What are the treatment options for basal cell carcinoma?

Treatment Options for Basal Cell Carcinoma

Surgical approaches are the most effective treatment for basal cell carcinoma (BCC), offering the highest cure rates and should be considered first-line therapy for most cases of BCC. 1

Risk Stratification

Treatment selection should be based on risk stratification:

• Low-risk BCC:

  • Small (<2 cm)
  • Well-defined borders
  • Primary (not recurrent)
  • Located on trunk or extremities (non-critical sites)
  • Non-aggressive histologic subtype 1

• High-risk BCC:

  • Large (≥2 cm)
  • Poorly defined borders
  • Recurrent
  • Located on face, central face, or other critical sites
  • Aggressive histologic subtype (morpheaform, infiltrative, micronodular)
  • Perineural invasion 1

Primary Treatment Options

Surgical Options

• Mohs Micrographic Surgery (MMS):

  • Gold standard for high-risk BCCs
  • Provides complete margin assessment
  • Highest cure rates: 99% for primary BCC, 94.4% for recurrent BCC
  • Preserves maximum healthy tissue
  • Recommended for facial lesions, recurrent tumors, aggressive subtypes 1

• Standard Surgical Excision:

  • Appropriate for most primary BCCs
  • 4-mm margins for low-risk tumors
  • 4-6 mm margins for high-risk tumors
  • 5-year cure rates >98% when margins are clear
  • Allows histologic confirmation of complete removal 1, 2

• Curettage and Electrodesiccation (C&E):

  • Suitable only for low-risk, superficial BCCs
  • Quick office procedure
  • Not recommended for:
    • Terminal hair-bearing areas (scalp, beard, pubic, axillary regions)
    • Lesions extending to subcutaneous fat
    • High-risk or recurrent tumors 1
  • Results are highly operator-dependent 1

Non-Surgical Options (for patients who are not surgical candidates)

• Radiation Therapy:

  • Alternative for patients who cannot undergo surgery
  • Generally reserved for patients >60 years due to long-term sequelae
  • Effective for primary and recurrent BCC
  • Multiple fractionation schedules available based on tumor size 1

• Topical Therapies (for superficial, low-risk BCC only):

  • Imiquimod: FDA-approved for superficial BCC when surgery is not feasible 1
  • 5-Fluorouracil (5-FU): Useful for superficial BCCs, especially with multiple lesions or difficult treatment sites 3
  • Photodynamic therapy (PDT): Using aminolevulinic acid (ALA) or methylaminolevulinate (MAL) 1

• Cryotherapy:

  • Consider only when more effective therapies are contraindicated
  • Higher recurrence rates (6.3-39%) compared to surgery
  • Limited to small, well-defined, superficial BCCs 1

Advanced/Metastatic BCC Treatment

• Hedgehog Pathway Inhibitors:
  • Vismodegib and sonidegib are FDA-approved for locally advanced or metastatic BCC
  • Indicated for patients with metastatic BCC or locally advanced BCC that has recurred after surgery or who are not candidates for surgery and radiation 4, 5
  • Response rates of 30-37.9% in metastatic BCC 4
  • Common side effects: muscle spasms, arthralgias, alopecia, dysgeusia, weight loss 4

Treatment Algorithm

1. Assess risk factors to classify as low-risk or high-risk BCC 1
2. For low-risk BCC:
   • Standard excision with 4-mm margins is preferred 1, 2
   • C&E is an alternative for small, superficial lesions on trunk/extremities 1
   • For non-surgical candidates: consider radiation therapy, topical therapies, or cryotherapy 1
3. For high-risk BCC:
   • Mohs micrographic surgery is preferred 1
   • If Mohs is unavailable, wide excision with margin control 1
   • For positive margins after surgery: re-excision or adjuvant radiation therapy 1
   • For non-surgical candidates: radiation therapy 1
4. For locally advanced/metastatic BCC:
   • Multidisciplinary tumor board consultation 1, 4
   • Consider hedgehog pathway inhibitors (vismodegib or sonidegib) 4, 5

Important Considerations

• Incomplete excision increases recurrence risk, especially when deep margins are involved (33% recurrence) versus lateral margins only (17% recurrence) 1
• Cosmetic and functional outcomes should be considered but should not compromise complete tumor removal 1
• Regular follow-up is essential as 30-50% of BCC patients develop another BCC within 5 years 4
• For complex or recurrent cases, multidisciplinary consultation is recommended 1, 4