Basal cell carcinoma of skin
ICD-10 C44.9 · ICD-11 2C32
What Is the Treatment of Localized Basal Cell Carcinoma at High Risk for Recurrence?
Not all basal cell carcinomas carry the same prognosis. When a tumor meets specific anatomic, histologic, or clinical criteria, it is classified as high-risk for recurrence — and the treatment approach differs substantially from low-risk lesions.
Clinical Scenario — High-Risk Features
This protocol applies to localized BCC presenting with one or more of the following:
- Location in area H (central face, eyelids, eyebrows, periorbital skin, nose, lips, chin, mandible, preauricular and postauricular skin, temple, ear, genitalia, hands, or feet) — high risk independent of tumor size
- Location in area M (cheeks, forehead, scalp, neck, pretibia) with tumor 10 mm or larger
- Location in area L (trunk and extremities) with tumor 20 mm or larger
- Poorly defined borders
- Recurrent tumor
- Immunosuppression
- Site of prior radiation therapy
- Aggressive histologic growth pattern
- Perineural involvement
Treatment Approach
For high-risk BCC, surgical management with complete margin assessment is the recommended approach. A specific surgical technique is preferred for these tumors — the full protocol identifies which modality is recommended and specifies the conditions under which an alternative may be considered, along with the cautions that apply.
References
- On the basis of several retrospective and prospective cohort studies, a positive surgical excision margin for BCC is most associated with tumor location in the “H-zone” of the face (central face, eyelids, eyebrows, periorbital, nose, lips, chin, mandible, preauricular and postauricular skin/sulci, temple, and ear), aggressive/infiltrative histologic growth pattern, recurrent tumor, and extension beyond the reticular dermis.
- According to current NCCN guidelines, location of BCC in the H-zone constitutes high risk, independent of size.
- Mohs micrographic surgery is recommended for high-risk BCC.
- Standard excision may be considered for select high-risk tumors.
- However, strong caution is advised when selecting a treatment modality without complete margin assessment for high-risk tumors.
DOI: 10.1016/j.jaad.2017.10.006
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