What are the anesthetic considerations for a patient with basal cell carcinoma?

Anesthetic Considerations for Patients with Basal Cell Carcinoma

The primary anesthetic consideration for patients with basal cell carcinoma (BCC) is selecting the appropriate anesthetic approach based on the surgical procedure planned, tumor location, and patient comorbidities, with most cases being amenable to local anesthesia with or without sedation. 1

Preoperative Assessment

• Evaluate the location, size, and invasiveness of the BCC to determine the appropriate surgical approach and consequently the anesthetic requirements 1
• Assess for high-risk features such as large tumor size (≥2 cm), location in high-risk areas (face, especially nose and ears), aggressive histologic subtypes, and perineural invasion 1
• Review any previous treatments for BCC, including prior surgeries, radiation therapy, or systemic treatments like hedgehog pathway inhibitors 1
• Screen for genetic conditions that predispose to skin cancer (e.g., basal cell nevus syndrome, xeroderma pigmentosum) as these may affect treatment decisions and anesthetic planning 1

Anesthetic Options Based on Surgical Approach

For Low-Risk BCC Procedures:

• Local anesthesia is typically sufficient for:
  • Curettage and electrodesiccation procedures 1
  • Standard excision with 4-mm clinical margins 1
  • Small Mohs micrographic surgery cases 1

For High-Risk or Complex BCC Procedures:

• Local anesthesia with monitored anesthesia care (MAC) may be appropriate for:

  • Extensive Mohs surgery 1
  • Wide local excision with complex reconstruction 1
  • Procedures in sensitive areas (face, especially periocular region) 2

• Regional anesthesia may be considered for:

  • Extensive procedures on extremities 1
  • Patients who cannot tolerate general anesthesia 3

• General anesthesia is typically reserved for:

  • Extensive surgical resections with complex reconstruction 1
  • Orbital exenteration for extensive periocular BCC with orbital invasion 2
  • Frail patients who cannot remain still for prolonged procedures 3
  • Patients with anxiety or inability to cooperate with local procedures 3

Special Considerations

Periocular BCC:

• Requires careful anesthetic planning due to proximity to vital structures 2
• May need specialized ocular anesthetic techniques (retrobulbar or peribulbar blocks) in addition to local infiltration 2
• Consider protective measures for the eye during surgery and recovery 2

Elderly and Frail Patients:

• BCC is common in older populations who often have multiple comorbidities 3
• Consider minimally invasive anesthetic techniques when possible 3
• Balance the risks of anesthesia against the benefits of tumor removal, especially in patients with limited life expectancy 3
• Carefully titrate sedatives and anesthetics due to altered pharmacokinetics in elderly patients 3

Radiation Therapy Considerations:

• For patients receiving radiation therapy instead of surgery (non-surgical candidates):
  • Typically performed as an outpatient procedure without anesthesia 1
  • May require multiple treatment sessions (fractionated therapy) 1
  • Radiation therapy is contraindicated in patients with genetic conditions predisposing to skin cancer 1

Postoperative Considerations

• Pain management is typically straightforward with oral analgesics for most BCC procedures 1
• Monitor for bleeding, especially in facial procedures with rich vasculature 4
• Consider the cosmetic and functional outcomes, particularly for facial procedures 1
• Arrange appropriate follow-up due to the risk of recurrence and development of new primary BCCs 1

Pitfalls to Avoid

• Underestimating procedure duration: Mohs surgery may require multiple stages with unpredictable timing, affecting anesthetic planning 1
• Inadequate local anesthesia: Infiltrative BCC may extend beyond visible margins, requiring wider anesthetic field 1
• Overlooking anxiety: BCC procedures, especially facial ones, can cause significant patient anxiety requiring additional sedation 3
• Neglecting follow-up planning: Patients with BCC have increased risk for subsequent skin cancers and require surveillance 1