. Skin cancer. Primary care. 2015;42:645-659.

5. Gandhi SA, Kampp J. Skin Cancer epidemiology, detection, and management. Med Clin North Am. 2015;99:1323-1335.

6. Wong CS, Strange RC, Lear JT. Basal cell carcinoma. BMJ (Clinical research ed.). 2003;327(:794-798.

7. Lewin JM, Carucci JA. Advances in the management of basal cell carcinoma. F1000Prime Rep. 2015;7:53.

8. Mohs Surgery Appropriate Use Criteria (AUC) app. AAoDMSA-pUCA. https://www.aad.org/members/aad-apps/mohs-auc.

9. Connolly SM, Baker DR, Coldiron BM, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Derm. 2012;67:531-550.