RECURRENT PERIOCULAR BASAL CELL CARCINOMA. CASE REPORT.

CHAPTER 2 Diagnosis of basal cell carcinoma CHAPTER 2.1 Agreement between histological subtype on punch biopsy and surgical excision in primary basal cell carcinoma CHAPTER 2.2 Subtyping basal cell carcinoma by clinical diagnosis versus punch biopsy CHAPTER 3 Treatment of basal cell carcinoma CHAPTER 3.1 Overall treatment success after treatment of primary superficial basal cell carcinoma: a systematic review and meta-analysis of randomized and non-randomized trials. CHAPTER 3.2 Three year follow-up results of photodynamic therapy versus imiquimod versus fluorouracil for treatment of superficial basal cell carcinoma: a single blind, non-inferiority, randomized controlled trial. CHAPTER 3.3 Photodynamic therapy versus topical imiquimod for treatment of superficial basal cell carcinoma: a subgroup analysis within a non-inferiority randomized controlled trial CHAPTER 3.4 Tumor thickness and adnexal extension of superficial basal cell carcinoma as determinants of treatment failure for methylaminolevulinate photodynamic therapy, imiquimod and 5-fluorouracil CHAPTER 3.5 Fractionated 5-aminolaevulinic acid photodynamic therapy following partial debulking versus surgical excision in nodular basal cell carcinoma: a randomized controlled trial with at least five year follow-up CHAPTER 4 Discussion and valorization

Objective To assess the cost-effectiveness of Mohs micrographic surgery (MMS) compared with the surgical excision for both primary and recurrent basal cell carcinoma (BCC). Design A cost-effectiveness study performed alongside a prospective randomized clinical trial in which MMS was compared with surgical excision. Setting The study was carried out from 1999 to 2002 at the dermatology outpatient clinic of the University Hospital Maastricht, Maastricht, the Netherlands. Participants A total of 408 primary (374 patients) and 204 recurrent (191 patients) cases of facial BCC were included. Main Outcome Measures The mean total treatment costs of MMS and surgical excision for both primary and recurrent BCC and the incremental cost-effectiveness ratio, calculated as the difference in costs between MMS and surgical excision divided by their difference in effectiveness. The resulting ratio is defined as the incremental costs of MMS compared with surgical excision to prevent 1 additional recurrence. Results Compared with surgical excision, the total treatment costs of MMS are significantly higher (cost difference: primary BCC, €254; 95% confidence interval, €181-€324; recurrent BCC, €249; 95% confidence interval, €175-€323). For primary BCC, the incremental cost-effectiveness ratio was €29 231, while the ratio for recurrent BCC amounted to €8094. The acceptability curves showed that for these ratios, the probability of MMS being more cost-effective than surgical excision never reached 50%. Conclusions At present, it does not seem cost-effective to introduce MMS on a large scale for both primary and recurrent BCC. However, because a 5-year period is normally required to determine definite recurrence rates, it is possible that MMS may become a cost-effective treatment for recurrent BCC.

Mohs Micrographic Surgery for the Treatment of Basal Cell Carcinoma

BACKGROUND:Basal cell carcinoma belongs to non-melanoma skin cancers and is the most prevalent neoplasia that shows a tendency to increase over the last few decades. It occurs most often in skin areas exposed to sunlight. It is characterised by slow progression, low tendency to metastasising and good prognosis when the right choice of treatment has been made. The difficulty in the treatment of basal cell carcinomas is determined by their localisation and puts to the test the aesthetic potential of dermatosurgeons. Complete surgical excision is the standard approach in most uncomplicated cases. In relapsing basal cell carcinoma or carcinoma with aggressive or unfavourable histopathological characteristics, the clinician faces the dilemma of identifying the most appropriate method of treatment. To find the decision, help comes from the individualisation of each case and the related risk factors.CASE REPORT:Two cases of basal cell carcinoma of similar localisation are presented, where the carcinomas are removed using island flaps. In spite of the desire to observe the recommended field of surgical security (by the desire for the ultimate esthetic effect for the patient), one of the tumours was not completely removed, and as an alternative, reoperation was proposed using Mohs micrographic surgery (MMS).CONCLUSION:The choice of a surgical technique, which would guarantee a better outcome and could be applied depending on the individual risk factor in each patient, is discussed.

Assess comparative effectiveness and safety of treatments for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

The rate of recurrence of basal cell carcinoma (BCC) in the periorbital region is higher than that in other areas because of the spread of the tumor along barrier structures. A better understanding of the biological behavior of BCC in this area, in particular as it relates to the lacrimal system, should improve the outcome of surgery. A study was made of two cases of BCC that developed in the periorbital region and invaded the lacrimal system. The tumors were found to have invaded the lacrimal system along the mucosal epithelium. Magnetic resonance imaging (MRI) did not suggest any abnormalities in this area. In one patient, the tumor had infiltrated the nasal cavity without destruction of the periorbital bone and nasal cartilage. A preoperative fiberscopic examination clearly demonstrated the involvement of the nasal cavity in this case. The lacrimal system is often invaded by BCC that originates from the periorbital region. Physicians and surgeons need to be well aware of the possibility of such aggressive infiltration by BCC.

Basal cell carcinoma (BCC) is the most common form of skin cancer. The most commonly utilized surgical therapies for BCC are curettage and electrodesiccation (E and C) and surgical excision. Whereas surgical modalities have acceptable levels of morbidity and a high cure rate, effective non-invasive topical medical treatments of BCC are of great interest. Imiquimod is FDA approved for the treatment of superficial BCC (sBCC), actinic keratoses, and genital warts. There are several situations in which imiquimod is commonly utilized. Patients with multiple or large sBCCs may wish to avoid surgical approaches more likely to be complicated by scarring. We have also found imiquimod to be useful in elderly patients with marginal involvement of nodular BCC when the patient wishes to avoid additional surgery. Imiquimod is also useful when sBCC recurs following surgical treatments such as electrodessication and currettage and when sBCC occurs in areas that heal poorly after surgery. It is essential for physicians to explain to patients that an exuberant skin reaction is a positive indication of treatment success. Using clinical images to demonstrate the range of possible local reactions may be more effective than verbal descriptions. This minimizes the potential for premature discontinuation of therapy by patients.

Colloid bodies (CB), also known as Civatte bodies, are commonly seen in inflammatory dermatoses and are thought to represent cell degeneration. No studies have investigated the incidence and clinical associations of CB in cutaneous basal cell carcinoma (BCC). The aim of this study is to assess the incidence of CB in BCC lesions and analyze their clinical associations. Four hundred and five sequential cases of cutaneous BCC from 396 patients diagnosed from 1/1/2023 to 12/31/2023 in our institution were studied for the presence of CB. Only cases of BCC with a single growth pattern were included. BCC subtype, patient age, location of the lesion, history of previous BCC at other site, smoking history, and allergy history were collected. Cases with and without CB were compared for each parameter using the paired t-test for age and the Chi-square test for categorical data. Patients were grouped based on the presence of CB into a study group (57 cases) and control group with no CB (348 cases). CB were identified in 14% (57/405) of BCCs. 19% (54/281) of nodular, 12.5% (1/8) of infiltrative, and 1.7% (2/116) of superficial type BCCs had CB. BCC with CB were more common on the face/scalp than other sites (66.7% vs. 34.2%, p < 0.001). Patients with CB were older (median 72 vs. 68 years ±12, p = 0.04), predominantly male (63% vs. 47%, p = 0.02), more frequently had a prior BCC (0.61% vs. 0.38%, p = 0.012), and did not differ in smoking history compared to the control cohort. We identified CB in 14% of BCCs studied, most commonly in nodular, followed by infiltrative, and least often superficial type. After cohort matching, significant clinical associations of CB in BCC were sun-exposed location and personal history of one or more prior BCC at other site(s). Their pathogenesis is not known, however their presence suggests tumor regression, which may potentially be exploited for new therapies in a subset of patients.

Conventional treatment of basal cell carcinoma (BCC) causes morbidity and/or disfigurement in some patients because of the location (e.g. mid-face) and size of the lesion. Following reports that such difficult-to-treat BCC lesions have been treated successfully with topical methyl aminolaevulinate (MAL) photodynamic therapy (PDT), a multicentre study was performed to determine the response of such BCC to MAL-PDT. An open, uncontrolled, prospective, multicentre study was conducted comprising patients with superficial and/or nodular BCC who were at risk of complications, poor cosmetic outcome, disfigurement and/or recurrence using conventional therapy. Patients were given one or two cycles within 3 months of topical MAL-PDT, each consisting of two treatments 1 week apart. Tumour response was assessed clinically at 3 months after the last PDT, with histological confirmation of all lesions in clinical remission. The cosmetic outcome was rated. Patients with a BCC in remission will be followed up for 5 years for recurrence, of which the 24-month follow-up is reported here. Ninety-four patients with 123 lesions were enrolled and treated with MAL-PDT at nine European primary care and referral university hospitals. An independent blinded study review board (SRB) retrospectively excluded nine patients and a total of 15 lesions from the efficacy analysis, for not having a difficult-to-treat BCC according to the protocol. The lesion remission rate at 3 months was 92% (45 of 49) for superficial BCC, 87% (45 of 52) for nodular BCC, and 57% (four of seven) for mixed BCC, as assessed by clinical examination, and 85% (40 of 47), 75% (38 of 51), and 43% (three of seven), respectively, as assessed by histological examination and verified by the SRB. At 24 months after treatment, the overall lesion recurrence rate was 18% (12 of 66). The cosmetic outcome was graded as excellent or good by the investigators in 76% of the cases after 3 months follow-up, rising to 85% at 12 months follow-up, and 94% at 24 months follow-up. Topical MAL-PDT is effective in treating BCC at risk of complications and poor cosmetic outcome using conventional therapy. MAL-PDT preserves the skin and shows favourable cosmetic results.

Although surgical therapy continues to be the gold standard for the treatment of basal cell carcinoma given high cure rates and the ability to histologically confirm tumor clearance, there are a number of nonsurgical treatment options that may be considered based on individual tumor characteristics, functional and cosmetic considerations, patient comorbidities and patient preference. Topical 5-fluorouracil 5% cream and imiquimod 5% cream have been US FDA-approved for the treatment of superficial basal cell carcinoma. Additionally, a number of new and emerging topical agents and techniques have been described for the treatment of basal cell carcinoma and will be reviewed herein.

Basal cell carcinoma (BCC) is the most common cancer type worldwide. Although there are several treatment options for the treatment of BCC, selecting the best treatment option for periorbital BCC is challenging and it varies case by case. More than half of periocular BCC cases initially occur on the inner angle and lower lid. The treatment options for BCC include radical surgical excision using Mohs micrographic technique, radiotherapy, neoadjuvant vismodegib, imiquimod, and combination therapy followed by reconstruction for functionality and aesthetic outcome. Selection of each treatment varies based on the severity and extension of BCC. We report a case of periorbital BCC invading the left lower eyelid in a 50-year-old Caucasian male which was initially excised a few years ago, and, following recurrence, the patient underwent Mohs micrographic surgery. Due to a recurrence after Mohs micrographic surgery, treatment with oral vismodegib was started, which led to near-total tumor shrinkage. To determine the outcome of periorbital BCC treated with vismodegib, we reviewed the literature on the periorbital BCC treated with vismodegib, their follow-up period, outcome, and whether they were metastatic or had recurrence. Neoadjuvant vismodegib, followed by surgery excision, such as Mohs micrographic surgery, has shown a promising clinical and aesthetic outcome in the treatment of periorbital BCC.

The need for effective treatment of patients with locally advanced or metastatic basal cell carcinoma (BCC), in conjunction with major advances in the elucidation of the molecular basis of this tumor has led to the advent of new targeted therapies - namely, hedgehog inhibitors. The rationale for their use in patients with advanced BCC is based on their inhibitory effect on the hedgehog pathway, which is aberrantly activated in BCCs due to mutations of its primary components, PTCH1 and SMO genes. Vismodegib (GDC-0449) is an orally bioavailable hedgehog pathway inhibitor that selectively inhibits SMO. The ERIVANCE BCC study is a Phase II, international, multicenter clinical trial evaluating the efficacy and safety of vismodegib 150 mg once daily in patients with locally advanced or metastatic BCC. Vismodegib has been approved for the treatment of adult patients with metastatic BCC, or with locally advanced BCC that has recurred following surgery or who are not candidates for surgery or radiation therapy. This article will outline the rationale, design and available results from the ERIVANCE BCC study and discuss the clinical implications of vismodegib in the management of patients with BCC. Challenges regarding vismodegib use include the recurrence of BCC after drug discontinuation, the development of acquired resistance, the dramatic efficacy in patients with Gorlin syndrome, and class-related drug toxicity. Ongoing clinical trials aim to explore the role of vismodegib in the neoadjuvant setting prior to surgery, the potential use of alternate dosing regimens in order to limit chronic adverse events, as well as the identification of patients with BCC that are more likely to respond to this targeted therapy based on genotypic and/or phenotypic characteristics.

Basal cell carcinoma (BCC) is the most common skin cancer form, and one first-line treatment is surgical excision. Complete excision is vital to minimize risk of recurrence. Studies on occurrence of incomplete excisions have given diverse results and seldom include large populations from a dermatological setting. The rate of positive surgical margins in primary surgery of BCC at a tertiary dermatology clinic is studied. Factors associated with an incomplete primary excision are analysed. Patients scheduled for standard excision, without perioperative margin control, of BCC during the years 2008-2015 were prospectively enrolled in the study. Tumour-specific factors, including histopathologic subtype, as well as postoperative outcome were registered. Incomplete excisions were analysed in relation to patient- and tumour-related factors. In total, 4.6% of 3911 BCC tumours were incompletely excised. The rate of incomplete excisions was higher for facial tumours and among tumours with an aggressive histological subtype. Morpheiform BCC on the nose or ear had the highest rate of an incomplete excision, 61.5% and 50%, respectively. Most BCCs, irrespective of subtype, were completely excised during the primary excision. Tumour sites nose and ears were associated with the highest rate of positive primary surgical margins, especially for infiltrative or morpheiform BCCs. Surgery with perioperative examination of margins is strongly recommended for these tumours.

This case discusses an 85-year-old patient with a history of cataract causing severe right eye vision impairment and repeated surgeries for a basal cell carcinoma (BCC) on the right temple and its local recurrences (wide local excision in 2010; re-excision and reconstruction with a skin graft in 2017), who presented with progressive growth and extension of the skin tumour. Upon examination, an irregular, erythematous plaque with multiple ulcerations on the surface (the largest measuring 4 × 3 cm on the left temple) was observed. The lesion extended from one temple to the other, over the forehead, along the margins of the surgical skin graft, and invaded the upper left eyelid, with a protruding mass extending out of the orbit. A punch skin biopsy of the largest ulceration revealed basal cell carcinoma, infiltrative subtype, with areas of bone invasion. Given the difficult clinical scenario, the complex anatomical location, and the potential morbidity associated with surgery, the patient was deemed suitable for radiotherapy after a thorough evaluation. The patient showed good tolerance to treatment, with mild radiodermatitis managed topically, and achieved a satisfactory therapeutic response. Clinical and radiological evaluations demonstrated substantial regression in lesion size, no significant toxicities, and preservation of vision in the left eye. This case highlights the successful use of palliative radiotherapy in a patient with recurrent giant basal cell carcinoma of the upper face with orbital invasion, achieving eyesight preservation when surgery or systemic therapy were not viable options. Radiotherapy is emerging as a valuable treatment option for recurrent basal cell carcinoma in challenging anatomical locations. However, careful monitoring and rigorous treatment planning are essential forachieving favourable outcomes while minimizing side effects.

Evaluation of histopathological margin and other recurrence parameters in basal cell carcinoma: A retrospective analysis of 8821 lesions