From the Guidelines
The best course of action for a 65-year-old male patient with a history of basal cell carcinoma and a non-healing lesion in the cervical area is to await the biopsy results and then consider referral to a dermatologist or surgical oncologist for evaluation and treatment of the suspicious lesion. Given his history of BCC, this non-healing lesion raises significant concern for recurrent or new skin cancer. The patient has already undergone a biopsy of the lesion, which contains the whole lesion, as per the guidelines of care for the management of basal cell carcinoma 1. If BCC is confirmed, treatment options would include surgical excision (Mohs micrographic surgery being preferred for head and neck lesions due to tissue preservation), electrodessication and curettage, radiation therapy, or topical medications like imiquimod or 5-fluorouracil for superficial lesions, as suggested by the NCCN clinical practice guidelines in oncology 1. The cervical location requires particular attention as BCCs in this area can be more aggressive and may involve deeper structures. Following treatment, the patient should undergo regular skin examinations every 3-6 months for at least 3-5 years, practice sun protection with broad-spectrum SPF 30+ sunscreen, wear protective clothing, and perform monthly self-examinations to monitor for new or changing lesions. It is also essential to consider patient-specific factors, such as general fitness, coexisting serious medical conditions, and the use of antiplatelet or anticoagulant medication, when choosing a treatment option, as outlined in the guidelines for the management of basal cell carcinoma 1. Early intervention is crucial as it improves prognosis and minimizes the extent of necessary treatment. Key considerations for treatment include:
- Patient's overall health and fitness
- Location and severity of the lesion
- Patient's preferences and values
- Availability of specialized services and expertise.
From the Research
Diagnosis and Treatment of Basal Cell Carcinoma
- The patient's history of basal cell carcinoma (BCC) and the presence of a non-healing lesion in the cervical area suggest the need for a thorough diagnosis and treatment plan 2, 3.
- A skin biopsy is essential to confirm the diagnosis and evaluate the risk of recurrence, as BCCs can be locally invasive and destructive 2.
- The treatment of primary lesions aims to complete tumor removal, and options include conventional surgical excision, Mohs micrographic surgery, cryosurgery, electrodesiccation and curettage, topical application of imiquimod or fluorouracil, photodynamic therapy, or radiation therapy 2.
Surgical Margin of Excision
- The ideal surgical treatment for BCC is complete removal, which can be achieved with safety margins or micrographic control 4.
- A 4-mm surgical margin is often recommended, but narrower margins may be feasible in certain cases, such as small, well-defined primary BCCs in low-risk areas 4, 5.
- For high-risk or recurrent tumors, margins of 5-6 mm or margin control of the surgical excision may be required 4, 5.
Follow-up and Monitoring
- Regular follow-up is crucial to monitor the patient's skin, especially in areas with a history of BCC or high-risk features 6.
- The patient's hyperpigmented skin on his back should be monitored closely, and any new or changing lesions should be biopsied to exclude malignancy 3.
- A schedule of every three months to review lab results and monitor the skin on his back seems reasonable, considering the patient's history and risk factors 2, 6.