Basal Cell Carcinoma on the nose

Q1. What is your differential diagnosis?

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A1. Basal cell carcinoma (nodular, superficial, micronodular, infiltrative, pigmented, morpheaform) squamous cell carcinoma, keratoacanthoma, amelanotic melanoma.

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Q2. How would you manage this lesion?

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A2. I would take a complete history from the patient and perform an examination of the lesion.

       I would ask him the following questions:

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    - When did he notice the lesion?

    - Has it changed in size and over what time period?

    -Any bleeding/ulceration?

    -History of to exposure to the sun?

    -Any previous skin cancers excised?

    -Any other similar lesions anywhere on the body?

    PMH

    DH (especially immunosuppressant's)

    SH (type of work, travel, lived abroad)

    FH (especially family history of skin cancer).

    Allergies

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    -I would then examine the lesion:

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    1) Inspection -raised edges, ulceration, crusting, bleeding, pearly, telangiectasia

    2) Palpation - lesion fixed or mobile. Surrounding skin laxity.

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In this case I would surgically excise this lesion with a 3-4 mm peripheral margin and reconstruct the defect with either a full thickness skin graft or a local flap. The patient will be seen in OPD plastics dressing clinic in 1 week and OPD clinic follow-up in 6-8 weeks.

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Q3. What surgical option would you use? Full thickness skin graft or local flap and why?

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A3. In case direct closure here is not possible I would opt for a full thickness skin graft over a local flap. This is because in case re-excision is required, this can be performed more accurately than with a local flap which distorts the surrounding margins and hence makes re-excision more difficult. 

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Note: There is no right or wrong answer here. Both options are acceptable. What is being assessed here is the reasoning behind a particular option.

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Q4. The histology report states that tumour is present at the 3 O'clock peripheral margin. In light of this result what be your next step in management? 

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A4. I would inform the patient of the results and list him for a further excision of the involved margin in order to achieve clearance.

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Points of note:

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1) Most common subtypes from most common to least common: Nodular, superficial spreading, micronodular, infiltrative pigmented, morpheaform (most aggressive)

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2) Treatment options include:

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- Medical :

 Imiquimod 5% or 5-flourouracil

 Radiotherapy

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- Destructive:

Curettage and electrodesication

Cryosurgery/cryotherapy

Laser phototherapy (CO2 laser)

Photodynamic therapy (PDT)

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- Surgical excision:

Primary excision

Mohs micrographic surgery

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3) Excision margins

 - Peripheral margin:

4mm margin if <2cm diameter or on face (a 3mm margin on cosmetically sensitive areas of the face is also acceptable)

6mm margin if >2cm diameter and on trunk or extremities

 - Deep margin

Down to subcutaneous fat/cuff of fat