Identifying Patients at Risk for Recurrent or Advanced BCC

November 2013 | Volume 12 | Issue 11 | Original Article | 1244 | Copyright © November 2013

Omid Hamid MDa and Gary Goldenberg MDb

aThe Angeles Clinic and Research Institute, Los Angeles, CA
bIcahn School of Medicine at Mount Sinai, New York, NY

Basal cell carcinoma (BCC) is a common skin cancer and its incidence is on the rise worldwide. Clinical presentation and histologic examination are used for diagnosis and to stratify BCCs as either low- or high-risk for recurrence or development of advanced disease. A number of surgical and nonsurgical options are available for BCC. BCC is most often managed with a surgical approach, but not all tumors and patients are suitable for surgery. Vismodegib is a recently approved first-in-class hedgehog pathway inhibitor that has expanded options for patients who have locally advanced or metastatic BCC.

J Drugs Dermatol. 2013;12(11):1246-1252.


Nonmelanoma skin cancer (NMSC) includes basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), with BCC accounting for approximately 80% of NMSCs.1,2 The National Cancer Institute estimates that more than 2 million new cases of NMSC occurred in the United States in 2012.3 The incidence of BCC has been rapidly increasing in recent decades in both the United States1,4 and worldwide,5,6 with the greatest increase noted in women under 40 years of age.4 The lifetime risk of developing a BCC may be as high as 30%.7
A variety of surgical and nonsurgical treatment options are available for managing BCC.8,9 Surgery is the most common treatment, but there are times when it is not suitable or not preferred by patients.10,11 Treatment decisions become more complex when there is recurrent disease and/or the BCC is locally advanced. The oral agent vismodegib—recently approved for the treatment of adults with metastatic BCC (mBCC), or with locally advanced BCC that has recurred following surgery or who are not candidates for surgery, and who are not candidates for radiation—provides an additional option for these patients.10
This second in a series of 3 CME articles examines the diagnosis and treatment of BCC, with particular focus on (i) identifying patients at risk for recurrent or advanced disease and (ii) using patient and disease characteristics to select among available treatment options. The first (published in the October 2013 issue) examined new agents for BCC and their mechanisms of action. The 3rd installment, scheduled to appear in the December 2013 issue, will review various nonsurgical options for BCC, their benefits and drawbacks, and how best to select appropriate patients for these therapies.

Diagnosis of BCC

Experienced dermatologists can usually clinically diagnose typical cases of BCC based on morphology and anatomic location. 12-14 When the presentation is less clear-cut, dermoscopy can aid in the differential diagnosis of BCC from other conditions that may clinically mimic its various subtypes.12,14,15 Dermoscopy may be particularly useful when dealing with pigmented BCCs.12
A biopsy is used to confirm initial clinical suspicion,15-18 as well as to stratify tumors in terms of risk.14 However, mixed BCC subtypes may be inaccurately diagnosed by shave or punch biopsies (ie, BCCs with a nonaggressive superficial component in the epidermis and more aggressive component in the deeper dermis).19-22 In such cases, the shave or punch biopsy may fail to correctly identify the deeper aggressive component that drives the overall growth pattern of the tumor and treatment decisions. A complete skin examination and clinical history may provide additional diagnostic clues, and should be obtained in all patients with a suspected BCC.23 Patients with an NMSC may report a history of nonhealing, ulcerative, bleeding lesions.16

Clinical Presentation

BCC subtypes and the location of the BCC help identify whether there is an increased risk for recurrence or aggressive growth. Nodular, superficial, morpheaform (also known as sclerosing or fibrosing), infiltrative, micronodular, and basosquamous are the major histologic subtypes of BCC. Less common subtypes include adenoid (cystic) and fibroepithelioma of Pinkus.24,25
Nodular and superficial BCCs are sometimes considered indolent- growth or low-risk BCC subtypes. That is, while any BCC