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 immediate referral to a dermatologist or surgical oncologist for evaluation and biopsy of the lesion, as recommended by the guidelines of care for the management of basal cell carcinoma 1. The patient should be seen within 1-2 weeks given his history and age, which are risk factors for skin cancer. The non-healing nature of the lesion in the cervical area is concerning for recurrent BCC or possibly a new skin malignancy. The specialist will likely perform a punch or excisional biopsy under local anesthesia (typically 1-2% lidocaine) to obtain tissue for histopathological examination, as outlined in the NCCN clinical practice guidelines in oncology 1. While awaiting the appointment, the patient should protect the area from sun exposure, avoid trauma to the lesion, and keep it clean with gentle washing using mild soap and water. No topical medications should be applied unless specifically prescribed. This approach is critical because early diagnosis and treatment of skin cancers significantly improve outcomes, and patients with a history of BCC have a 35-50% increased risk of developing additional skin cancers within 5 years compared to the general population, as noted in the guidelines for the management of basal cell carcinoma 1.
Some key considerations in managing this patient include:
- The importance of a full skin examination to identify any other suspicious lesions, given the patient's history of BCC and increased risk of developing additional skin cancers 1
- The need for patient education on sun protection and regular self-examination of the skin to reduce the risk of further skin cancers 1
- The potential for hedgehog pathway inhibitors as a treatment option for advanced or metastatic BCC, although this would require multidisciplinary consultation and consideration of the patient's overall health and treatment goals 1
- The role of curettage and electrodessication as a treatment option for low-risk BCC, although this may not be suitable for all patients or lesions 1
- The importance of considering patient-specific factors, such as general fitness and coexisting medical conditions, when selecting a treatment approach 1
From the Research
Patient Assessment and Diagnosis
- The patient is a 65-year-old male with a history of basal cell carcinoma (BCC) and a non-healing lesion in the cervical area, which has been present for months 2, 3.
- The patient's skin on his back appears hyperpigmented due to excess sun exposure, which is a risk factor for non-melanoma skin cancers (NMSCs), including BCC 2.
- A biopsy of the lesion was performed, and the specimen contains the whole lesion, which will help determine the histologic subtype and guide treatment 2, 3.
Treatment Options
- Surgical techniques, such as excision, curettage and electrodessication, and Mohs micrographic surgery, are common treatment options for BCC lesions 2, 3.
- Nonsurgical therapies, such as topical therapy or photodynamic therapy, may be used for BCC lesions if surgical techniques are not appropriate 2, 3.
- The choice of treatment modality depends on the patient's condition, tumor location, and risk of recurrence 3, 4.
Follow-up and Prevention
- The American Academy of Dermatology recommends skin examinations for all patients with NMSC at least annually 2.
- Primary interventions for prevention include counseling on reducing sun exposure, use of UV-protective clothing and sunscreen, and discouragement of tanning bed use 2.
- The patient will be scheduled to review the lab results and every three months to monitor the skin on his back, which is a reasonable follow-up plan given the patient's history of BCC and risk factors for NMSCs 2, 3.