Basal Cell Carcinoma, Aggressive Versus Non-Aggressive Subtypes

Basal cell carcinoma is incredibly common and increasing in incidence around the world. There are well over one million new cases a year diagnosed in the United States alone, not including patients who will get two, three, sometimes more basal cell carcinomata every year. These patients have had early childhood sunburns, a genetic risk, and have ongoing sun-exposure leading to basal cell carcinoma, and other skin cancers later on in life.

Basal cell carcinoma of the central face often has an aggressive growth pattern under the microscope with spiky or irregular strands invading deeper tissues and thus these cases need more careful surgical removal and sometimes Mohs Micrographic Surgery, which is the most thorough way to remove skin cancers. On the other hand, basal cell carcinomata of the trunk are often not aggressive and are superficial in nature. These can be removed with simple procedures such as scraping them with a small semi-sharp tool called a curette. They can even be treated with a cream (imiquimod) where patients may obtain up to 80% cure rates without surgery. These non-aggressive growth pattern basal cell carcinomata are often treated with large excisions unnecessarily. Most Dermatopathologists will subtype basal cell carcinoma appropriately into these different categories, which instructs the clinician as to how to best manage each patient. Unfortunately general pathologists often do not subtype basal cell carcinoma in patients; thus their clinicians do not have the most accurate information in order to allow them to provide the best treatment.

Basal cell carcinoma should be subdivided into different types, i.e. infiltrative, sclerosing or morpheaform, or micronodular as the aggressive subtypes and superficial and nodular as the circumscribed or non-aggressive subtypes. This will lead to better care for any individual’s specific basal cell carcinoma.

If you are scheduled for surgery for basal cell carcinoma, it would be appropriate to ask what type of basal cell carcinoma you have. If it is unknown, a second opinion of your biopsy might better instruct your clinician on how to best manage your particular cancer. Mohs Micrographic Surgery is the treatment of choice for any basal cell carcinoma on the nose, eyelids, lips or ears and for aggressive growth-patterns elsewhere. This unfortunately is not always offered to patients, nor is it always performed by those best able to do the procedure. The first step for patients to make sure they are getting the best possible care is to ensure their biopsy has been interpreted accurately.