​Kembara Xtra - Medicine - Basal Cell Carcinoma

​Kembara Xtra - Medicine - Basal Cell Carcinoma 
Introduction 
The most prevalent form of skin cancer, basal cell carcinoma (BCC), develops in the basal cell layer of skin appendages.
Rarely metastasizes, however it can invade locally, causing localized tissue damage and deformity.

STATISTICS AND EPIDEMIOLOGY 
The most prevalent cancer in Europe, Australia, and the US. a form of skin cancer that is most typical.
Incidence
 In the United States, there are about 2 million new cases per year; they are 2.5 times more common than squamous cell carcinoma (SCC). Australia has the highest incidence worldwide.
In the course of their lifetime, white people have a 1 in 5 chance of developing BCC.
Skin cancer is most prevalent among Asian and Hispanic people, and second in African Americans and black people. 
Predominant sex: male > female (2:1 ratio) Predominant age: typically >60 years 
Prevalence

Unreliable foundation

PATHOPHYSIOLOGY AND ETIOLOGY
Inflammation and cyclooxygenase activation are brought on by UV radiation in the skin.

Genetics
A number of genetic disorders raise the possibility of getting BCC:
(Recessive alleles) Albinism
 (Autosomal recessive) Xeroderma pigmentosum Rare, X-linked dominant condition known as Bazex-Dupré-Christol syndrome Gollin syndrome, also known as nevoid BCC syndrome (rare, autosomal dominant)  Gene alterations in the detoxifying enzymes glutathione Stransferase and cytochrome P450 CYP2D6 (particularly in truncal BCC, characterized by clusters of BCCs and a younger age of onset)  Smoothened or patched alterations in the tumor suppressor gene triggered mutations that increased hedgehog pathway activation.

RISK FACTORS: Prolonged sun exposure (UV radiation); elevated susceptibility in the phenotypes listed below. - Skin types with a light complexion include skin types I and II (who frequently burn but don't tan). - Blonde or red hair - Green or blue eyes
Male sex, while women are at an increased risk of sunburn due to lifestyle changes including using tanning beds. 
Xeroderma pigmentosum, chronic immunosuppression, lymphomas, HIV infection, transplant recipients (5 to 10 times higher incidence), arsenic exposure, prior nonmelanoma skin cancer, family history of skin cancer, prior nonmelanoma skin cancer, prior nonmelanoma skin cancer, prior nonmelanoma skin cancer, prior nonmelanoma skin cancer, prior nonmelanoma skin cancer, prior nonmelanoma skin cancer, prior nonmelanoma skin


PREVENTION

Avoid overexposure to the sun by using broad-spectrum sunscreens with at least SPF 30 every day and reapplying after swimming or perspiring. Avoid using tanning beds. The USPSTF comes to the conclusion that there is not enough information available to weigh the benefits and risks of a physician performing a visual skin examination to detect skin cancer in adults. The American Cancer Society advises patients aged 20 to 39 to get cancer-related exams every three years, while patients aged 40 and beyond should have them annually.

COMMONLY ASSOCIATED CONDITIONS 
Ulcerating neoplasms are susceptible to infections Loss of nerve function due to perineural spread or severe and deep invasion Cosmetic deformity (head and neck most frequently affected) Loss of eyesight with orbital involvement.

 HISTORY TAKING AND PHYSICAL EXAMINATION : History of a developing, ulcerating, or bleeding skin lesion frequently in a sun-exposed area; exposure to risk factors; family history of skin cancer


MEDICAL EXAMINATION 
80% occur on the face and neck, 20% on the trunk and lower limbs. 
Nodular: most prevalent (50-80%); presents as a pinkish, pearly papule, plaque, or nodule, frequently with telangiectatic vessels, ulceration, and a rolled periphery, usually on the head or neck. 


Pigmented: presents as a translucent papule with "floating pigment"; more frequently seen in darker skin types; may give a blue,  Superficial: 10–30%; light red, scaly plaque with thin, rolling borders and central clearing; least invasive of BCC subtypes; typically on trunk or extremities  


Morpheaform (sclerosing): 5-10%; most prevalent on the head or neck; looks as a scar-like waxy plaque with ill-defined edges, occasionally with ulceration.
SCC, sebaceous hyperplasia, and epidermal inclusion cyst are three different diagnoses.
Molluscum contagiosum, actinic keratosis, nummular dermatitis, psoriasis, melanoma (pigmented lesions), atypical fibroxanthoma, fibrous papule, keratoacanthoma, and intradermal nevi (both pigmented and nonpigmented).


 ANALYSIS OF DIAGNOSIS
Initial Examinations (lab, imaging) Biopsy is required to confirm the diagnosis; dermoscopy may increase the precision of BCC diagnosis.


Other/Diagnostic Procedures
Skin biopsy and pathologic investigation are used to confirm the clinical diagnosis and histologic subtype.
In most cases, a shave biopsy is sufficient and used for nodular lesions. 


Punch biopsy or a shave biopsy with a scoop approach can be used to evaluate the depth of the tumor and perineural invasion in flat lesions.


Interpretation of Tests
Nodular BCC - Aggregates of basaloid cells that protrude from the epidermis. Uniform tumor cells lack mitotic figures, have big, oval, hyperchromatic nuclei, minimal cytoplasm, and are encircled by a peripheral palisade. - A rise in mucin levels in dermal stroma
 Peripheral palisading and buds of basaloid cells adhering to the underside of the epidermis are characteristics of superficial BCC.
Less peripheral palisading and retraction, higher subclinical involvement, and thin cords and strands of basaloid cells buried in dense, fibrous, scar-like stroma are characteristics of morpheaform BCC.
Infiltrating BCC is similar to morpheaform BCC, but has thicker, spikier, irregular strands and less of a scar-like stroma. It also exhibits less peripheral palisading and retraction and more subclinical involvement.
Small, nodular tumor cell aggregates called micronodular BCC had higher subclinical involvement and less retraction artifact than nodular BCC.


MANAGEMENT AND TREATMENT 

GENERAL  MEASURES
The following strategies are outlined in the recommendations of the National Comprehensive Cancer Network (NCCN): Radiation therapy, conventional excision, curettage and electrodesiccation, and low-risk BCC  Standard excision, Mohs surgery, and radiation therapy for high-risk BCC


MEDICATION

 May be especially helpful for people with low-risk superficial and/or nodular BCC who cannot tolerate surgery, refuse treatment, or both.
– Imiquimod (Aldara) cream is approved for the treatment of low-risk superficial BCC; daily dosing for 6 to 12 weeks; 80% clearance rate. 


5-Fluorouracil (5-FU) cream inhibits thymidylate synthetase, interrupting DNA synthesis for superficial lesions in low-risk areas. This cream is used as a primary treatment only. It is applied at a dose of 5% BID for 3 to 10 weeks.



Emerging therapeutics include vismodegib, a sonic hedgehog pathway inhibitor, which is helpful for advanced BCC patients who have exhausted all other treatment choices as well as for multiple BCC and BCC nevus syndrome. - Intralesional injection: Depending on the agent utilized, efficacy for small (1 cm) nodular and superficial BCCs ranges from 67% to 94%. In one trial, 63% of the lesions showed substantial histologic cure rates 85 days after therapy when using the drug ingenol mebutate, which is derived from the plant Euphorbia peplus.


Laser therapy: Although there are currently no randomized controlled trials that demonstrate the efficacy of monotherapy, anecdotal evidence suggests that superficial BCC can be treated; one retrospective study using superpulsed carbon dioxide therapy for superficial and nodular BCC revealed no recurrence in a 3-year follow-up.
Initial Line
Excision surgery is typically performed .


ADVANCED THERAPIES
Radiation therapy is beneficial for patients, often older (>60 years), who are unable to have surgery and for cancers that are unresectable.


Adjuvant therapy used after surgery, especially if tumor margins weren't cleared - 90% of cases are cured.
Recurrence rates range from 4 to 16%.
Photodynamic treatment (PDT): PDT accumulates photosensitizing chemicals in the target cells through injection or topical application.


Methyl aminolevulinate and 5-aminolevulinic acid, photosensitizers, are currently authorized in Canada, Europe, Australia, and New Zealand; they are used as an off-label treatment for BCC in the United States. 


SURGICAL  PROCEDURE
S 
The first-line treatment is surgical excision; the choice of specific treatment depends on the size and location of the lesion as well as the delineation of the tumor border.
High-risk areas include the inner canthus, nasolabial sulcus, philtrum, preauricular area, retroauricular sulcus, lip, temple, and "mask areas" of the face. Curettage and electrodesiccation should be avoided in hair-bearing areas due to the possibility of the tumor spreading down follicular structures in those areas.
- Recurrence as high as 27% for high-risk tumors; 5-year cure rate of 91–97% (3) - A pathology sample was sent at the time of curettage and electrodesiccation to confirm that there was no high-risk pathology. 


Excision with postoperative margin evaluation is the preferred course of treatment for low-risk lesions under 2 cm in diameter. The desired margin is 4 mm.
- 98% 5-year cure rate
Cryosurgery is typically used for tumors with low risk of recurrence and is reserved for nodular and superficial BCC. It is not recommended for tumors with a depth greater than 3 mm or over the lower extremities.
– The mean recurrence rates in various studies varied from 0% to 39%.
Only cancer-free tissue is left after a Mohs surgery, in which small layers of the tumor are gradually removed and analyzed to determine its border. For lesions in high-risk locations, recurrent lesions, and lesions demonstrating an aggressive development trend, microsurgically controlled surgery is the preferred treatment. Referral to a dermatologic surgeon with the necessary training is necessary due to 5-year recurrence rates up to 10.1% in initial BCC and 17.4% in recurrent BCC.


ALTERNATIVE & SUPPORTIVE MEDICINE
This has not been demonstrated that -carotene lowers the incidence of developing skin cancers in persons with a prior nonmelanoma skin cancer.


CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING
 :except in cases of severe lesion, outpatient


CONTINUING CARE AFTERCARE 
RECOMMENDATIONS
Find shade, especially between the hours of 10 AM and 4 PM. In patients with Gorlin syndrome, kidney transplant recipients, and those with severe actinic damage, oral retinoids may suppress the growth of new BCCs.
patient observation
 After the first 2 to 5 years, every year for the rest of your life. If there isn't a recurrence within the first two years, monitoring frequency can be reduced.
 Enhanced chance of further skin cancers
• Recurrence:
- Local: Adhere to NCCN 2021 recommendations for initial care.
- Regional: radiation therapy and/or surgery
- Multidisciplinary tumor board consultation for metastatic.
Monthly skin self-examination Inform patients about the importance of getting enough vitamin D. Use SPF 15 UVA/UVB broad spectrum sunscreen.
Keep infants away of the sunlight. Babies under 6 should use sunscreen.


PROGNOSIS
90–95% of patients who receive the right care are cured.
Most recurrences occur in the first five years. BCCs that form in the head or neck region are more likely to return.
Development of new BCCs: Within 5 years, 30–50% of patients would develop a new lesion.
COMPLICATIONS
Recurrence rates in primary BCC are up to 56%, and in recurrent BCC they are 14%; high-risk tumors should have long-term follow-up.
Recurrences typically show up within 5 years.
The location, depth, and tumor diameter greater than 4 cm in the head and neck are risk factors for metastasis and death, however metastasis is uncommon (0.1%).

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