Basal Cell Carcinoma on the nose

A 65 year old gentleman with the following lesion on his nose presents to your clinic. 

Q1. What is your differential diagnosis?

Q2. How would you manage this lesion?

Q3. What surgical option would you use?

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? 

Answers

 

Q1. What is your differential diagnosis?

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

Q2. How would you manage this lesion?

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

       I would ask him the following questions:

    - 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

    -I would then examine the lesion:

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

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

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.

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

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. 

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.

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? 

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.

Points of note:

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

2) Treatment options include:

- Medical :

 Imiquimod 5% or 5-flourouracil

 Radiotherapy

- Destructive:

Curettage and electrodesication

Cryosurgery/cryotherapy

Laser phototherapy (CO2 laser)

Photodynamic therapy (PDT)

- Surgical excision:

Primary excision

Mohs micrographic surgery

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

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