From the Guidelines
Management of basal cell carcinoma (BCC) primarily involves surgical removal as the gold standard treatment, with Mohs micrographic surgery offering the highest cure rates (97-99%) while preserving the maximum amount of healthy tissue, particularly for high-risk BCCs on the face, as recommended by the NCCN Guidelines 1. The most effective approach for high-risk BCCs is Mohs micrographic surgery, which provides the highest cure rates while preserving the maximum amount of healthy tissue. For low-risk, small BCCs, standard surgical excision with 4-5mm margins is appropriate. Some key points to consider in the management of BCC include:
- Alternative treatments, such as electrodessication and curettage for superficial BCCs less than 2cm in diameter, cryotherapy for small superficial lesions, topical medications (imiquimod 5% cream or 5-fluorouracil), photodynamic therapy, and radiation therapy for patients who cannot undergo surgery 1.
- For advanced or metastatic BCC, targeted therapy with Hedgehog pathway inhibitors like vismodegib or sonidegib may be used, with an overall response rate of 37.9% reported in the STEVIE trial 1.
- Post-treatment follow-up is essential, with skin examinations every 6-12 months, as patients with a history of BCC have a 35-50% risk of developing another BCC within 5 years.
- Prevention strategies include regular use of broad-spectrum sunscreen, protective clothing, avoiding peak sun hours, and routine skin self-examinations. Treatment choice depends on tumor size, location, subtype, patient age, and comorbidities, with the goal of complete tumor removal while preserving function and cosmetic outcomes, as outlined in the NCCN Guidelines 1.
From the FDA Drug Label
Fluorouracil is recommended for the topical treatment of multiple actinic or solar keratoses. In the 5% strength, it is also useful in the treatment of superficial basal cell carcinomas when conventional methods are impractical, such as with multiple lesions or difficult treatment sites. The diagnosis should be established prior to treatment, since this method has not been proven effective in other types of basal cell carcinomas. With isolated, easily accessible basal cell carcinomas, surgery is preferred since success with such lesions is almost 100%. The success rate with fluorouracil cream and solution is approximately 93%, based on 113 lesions in 54 patients
Management of basal cell carcinoma with 5-fluorouracil (TOP) is recommended for:
- Superficial basal cell carcinomas when conventional methods are impractical
- Multiple lesions or difficult treatment sites The preferred treatment for isolated, easily accessible basal cell carcinomas is surgery, with a success rate of almost 100% 2.
From the Research
Treatment Options for Basal Cell Carcinoma
- Surgical excision is a standard treatment for basal cell carcinoma (BCC), with Mohs micrographic surgery typically utilized for high-risk lesions 3, 4, 5
- Other treatment options include radiotherapy, curettage and electrodessication, photodynamic therapy, and topical therapies such as imiquimod and 5-fluorouracil 3, 4
- Hedgehog pathway inhibitors, such as vismodegib and sonidegib, have emerged as an important treatment option for advanced BCC 3, 4
Surgical Treatment of Basal Cell Carcinoma
- Surgical margins of 4mm seem to be suitable for small, primary, well-defined basal cell carcinomas, although some good results can be achieved with smaller margins and the use of margin control surgical techniques 6
- For treatment of high-risk and recurrent tumors, margins of 5-6 mm or margin control of the surgical excision is required 6
- Factors such as previous treatment, histological subtype, site and size of the lesion should be considered in surgical planning because these factors have been proven to affect cure rates 6, 7
Factors Influencing the Risk of Incomplete Primary Excision
- The rate of positive surgical margins in primary surgery of BCC is higher for facial tumors and among tumors with an aggressive histological subtype 7
- Tumor sites such as the nose and ears are associated with the highest rate of positive primary surgical margins, especially for infiltrative or morpheiform BCCs 7
- Surgery with perioperative examination of margins is strongly recommended for these tumors 7, 5