Management of Basal Cell Carcinoma
Publication Date: March 1, 2018
Recommendations
Grading and staging, biopsy, clinical information, and pathology report for the treatment of BCC
Stratification of localized BCC using the NCCN guideline framework is recommended for clinical practice. (C)
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The recommended biopsy techniques for BCC are punch biopsy, shave biopsy, and excisional biopsy. The biopsy technique used will depend on the characteristics of the suspected malignancy (morphology, location, etc) and the judgment of the physician. (B)
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The biopsy size and depth should be adequate to provide the recommended clinical information and pathology report elements to permit accurate diagnosis and guide therapy. (A)
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Repeat biopsy may be considered if initial biopsy specimen is inadequate for accurate diagnosis. (B)
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Clinical information provided to pathologist
- Age
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- Sex
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- Anatomic location
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- Recurrent lesion
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- Size of lesion
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- Immunosuppression
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- History, especially radiation, burn, organ transplant
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Pathology report elements
- Histologic subtype
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- Invasion beyond reticular dermis
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- Perineural involvement
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SURGICAL TREATMENT
A treatment plan that considers recurrence rate, preservation of function, patient expectations, and potential adverse effects is recommended. (A)
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C&E may be considered for low-risk tumors in none terminal hairebearing locations. (B)
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For low-risk primary BCC, surgical excision with 4-mm clinical margins and histologic margin assessment is recommended. (B)
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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.
- Low-risk BCC
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- High-risk BCC
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Mohs micrographic surgery is recommended for high-risk BCC. (A)
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NONSURGICAL TREATMENT
Cryosurgery may be considered for low-risk BCC when more effective therapies are contraindicated or impractical. (A)
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If surgical therapy is not feasible or preferred, topical therapy (eg, imiquimod or 5-FU), MAL- or ALA-PDT, and radiation therapy (eg, superficial radiation therapy, brachytherapy, external electron beam, and other traditional radiotherapy forms for BCC) can be considered when tumors are low risk, with the understanding that the cure rate may be lower.
- Imiquimod
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- 5-FU
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- Adjustment of topical therapy dosing regimen on the basis of side effect tolerance is recommended.
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There is insufficient evidence to recommend the routine use of laser or electronic surface brachytherapy in the treatment of BCC. (-)
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Photodynamic therapy
- aminolevulinic acid
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- methylaminolevulinate
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Radiation therapy
- Traditional radiotherapies and modern superficial radiation therapy
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- Electronic surface brachytherapy
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Laser therapy (C)
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MANAGING PATIENTS WITH METASTATIC AND ADVANCED BASAL CELL CARCINOMA
Multidisciplinary consultation and smoothened inhibitors are recommended for patients with metastatic BCC. (A)
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If treatment of metastatic BCC with smoothened inhibitors is not feasible, platinum-based chemotherapy or best supportive care is recommended. (C)
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If surgery and radiation therapy are contraindicated or inappropriate for the treatment of locally advanced BCC, or if residual tumor persists following surgery and/or radiation therapy and further surgery and radiation therapy are contraindicated or inappropriate, systemic therapy with a smoothened inhibitor should be considered. (A)
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Patients with advanced disease should be provided with or referred for best supportive and palliative care, to optimize symptom management and maximize quality of life. (C)
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Treatment with SMO inhibitors
Metastatic and Locally advanced BCC (A)
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Gorlin syndrome (B)
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FOLLOW-UP AND REDUCING RISK FOR FUTURE SKIN CANCERS
After diagnosis of a first BCC, skin cancer screening for new keratinocyte cancers (BCC or cSCC) and for melanoma should be performed on at least an annual basis. (A)
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Patients with a history of BCC should be counseled on skin self-examination and sun protection. (A)
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The use of topical and oral retinoids (eg, tretinoin, retinol, acitretin, and isotretinoin) is not recommended to reduce the incidence of future keratinocyte cancers in those with a history of BCC.
- Tretinoin
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- Acitretin
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- Isotretinoin
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- Oral retinol
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Dietary supplementation of selenium and b-carotene is not recommended to reduce the incidence of future keratinocyte cancers in those with a history of BCC.
- Selenium
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- β-Carotene
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There is insufficient evidence to make a recommendation on the use of oral nicotinamide, DFMO, or celecoxib in the chemoprevention of BCC.
- Celecoxib
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- DFMO
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- Oral nicotinamide
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Recommendation Grading
Disclaimer
Overview
Title
Management of Basal Cell Carcinoma
Authoring Organization
American Academy of Dermatology
Publication Month/Year
March 1, 2018
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline addresses the management of patients with basal cell carcinoma (BCC) from the perspective of a US dermatologist. The main focus of the guideline is on the most commonly considered and utilized approaches for the surgical and medical treatment of primary BCC, but it also includes recommendations on the treatment of recurrent tumors when applicable, appropriate biopsy techniques, staging, follow-up, and prevention of BCC.
Target Patient Population
Patients with basal cell carcinoma
Target Provider Population
Providers who treat patients with basal cell carcinoma
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D002280 - Carcinoma, Basal Cell
Keywords
skin cancer, basal cell carcinoma