Nodular basal cell carcinoma

Synonym (s)

Nodular basal cell carcinoma.
Basalioma solidum, solid basal cell carcinoma

Definition

Most common basal cell carcinoma (approx. 60%), which is notable for its nodular appearance.

Clinical features

Slowly growing, erythematous or skin-coloured, sharply demarcated, shiny, dermal, indolent, partially pigmented nodule. The marginal area shows telangiectasia as well as a pearl cord-like rim. A central depression up to ulceration (ulcus rodens) is often visible.

Localization

Almost exclusively on the head, zygomatic region, bridge of the nose, inner corner of the eye, pinna, capillitium.

Dermatopathology

Resembling solid basal cell carcinoma.

Therapy

Therapy of 1st choice according to Lebwohl	Evidence level
Curettage and electrodesiccation	B
Surgical excision	B
Moh's surgery (micrographically controlled)	B
Cryotherapy	B

Therapy of the 2nd choice after Lebwohl
Radiation therapy	B

Therapy of the 3rd choice according to Lebwohl
Interferon intralesional	B
Retinoids	D
Imiquimod	A
Photodynamic therapy	A
5-Fluorouracil	A
CO² laser	D
PEG-interleukin 2	D
NSAIDs	D
Ingenol mebutate	D
Vismodegib	A
Intralesional interleukin application	D
Systemic chemotherapy	D

Operative therapy
- Excision

The gold standard of basal cell carcinoma therapy
- Especially infiltrative growing and sclerodermiform basal cell carcinomas should be surgically excised.

- In the case of incomplete resection, re-excision should be performed except in well justified cases.

- Cure rate depends on tumour diameter, histological type and safety margin.

	BCC Ø < 2 cm		Infiltrative BCC
Safety distance	3 mm	4-5 mm	3 mm	5 mm	13-15 mm
Likelihood of tumour remnants remaining	15%	5%	34%	18%	5%

Source: Hauschild, A. (2016). Long version of the guideline "Basal cell carcinoma of the skin". Awmf.org. Retrieved 30 May 2016, from http://www.awmf.org/leitlinien/detail/ll/032-021.html

- Micrographic control (Moh's surgery) should be performed on "problem sites" in the face, in recurrent tumours and depending on the histological type. Type. Recurrence rate: 2-12%.

- Curettage with/without electrodesiccation

Recurrence rate: 3-19%
- Cryotherapy

Mostly for superficial basal cell carcinoma.
Aesthetic results are worse.
Cure rates: 4-17%
- Laser therapy

- Photodynamic therapy

Cure rates: 72-100%
- Imiquimod cream 5%, daily 5x/week for a total of 6 weeks.

- Useful in superficial and in Gorlin syndrome.

Cure rate: approx. 80-84% (for superficial basal cell carcinoma).
5-Fluorouracil (5% in cream), applied topically daily for four to six weeks
- Disadvantage: no control whether basal cell carcinoma has been completely removed.

- Cure rate: approx. 81% (for superficial basal cell carcinoma).

Radiation therapy
- Unless surgical (re-)excision is possible.

- Contraindicated: in Gorlin syndrome.

- Radiotherapy alone: 84-96% remission.

- Single doses between 2.0 and 3.0 Gy performed.

- Total doses of 60 to 70 Gy.

- Patients with basal cell carcinoma syndrome (Gorlin-Goltz) should not be treated with ionising radiation.

Hedgehog inhibitor (Vismodegib)
- Indicated for use in metastatic basal cell carcinoma.

Experimental therapies
- Intralesional application of Dz13, a DNAzyme that targets JUN mRNA.

- Itraconazole has successfully disrupted the hedgehog signalling pathway in single cases.

References

Clark CM, Furniss M, Mackay-Wiggan JM. Basal cell carcinoma: an evidence-based treatment update. Am J Clin Dermatol 2014;15:197-216.
Kwasniak LA, Garcia-Zuazaga J. Basal cell carcinoma: evidence-based medicine and review of treatment modalities. Int J Dermatol 2011;50:645-58.
Hauschild, A. (2016). Langfassung der Leitlinie "Basalzellkarzinom der Haut". Awmf.org. Retrieved 30 May 2016, from http://www.awmf.org/leitlinien/detail/ll/032-021.html