Basal Cell Carcinoma
Basal Cell Carcinoma (BCC) is the most common form of skin cancer. Over 50,000 new cases of BCCs are reported each year in the U.K. Fortunately, it is a very slow growing type of cancer and extremely rarely spreads to other areas or organs in the body. If left untreated however, BCCs continues to grow and is locally invasive so can disfigure tissues, especially on the face where they are commonly found. This is why early recognition and treatment are important.
BCCs are caused by long-term, intermittent exposure to sunlight. This is why it frequently occurs on sun exposed areas of the body – face, scalp, ears, hands, shoulders and back. BCCs are frequently seen in persons aged over 50 years, but increasing number of younger adult report this problem over the last decade.
At particular risk of developing BCCs are the white adult population, those with a history of sunburn, recreational sun exposure, outdoor occupations and fair skin.
Early warning signs
Most lesions on the skin are benign, temporary and clinically not worrisome. Those appear as a result of constant skin metabolic changes, dynamic cellular changes, external irritations etc. If however, you notice a skin lesion or sore that falls to heal within 4-6 weeks and has two or more of the following features, you should have the lesion checked by an expert:
- BCCs may appear as an open sore or ulcer. A smooth raised growth can appear with an ulcer in the centre.
- BCCs can look like a red patch on the skin, which may be itchy, painful or crusty. Sometimes no symptoms are felt but the lesion does not heal or fade.
- BCCs can also look like a firm nodule in the skin. These, too, can appear flesh coloured, pink, shiny, red or pigmented, or sometimes, just like a mole.
- BCCs can take on the appearance of a flat, scarred area in the skin, this area appears pale or white compared to surrounding skin and may have an ulcer or indentation in the centre. This form of BCCs can grow more quickly, making the affected skin look taut and shiny.
The diagnosis is often clinical, but ultimate confirmation is obtained by histopathological (under the microscope) examination. This can be done by sending only a small portion (biopsy) or the whole tumour (excision) away. Sometimes biopsy is taken after non-surgical treatments to check if the lesion has been fully cleared. It may take up to two weeks or more for the results of the biopsy to be ready.
All treatments modalities aim to cure the lesion permanently. The superficial skin cancers can be treated in a number of ways whereas skin cancers which extend into the deeper layers are more likely tackled by surgery.
The most appropriate form of treatment depends on exact type, size, site and history of the particular lesion. You should hear expert opinion on the possible option for your treatment, but do not be surprised if various specialists give you different opinions. This is because most lesions can be address differently and clinician’s preferences may vary. However, most expert would agree on a single best treatment option for a particular tumour formations as per skin cancer guidelines protocol.
- Topical treatment – cream and/or ointments (for example Efudix and Aldara) which cause skin inflammation and in that way attracts body’s own immune cells to fight and eradicate tumour cells. Treatment is normally applied for 3-6 weeks and takes up to 3 months to settle down
- Cryotherapy – eradicating the tumour and superficial layer of skin by freezing (liquid nitrogen is applied to the area via special spray pump). This procedure is carried out in outpatients and incurs minimal localised discomfort
- Photodynamic therapy (PDT) – treatment with light after ‘sensitisation’ of skin with a special cream (this is usually a single outpatient procedure)
- radiotherapy – usually used for any remaining tiny tumour cells around the surgical area; for large ones which affect a big area making surgical reconstruction difficult, too complex or impossible; radiotherapy can have unfavourable effect on the surrounding tissues; it requires several visits over the short period of time in order to complete the treatment
Treatment is usually carried out under local anaesthesia, on an outpatient basis, with minimal disruption to your daily routine.
Curretage – simple scraping away of the damaged cells in the superficial, top layers of the skin leaving the wound to heal on its own over the next few days (this is possible as these wounds are very superficial)
Excision – Surgery aims to remove the abnormal lesion and a narrow rim of normal tissue around it in order to adequately clear the area of the cancer. One of the major advantages of surgery is an opportunity to obtain a specimen for histological assessment and reliable confirmation as to weather tumour has been removed completely.
Certain wounds are small and/or superficial enough that can heal on their own (even without suturing) with regular change of dressings. In most cases however, once the cancer has been removed, the edges of the wound are stitched together (the simplest mode of surgical reconstruction). If the defect is larger or at a specific anatomical sites (especially on the face), sometimes it might be necessary to close the wound with a skin graft or flap. Skin grafts are harvested from certain areas of the body as a thin or thick piece of skin and placed over the wound. Grafts will have to acquire a new blood supply at the site of reconstruction. Skin flaps on the other hand, have their own blood supply and are raised from the area around the wound or even further away and transposed into the defect. Flaps provide very good colour and contour match and usually lead to a very favourable aesthetic outcome.
Regardless of reconstructive option used, I prefer to use the stitch which is hidden under the skin surface and needs to be pulled out in 7-14 days (see picture). In my experience, such stitches are least irritating, produce the fine line scar and leave no stitch marks. I always use magnifying surgical loops during surgery to ensure accurate and neat operating.
- in cases which might require more extensive operation and/or reconstruction, anticoagulation medication (Warfarin, Clopidrogel) might need to be stopped few days before the operation to reduce the risk of bleeding. This will be discussed at the time of your consultation and sometimes, advise from the clinician who prescribed this medication is needed too
- Please make sure that you arrange to be collected from the hospital as you might not be able to drive after the surgery.
- Plan your time off school / work / sports.
- Allow at least few weeks after surgery before considering a holiday.
Once the BCC is completely removed, you should considered yourself ‘cured’ and can be discharged. No follow ups are required. If the margin of safety is too narrow or tumour has not been completely excised, additional surgery and/or radiotherapy might be required as well as a longer follow up.
Potential risks and complications of surgery
- Bleeding and haematoma formation (rarely requiring return to theatre)
- Scarring (including hypertrophic scarring)
- Graft loss or flap necrosis
- Painful scar
- Incomplete excision
- Secondary procedures
Examine your skin every 6-12 months for early warning signs. Systematically look and feel for any changes in your skin, ask someone you feel comfortable with to examine your back, neck, ears or scalp or seek advice from your G.P.
- Aim to cover up and wear wide-brimmed hats when outdoors to protect the area’s most at risk.
- High factor sunscreens (minimum SPF 15+) are vital. Apply them before going out in the sun and re-apply every 2-3 hours, or more frequently if perspiring or swimming.
- Wear 100% U.V protective sunglasses as the skin surrounding the eyes is vulnerable to sun damage.
- Seek shade between 11:00am and 3.00pm.
- Make sure you do not burn and take extra care with children.
- Avoid using artificial sun tanning beds.
- Advise others to protect themselves and carry out annual whole body skin checks.
Remember – early recognition is important as it may reduce the necessity for more invasive treatment. PREVENTION IS BETTER THAN CURE !
This leaflet provides only basic and generic information, but full details and explanations are provided at the consultation as no two patients are the same and personal circumstances vary greatly between individuals.
If you have any concerns following your surgery please contact:
- Hospital where you were operated:
– Ashtead 01372 221 442; St Anthony’s 020 8337 6691; Parkside 020 8971 8000
- Your GP practice
- My secretary on 0845 026 7776 (Monday – Friday, 9.30 – 18.00)
|Hospital stay||Outpatients or Day care|
|Surgery time||30-60 min|
|Wound healing||7 days (face and neck); 14 days limbs/trunk|
|Shower / Bath||from week 1|
|Time off work||1 week|
|Sports and exercise||from week 2|