From the Guidelines
The staging of facial basal cell carcinoma is not formally defined by a specific staging system, but rather by the differentiation between localized tumors at low versus high risk for recurrence, as outlined in the American Joint Committee on Cancer (AJCC) guidelines 1. The American Joint Committee on Cancer (AJCC) staging manual does not have a specific staging system for basal cell carcinoma (BCC), and the TNM (tumor, node, metastasis) classification is rarely applied due to the low incidence of regional and distant metastasis.
- Key factors in determining the risk of recurrence include:
- Tumor size and depth of invasion
- Presence of high-risk features such as perineural invasion or deep invasion
- Location of the tumor, with central face, around eyes, nose, lips being higher risk
- Histologic subtype, with morpheaform and infiltrative types being more aggressive
- Recurrence status and immunosuppression status According to the guidelines of care for the management of basal cell carcinoma, published in the Journal of the American Academy of Dermatology in 2018 1, the most clinically relevant stratification to guide the management of patients with BCC is the differentiation between localized tumors at low versus high risk for recurrence.
- The selection of the specific biopsy technique is contingent on the clinical characteristics of the suspected tumor, including morphology, expected histologic subtype and depth, natural history, and anatomic location; patient-specific factors, such as bleeding and wound healing diatheses. The use of cross-sectional imaging to stage for metastatic disease is rarely indicated for BCC, but may be considered to assess for deep structural involvement with extensive BCC 1.
From the Research
Staging of Facial Basal Cell Carcinoma
The staging of facial basal cell carcinoma can be understood through the TNM classification system, which considers the size and depth of invasion of the tumor 2.
- Tumor Size and Depth: The TNM classification system is used to categorize the primary tumors by size and depth of invasion. According to this system, large (T2 and T3) and deep (T4) basal cell carcinomas account for approximately 75% of metastatic tumors 2.
- Facial Sites: Approximately 67% of metastatic basal cell carcinomas originate from facial sites 2.
- Metastasis Risk: The risk of metastasis is higher for larger tumors, with basal cell carcinomas greater than 3 cm in diameter having approximately a 1.9% incidence of metastasis 2.
Treatment and Management
The treatment and management of basal cell carcinoma depend on various factors, including the size, location, and histopathological subtype of the tumor 3.
- Nonsurgical Options: Nonsurgical treatment alternatives, such as destructive techniques, photodynamic therapy, topical drugs, radiotherapy, or hedgehog pathway inhibitors, can be effective for basal cell carcinoma 3.
- Hedgehog Pathway Inhibitors: Hedgehog pathway inhibitors, such as vismodegib, are indicated for the treatment of adults with metastatic basal cell carcinoma or with locally advanced basal cell carcinoma that has recurred following surgery or who are not eligible for surgery or radiation 4.
- Oral Hedgehog Pathway Inhibition: Oral hedgehog pathway inhibition can be a means for ocular salvage in locally advanced intraorbital basal cell carcinoma 5.