Basal cell carcinoma on face

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Basal Cell Carcinoma on the Face: Diagnosis, Treatment, and Management

Overview of Basal Cell Carcinoma (BCC)

Basal Cell Carcinoma (BCC) is the most common form of skin cancer, particularly prevalent among Caucasians. It originates from the basal cells in the epidermis and is characterized by local invasiveness and a low propensity for metastasis . BCC predominantly affects areas exposed to ultraviolet (UV) radiation, such as the face, ears, and neck.

Incidence and Presentation

BCC accounts for approximately 75-80% of non-melanoma skin cancers, with up to 85% of these cases occurring on the head and neck. The incidence of BCC is rising globally, and it is expected to surpass all other cancers in terms of frequency . Delay in presentation often leads to increased tumor growth, making early recognition crucial for limiting facial tissue involvement and improving cosmetic and functional outcomes.

Diagnostic Approaches

Clinical and Histopathological Diagnosis

Diagnosis of BCC typically involves clinical examination and dermatoscopic evaluation. Histopathological confirmation is essential, especially for ambiguous lesions and those located in high-risk areas. BCC can be classified into various histological subtypes, including nodular, infiltrative, superficial, and mixed patterns, which help in predicting the likelihood of complete excision and recurrence.

Treatment Modalities

Surgical Excision

Surgical excision (SE) is considered the gold standard for treating BCC, offering a high cure rate with histological control of excision margins. The 5-year recurrence rate for SE on the face is less than 3%. SE is particularly effective for primary BCC (pBCC), with a 10-year cumulative recurrence probability of 12.2%.

Mohs' Micrographic Surgery (MMS)

Mohs' micrographic surgery (MMS) is preferred for high-risk and recurrent BCC (rBCC) due to its tissue-sparing technique and lower recurrence rates. For rBCC, MMS shows a significantly lower 10-year recurrence probability (3.9%) compared to SE (13.5%) . MMS is also recommended for BCCs in critical anatomical sites and those with aggressive histological subtypes.

Non-Surgical Treatments

For superficial BCC, non-surgical treatments such as topical therapies (5% imiquimod, 5% fluorouracil), photodynamic therapy, and destructive approaches (curettage, electrocautery, cryotherapy, laser ablation) are effective options . These treatments are particularly suitable for patients with low-risk superficial BCC or those who are not candidates for surgery.

Advanced and Metastatic BCC

For locally advanced or metastatic BCC, hedgehog pathway inhibitors like vismodegib and sonidegib have shown promising results, with objective response rates of 30-55% and tumor control rates of 80-90% . Immunotherapy with anti-programmed cell death 1 (PD-1) antibodies is currently being investigated as a potential treatment for hedgehog inhibitor-refractory tumors.

Radiotherapy

Radiotherapy is a viable alternative for patients who are not suitable for surgery, particularly elderly patients. It offers high tumor control rates (89-96%) and is effective for invasive, inoperable BCC .

Prognosis and Follow-Up

The prognosis of BCC is generally favorable, especially with early detection and appropriate treatment. Long-term follow-up is recommended for patients with high-risk BCC subtypes, high-risk sites, multiple BCCs, and genetic predispositions like naevoid basal cell carcinoma syndrome (NBCCS). Regular skin examinations are crucial for early diagnosis and treatment of new or recurrent lesions.

Conclusion

Basal cell carcinoma on the face requires a multidisciplinary approach for optimal management. Early diagnosis and appropriate treatment, whether surgical or non-surgical, are essential to minimize tissue damage and improve cosmetic outcomes. Advances in targeted therapies and immunotherapy offer new hope for patients with advanced BCC, underscoring the importance of ongoing research and clinical trials.