Infiltrating Basal cell carcinoma
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, favourited this 4 Years ago.
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Infiltrating Basal Cell Carcinoma Laura S. Gilmore, MD Department of Ophthalmology October 8, 2004 Discussant: Kenn Freedman, MD
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Case Presentation CC: growth on right side of nose HPI: 81 yo HF who first noted growth on right side of nose “last December”, progressively growing. PMH: arthritis SH: ½ ppd smoker X 25 years ROS: denies F/C, significant weight loss FH: non-contributory
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Physical Exam General: AAO, VSS and good VA: 20/80 OD, 20/50 OS Pupils: 3mm OU, no APD External: extensive ulcerative lesion from bridge of nose to RLL and R cheek, with almost complete destruction of RLL and nearly complete ptosis of RUL IOP, CVF, DFE normal OS, unobtainable OD
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Differential Diagnosis Malignant melanoma Squamous cell carcinoma Basal cell carcinoma, infiltrative Infectious
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Basics of BCC Background Most common cutaneous malignancy (~80-90%) Typically slow-growing, rarely metastasizes Sun-exposed skin, mostly face and scalp, esp nose, cheek, and periorbital regions (~80%) Frequency 900,000 Dx in US/year estimated lifetime risk of 33-39% for men and 23-28% for women Sex Men 2X over women
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Basics of BCC Mortality/Morbidity <0.1% metastasize Very low mortality Significant morbidity with direct invasion of adjacent tissues, especially when on face or near an eye Age Likelihood increases with age Rare in <40 yo Race Most often in light-skinned, rare in dark-skinned races
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Variants of Basal Cell Carcinoma Superficial Nodular Micronodular Infiltrating (5%) Sclerosing/ morpheaform (5%) Metatypical Infundibulocystic Nodulocystic Adenoid Clear cell Follicular Sebaceous Perineurally invasive
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Perineural Invasion May be seen in 3% of pts with infiltrating and morpheaform types Most often infiltrating type, which has highest rate of local recurrence Requires CT scan for full work-up Causes? inherently aggressive behavior vs inadequate early management?
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Treatment Options Electrodessication and curettage Curettage alone Surgical excision Mohs micrographically controlled surgery Cryosurgery Ionizing radiation Surgical excision plus radiation Exenteration
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Factors Considered in Treatment Planning Pt preference to keep eye Pt age Surgical excision-considered definitive tx “Careful frozen section controlled excision of periocular BCCs yields cure rates comparable to Mohs micrographic surgery at 5-year follow-up” 5 year recurrence of 2.2% in one study Wong, et al. “Management of Periocular Basal Cell Carcinoma with Modified En Face Frozen Section Controlled Excision.” Ophthalmic and Plastic Reconstructive Surgery. 2002. Vol 18 (6): 430-435. Therefore, avoiding exenteration was considered a good possibility
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Conclusion Basal cell carcinomas are not always as innocent as we tend to believe In formulating treatment course: Strong pt preference and other pt factors Current research
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