How To Prevent Basal Cell Carcinoma Recurrence

Target Therapy: Hedgehog Inhibitors

Given the diffuse alteration of the Hh pathway in BCC, its inhibitors have been studied and approved recently as a first-line therapy for patients with aBCC. Moreover, a joint expert consensus has proposed criteria to define those cases for which surgery or irradiation are not indicated and therapy with systemic HPI is recommended . The first natural HPI identified was the cyclopamine, discovered in corn lily plants, which acts as binding SMO. Cyclopamine resulted to be teratogenic, leading to embryonic craniofacial defects . Subsequently, modifying cyclopamine, patidegib was synthesized, which was administered by mouth in a phase I trial, demonstrating a not favourable adverse effect profile . On the other hand, topical administration is followed by tumour shrinkage, in the absence of side effects . Consequently, the research of oral HPI with a better safety profile led to the discovery of vismodegib and sonidegib . Vismodegib and sonidegib are the only targeted oral therapy approved by FDA and EMA for the treatment of aBCC ineligible for curative surgery or radiotherapy . Furthermore, other known molecules, such as azole antimycotic compounds, particularly itraconazole, show inhibition of the Hh pathway. Itraconazole suppresses SMO migration and accumulation in the primary cilium . Its efficacy as an oral treatment for BCC was demonstrated in an open-label, exploratory phase II trial .

Table 3.

Criteria to define patients with BCCs not eligible for surgery or irradiation

How Is Nodular Basal Cell Carcinoma Of Skin Treated

In general, the treatment of Basal Cell Carcinoma of Skin depends upon a variety of factors including:

• The subtype of BCC
• The location of the tumor
• The number of tumors
• The size of the tumor
• Whether the tumor has metastasized

A combination of treatment methods may be used to treat Nodular Basal Cell Carcinoma of Skin. The type of surgery may include:

• Shave biopsy of skin: This procedure is used for small tumors. There is no requirement of sutures after the surgery
• Excision of tumor: In this procedure, the tumor and surrounding tissue are removed with clear margins. Depending upon the amount of skin removed, surgical sutures may be necessary
• Mohs surgery: In this procedure, the tumor is removed layer by layer precisely, until clear margins are achieved. Each layer removed is examined under a microscope through a âfrozen sectionâ procedure, for the presence of residual tumor

In most cases, a surgical removal of the entire tumor is the preferred treatment option. This can result in a cure.

Other techniques to treat this skin cancer may include:

• Cryotherapy: Here the tumor tissue is destroyed through a freezing technique. Typically liquid nitrogen is used to freeze the tumor
• Topical creams, such as 5-fluorouracil cream and imiquimod cream, are two examples that can be used for topical treatment. These creams may be applied for several weeks, which slowly destroys the tumor

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Diagnosis And Treatment Of Basal Cell And Squamous Cell Carcinoma

JONATHON M. FIRNHABER, MD, East Carolina University, Brody School of Medicine, Greenville, North Carolina

Am Fam Physician. 2012 Jul 15 86:161-168.

• References

Nonmelanoma skin cancer, which includes basal cell carcinoma and squamous cell carcinoma, is the most common cancer in the United States. Approximately 80 percent of nonmelanoma skin cancers are basal cell carcinoma and 20 percent are squamous cell carcinoma. Although the National Cancer Institute does not formally track the incidence and prevalence of nonmelanoma skin cancers, multiple longitudinal studies indicate that the incidence has risen sharply over the past two decades.1

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Infiltrative Basal Cell Carcinoma

Infiltrative basal cell carcinoma is an aggressive type of skin cancer that requires surgical treatment. Subtypes of infiltrative basal cell lesions include micronodular carcinoma and morpheaform carcinoma.

Causes: Infiltrative forms of basal cell cancer, like those of the nodular and superficial types, are linked to both genetic factors and environmental factors such as prolonged sun exposure in youth.

Symptoms: The symptoms of infiltrative basal cell lesions vary according to subtype. Micronodular lesions are typically firm, yellowish-white in color, and have a distinct border. Morpheaform lesions resemble plaque or scar tissue, have vague and far-reaching borders, and are prone to crusting and bleeding.

Diagnosis and Treatment: A thorough skin biopsy is necessary for this type of basal cell cancer, as infiltrative lesions are visually easy to mistake for other non-cancerous forms of scar tissue. Surgical excision with margin examination, radiation therapy, and Mohs micrographic surgery are the most effective treatment options.

Once a patient has been diagnosed with one of the types of basal cell cancer, he or she can discuss treatment options with medical professionals and can proceed with having the cancer removed. Because several effective basal cell surgical procedures and medication options are available, patients who are diagnosed while the disease is in early stages often have a very good prognosis.

Infiltrated Basal Cell Carcinoma

This version of basal cell carcinoma is presented as thin bundles of basaloid cells with nest-like configuration located between the collagenous fibers on the dermis and infiltrating in the depth. Clinically, it is a whitish, compact, not-well defined plaque . The most common localization is in the upper part of the trunk or the face. Seldom had the paresthesia or hyperesthesia as a symbol of perineural infiltration appeared, especially when the tumor is localized on face. This clinical version is often underestimated when the borders of surgical excision are estimated. Histologically this variant is presented as thin, nest-like bundles of basaloid cells infiltrating in the dermal collagenous fibers .

Infiltrated basal cell carcinoma. Thin bundles of basaloid cells invade the dermis

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Certain Factors Affect Prognosis And Treatment Options

The prognosisfor squamous cell carcinoma of the skin depends mostly on the following:

• Stage of the cancer.
• Whether the patient is immunosuppressed.
• Whether the patient uses tobacco.
• The patients general health.

Treatment options for basal cell carcinoma and squamous cell carcinoma of the skin depend on the following:

• The type of cancer.
• The stage of the cancer, for squamous cell carcinoma.
• The size of the tumor and what part of the body it affects.
• The patients general health.

Causes Of Basal Cell Carcinoma

Pro Tip

Newer treatments for severe, advanced basal cell carcinoma target the PTCH gene. PTCH is a tumor suppressor gene that normally prevents uncontrolled cell growth but has malfunctioned in many basal cell carcinomas, causing abnormal cell replication. Dr. MacCormack

Cancers develop because of abnormal, uncontrolled cell growth. BCCs are caused by an overgrowth of basal cells. Often, the overgrowth occurs because cell DNA has been damaged.

The most likely reason you have a BCC is from being exposed to sunlight. Exposure to UV radiation, especially severe, intermittent sunburns, increases the risk of developing BCC. People with pale skin, blue eyes, and blond hair are a greater risk of BCC than individuals with darker complexions.

Basal cell DNA can also be damaged by other UV light exposure, such as from tanning beds, by ionizing radiation , and from chemicals like arsenic, which can be found in well water.

Some genetic syndromes, diseases , and medical treatments that suppress the immune system, like chemotherapy, may impair cell DNA repair, increasing the likelihood of getting BCCs.

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Risk Factors For Recurrence

The chance of recurrence varies by type of BCC. Tumors are more likely to recur if they:3

• Are large
• Develop at the site of prior radiation therapy
• Surround a nerve
• Grow aggressively

People with a weakened immune system due to medications are more likely to have recurrent BCC.

Recurrence rates also vary by initial treatment. Tumors are least likely to recur after Mohs surgery. The 5-year recurrence rate after Mohs surgery is 1% for a primary BCC and 5.6% for recurrent BCC.3Excision is also highly effective, with a 5-year recurrence rate of 2%.3

Some treatments used for thin, low-risk BCC are not appropriate when the risk of recurrence is high. This includes curettage and electrodesiccation, topical medication, cryotherapy, or . These treatments have lower cure rates.

Mohs Micrographically Controlled Excision

Mohs micrographically controlled surgery involves examining carefully marked excised tissue under the microscope, layer by layer, to ensure complete excision.

• Very high cure rates achieved by trained Mohs surgeons
• Used in high-risk areas of the face around eyes, lips and nose
• Suitable for ill-defined, morphoeic, infiltrative and recurrent subtypes
• Large defects are repaired by flap or skin graft

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How Common Is Kidney Cancer

Each year an estimated 75,000 patients are found with a kidney tumor. Approximately 65,000 of these are ultimately found to be renal cell carcinoma .

The most common type is clear cell carcinoma. Renal cell cancer is not one disease but rather a collection of 15-20 types of renal tumors that can arise from the kidney. Kidney cancer is among the 10 most common cancers in both men and women, and the risk for developing kidney cancer is higher in men than in women. More information about kidney cancer risk factors >

Squamous Cell Carcinoma Recurrence

Recommended follow-up. After treatment for local squamous cell carcinoma , national guidelines recommend a complete skin examination by your dermatologist every 3 to 12 months for the first 2 years.4 The reason for this frequent follow-up schedule is that most SCC recurrences happen within 2 years.1 Follow-up should continue every 6 to 12 months for 3 more years. After that, the guidelines call for yearly skin examinations for the rest of your life.

You may need more frequent follow-up visits if the initial SCC had spread beyond the skin. Ask your doctor what she or he recommends for you.

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How Skinvision Can Help With Bcc

Taking care of the skin is not just a matter of aesthetics, it is a matter of health. The earlier the skin cancer is detected, the easier it is to treat. Learning about the warning signs on your skin gives you the power to detect cancer early when its easiest to cure.

SkinVision can be used as an important tool in screening skin cancer or tracking changes in suspicious skin spots.

Always check your whole skin and look for new or changing lesions that increase in size, bleed or do not heal.

What Are The Clinical Features Of Basal Cell Carcinoma

BCC is a locally invasive skin tumour. The main characteristics are:

• Slowly growing plaque or nodule
• Skin coloured, pink or pigmented
• Varies in size from a few millimetres to several centimetres in diameter
• Spontaneous bleeding or ulceration

BCC is very rarely a threat to life. A tiny proportion of BCCs grow rapidly, invade deeply, and/or metastasise to local lymph nodes.

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Recurrence Of Squamous Cell Skin Cancer

Squamous cell skin cancer is the second most common type. It spreads a little more easily than basal cell skin cancer. Still, it is almost always curable. Less than 1% of people with this type of skin cancer die from it.

The chances of recurrence depend on the site of the cancer but range from 3 to 23%, according to the National Cancer Institute. Squamous cell cancers on the nose, ears and lips are the most likely to come back. If you had treatment for a squamous cell skin cancer, you should see your doctor every 3 to 6 months for several years to check for recurrence. If it does return, treatment would be similar to treatment for a basal cell recurrence.

Signs And Symptoms Of Kidney Cancer

Though renal and transitional cancer types affect the kidney in slightly different ways, the signs and symptoms are largely the same. In addition, kidney cancer often doesnât show any obvious signs, especially in the early stages. Plus, many possible kidney cancer symptoms, like blood in the urine, can also result from less serious illnesses, like a bladder infection or kidney stones.

But itâs a good idea to talk to your doctor if you notice:

• Blood in your pee
• Lower back or belly pain with no clear cause
• A fever that doesnât go away and has no obvious cause
• Youâre more tired than normal
• You arenât as hungry or donât eat as much
• Youâve lost weight without trying
• A lump on your lower back, side, or belly

Because kidney cancer sometimes has no early symptoms, the first sign might not show up until after the cancer has spread.

It can go almost anywhere in your body, and symptoms depend on the location. It might show up as a skin lesion. Or, if it spreads to a lung, you might cough up blood. If it reaches your brain, you might have balance or vision problems, among other symptoms in your nervous system.

Regular checkups can help catch early warning signs so that you and your doctor can create a treatment plan.

Urology Care Foundation: âKidney Cancer?â

American Cancer Society: âKidney Cancer,â âKidney Cancer Signs and Symptoms,â âWhat Is Kidney Cancer?â

Cleveland Clinic: âKidney Cancer Overview.â

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What Are The Complications/side Effects Of The Treatments For Basal Cell Carcinoma

Most of the complications related to BCC treatments other than the hedgehog inhibitors are cosmetic, such as scarring or redness.

People who use sonidegib or vismodegib should make sure to use effective birth control to avoid pregnancy due to the risk of birth defects. In addition, sonidegib has other potential risks, including problems with nerves and muscles.

Recurrence Of Basal Cell Carcinoma Uncommon After Mohs Surgery

Dear Mayo Clinic:

I have had Mohs surgery three times in the past 18 months to remove a basal cell carcinoma on my nose. Is there some other treatment that I should be pursuing? Is it common to have so many recurrences in such a short amount of time?

Answer:

Our noses are the No. 1 spot for skin cancer. So it’s not surprising that basal cell carcinoma appeared on your nose.

Basal cell carcinoma is the most common skin cancer, the most easily treated and the least likely to spread. Previously thought to be a condition that affected mostly the elderly, it’s increasingly common in patients in their 20s and 30s.

Getting more than one basal cell carcinoma is common. Patients with a previous diagnosis of skin cancer are 40 percent more likely to be diagnosed with new skin cancer, compared to those who have never had skin cancer. However, three times in 18 months in one location is unusual. A basal cell carcinoma recurrence after Mohs surgery is uncommon.

Mohs is very effective when done by a physician trained in this approach. The five-year cure rate is 99 percent. Given the success rate of these procedures, your situation is very rare, but possible explanations include:

Compromised immune system: Basal cell carcinoma is more likely to recur in immunosuppressed patients, such as those with AIDS or patients who have undergone organ transplants. If this is your situation, the recurrence is less surprising.

Randall K. Roenigk, M.D., Dermatology, Mayo Clinic, Rochester, Minn.

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More Information About Basal Cell Carcinoma

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

See the following sites for comprehensive information about basal cell carcinoma, including detection, prevention, treatment options, and other resources:

What Is The Treatment For Primary Basal Cell Carcinoma

The treatment for a BCC depends on its type, size and location, the number to be treated, patient factors, and the preference or expertise of the doctor. Most BCCs are treated surgically. Long-term follow-up is recommended to check for new lesions and recurrence the latter may be unnecessary if histology has reported wide clear margins.

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How Can You Prevent Basal Cell Carcinoma

Being safe in the sun is the best way to prevent BCC and other skin cancers. Here are some tips:

• Avoid being in the sun from 10 am to 4 pm.
• Avoid tanning beds.
• Use a broad spectrum sunscreen with an SPF of 15 or higher each day. If you will be outside for longer periods of time, use a broad spectrum sunscreen that is water-resistant and has an SPF of 30 or higher. Put the sunscreen on 30 minutes before going outside. Put sunscreen on again every two hours, or more frequently if you have been swimming or sweating a lot.
• Use protective clothing that has built-in sun protection, which is measured in UPF. Also, use broad-brimmed hats and sunglasses.
• Do your own skin self-exam about once per month and see a dermatologist about one time per year for a professional skin exam.
• Have any skin changes examined as soon as possible by a healthcare provider.

Ask Your Doctor For A Survivorship Care Plan

Talk with your doctor about developing a survivorship care plan for you. This plan might include:

• A suggested schedule for follow-up exams and tests
• A schedule for other tests you might need in the future, such as early detection tests for other types of cancer, or tests to look for long-term health effects from your cancer or its treatment
• A list of possible late- or long-term side effects from your treatment, including what to watch for and when you should contact your doctor
• Diet and physical activity suggestions

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Basal Cell Carcinoma Recurrence After Mohs Surgery

Basal cell carcinoma is the most common skin cancer in the US and can cause significant adverse effects.

Mohs micrographic surgery, the treatment of choice for higher risk BCC, allows for removal of lesions with preservation of healthy tissue. Although the BCC recurrence rate post Mohs surgery is estimated at 1-2%, recent data is lacking to validate this historical measurement.

Our purpose is to determine the current recurrence rate of BCC after Mohs surgery.

The Mohs surgery technique is associated with a low recurrence rate for BCC and is preferred for higher risk tumors and for tumors in cosmetically sensitive sites on the head and neck. While recurrence rates of BCC post Mohs are 1-2% for primary basal cells, recent data is not available to validate this historical assessment. Currently, comprehensive rates of recurrence are not available because a national registry of recurrence rates for BCC and squamous cell carcinoma does not exist.