From the Guidelines
The best course of action for a 65-year-old male with a history of basal cell carcinoma presenting with a non-healing lesion in the cervical area is immediate referral to a dermatologist or surgical oncologist for evaluation and biopsy, as recurrent BCC or a new skin cancer is highly suspected in patients with prior history. The lesion should be biopsied to confirm diagnosis, and according to the guidelines of care for the management of basal cell carcinoma, the recommended biopsy techniques for BCC are punch biopsy, shave biopsy, and excisional biopsy 1. Given that the patient has already undergone a punch biopsy, which contains the whole lesion, the next step would be to await the pathology results to guide further treatment.
Following biopsy confirmation, treatment typically involves complete surgical excision with appropriate margins (usually 4-6 mm for BCC), which may be performed via standard excision or Mohs micrographic surgery depending on the location and characteristics of the lesion. For cervical lesions, Mohs surgery is often preferred due to tissue preservation in a cosmetically sensitive area. The NCCN Guidelines for Basal Cell Skin Cancer support the use of surgical approaches, with radiation therapy as an alternate or adjuvant option, and also highlight the importance of assessing risk to inform treatment selection 1.
Post-surgical follow-up should include wound care with daily cleaning and antibiotic ointment application for 1-2 weeks, suture removal in 7-14 days depending on location, and regular skin examinations every 3-6 months for at least 3-5 years to monitor for recurrence or new lesions. This approach is necessary because patients with previous BCC have a 35-50% increased risk of developing additional skin cancers, and early intervention provides the best chance for complete cure with minimal tissue removal, as noted in the guidelines for basal cell skin cancer 1.
Key points to consider in the management of this patient include:
- The high risk of developing additional skin cancers in patients with a history of BCC
- The importance of early intervention and complete surgical excision for optimal outcomes
- The role of Mohs surgery in preserving tissue in cosmetically sensitive areas
- The need for regular follow-up to monitor for recurrence or new lesions, as supported by the guidelines for the management of basal cell carcinoma 1.
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.
- A punch biopsy was performed, which is a recommended method for diagnosing BCC, with studies showing an accuracy rate of around 80% in diagnosing subtypes of BCC 3, 4, 5.
- However, it is essential to note that punch biopsy may not always provide a complete picture of the tumor, with studies showing a discordance rate between punch biopsy and excision in establishing BCC subtype 3, 4.
Management and Follow-up
- Given the patient's history of BCC and the presence of a non-healing lesion, regular follow-up appointments are crucial to monitor the skin on his back for any suspicious lesions 2.
- The patient's hyperpigmented skin on his back due to excess sun exposure also warrants regular monitoring, as sun exposure is a significant risk factor for BCC 2.
- Scheduling the patient for regular review of lab results and follow-up appointments every three months is a reasonable approach to ensure timely detection and treatment of any potential skin cancers 2.
Importance of Biopsy in Non-Healing Lesions
- The case highlights the importance of performing a biopsy in non-healing lesions, as it can be challenging to differentiate between infection, local ischemia, or malignancy in the area of a scar 6.
- A biopsy can provide a definitive diagnosis and guide treatment, emphasizing the need for prudent management of clinically unclear lesions 6.