What is the best line of treatment for an elderly female patient with infiltrative basal cell carcinoma (BCC) presenting as an ulcerative lesion at the nose?

Treatment of Infiltrative Basal Cell Carcinoma on the Nose in an Elderly Female

Mohs micrographic surgery (MMS) or surgical excision with complete circumferential peripheral and deep margin assessment (CCPDMA) is the definitive first-line treatment for infiltrative basal cell carcinoma on the nose, as this represents a high-risk lesion requiring margin-controlled surgery. 1

Why This Case is High-Risk

Your patient has multiple high-risk features that mandate aggressive surgical management:

• Infiltrative histologic subtype - This is classified as an aggressive histological pattern with higher recurrence risk 2
• Nasal location - The nose is a central facial site with the highest risk of recurrence 2, 1
• Ulcerative presentation - Suggests deeper invasion and poorly defined clinical margins 2

Surgical Approach: The Gold Standard

For high-risk BCC, Mohs micrographic surgery or resection with CCPDMA is the preferred treatment for optimal margin control. 1

• MMS achieves 5-year cure rates of 99% for primary BCC and 94.4% for recurrent lesions 1
• Standard surgical excision with histologically complete margins has recurrence rates <2% at 5 years 2
• The infiltrative subtype has subclinical tumor extensions that require margin-controlled techniques to detect 2

Critical Surgical Considerations

• Adequate margins are essential - The peripheral and deep surgical margins must correlate with the likelihood of subclinical tumor extensions 2
• Excision through subcutaneous fat is generally advisable for the deep margin 2
• Curettage prior to excision may increase cure rates by accurately defining true tumor borders 2

When Surgery May Not Be Appropriate

In elderly patients with poor general health or significant comorbidities, a palliative rather than curative treatment regimen may be in the patient's best interests. 2

Patient-specific factors that may influence treatment choice include:

• General fitness and coexisting serious medical conditions 2
• Use of antiplatelet or anticoagulant medication 2
• Life expectancy and functional status 2

Alternative for Non-Surgical Candidates

Radiation therapy is an effective option for patients who refuse surgery or have contraindications, though it is generally limited to patients older than 60 years due to long-term toxicity risks. 1

• Radiation has an important role in managing high-risk BCC when surgery is not feasible 2
• It should not be used in patients with genetic conditions predisposing to skin cancer or connective tissue diseases 1

What NOT to Do: Critical Pitfalls

Non-surgical treatments (topical imiquimod, 5-fluorouracil, photodynamic therapy, cryotherapy, curettage and electrodesiccation) are absolutely contraindicated for infiltrative BCC on the nose. 1, 3

• These modalities are only appropriate for low-risk superficial BCC 1, 3
• The FDA label for 5-fluorouracil explicitly states it is only for superficial BCC "when conventional methods are impractical" 4
• Curettage and electrodesiccation should never be used on the nose (terminal hair-bearing area) and has only a 60% cure rate for recurrent lesions 1, 3
• All topical and non-surgical treatments are inferior to surgery, even for low-risk lesions 3

If Incomplete Excision Occurs

Re-treatment is strongly advised if incomplete excision occurs, especially when involving critical midfacial sites like the nose, when deep margins are involved, or with aggressive histological subtypes. 2

• When only lateral margins are involved: 17% risk of recurrence 2
• When deep margins are involved: 33% risk of recurrence 2
• Re-excision with or without frozen section control, or MMS, are the treatments of choice 2

Advanced Disease Considerations

If the tumor has invaded facial bones or sinuses (rare but possible with neglected infiltrative BCC):

• Major multidisciplinary craniofacial surgery may be necessary 2
• Hedgehog pathway inhibitors (vismodegib or sonidegib) should be considered if surgery and radiation are contraindicated or inappropriate 2, 1
• Multidisciplinary consultation is strongly encouraged for locally advanced disease 2