Basal+Cell

Signs that should be observed. [2] Tumor cells of nodular BCC, sometimes called basalioma cells, typically have large, hyperchromatic, oval nuclei and little cytoplasm. Cells appear uniform, and if present, mitotic figures are usually few. [6]The nuclei resemble that of the basal cells of the epidermis, although they have a larger nuclear-to-cytoplasmic ratio and lack intercellular bridges. A mitotic figure is very rarely observed.[6] Nodular tumor aggregates may be of varying sizes, but tumor cells tend to align more densely in a palisade pattern at the periphery of these nests (see the image below).[6] || II. Tumor present in but does not fill and expand papillary dermis III. Tumor fills and expands papillary dermis IV. Tumor invades into reticular dermis V. Tumor invades subcutis || High risk features of tumors that are used to distinguish T1 and T2  || []. **Radiation treatment:** If they are treated with electrons the margin around the basal cell will be increased to ensure adequate coverage. Dose and fractionation depends on the type, size, and depth of the tumor. Daily treatments vary from 2-5 Gy in 6-20 fractions, with a total dose of 30-50 Gy. [3] []. || ||
 * **Epidemiolgy:** || Estimated lifetime risk for BCC in the white population is 33-39% for men and 23-28% for women. The incidence doubles every 25 years. States near the equator show an incidence approximately at a 3-fold. Highest rates are in areas that receive high amounts of UV radiation. Accounts for around 80% of all skin cancers, however, it is the least likely to behave in a malignant fashion and metastasize. Most common in individuals with fair skin, red or blond hair, freckles, and/or type II skin. Likelihood of developing BCC increases with age, with the median age at diagnosis being 67 +/- 2.5 years. [1] ||
 * **Etiology:** || Exact cause is unknown, but environmental and genetic factors play a role.
 * Sunlight
 * Radiation exposure – tanning booths, UV light therapy
 * UVB, UVA and UVC
 * TP52 gene mutations
 * Familial basal cell nevus syndrome
 * X-ray or grenz-ray exposure
 * Arsenic exposure through ingestion
 * Immunosuppression
 * Xeroderma pigmentosum
 * Epidermodysplastic verruciformis
 * Nevoid basal cell carcinoma syndrome
 * Bazex syndrome
 * Previous nonmelanoma skin cancer
 * Skin type
 * Rombo syndrome
 * Alcohol consumption [1] ||
 * **Signs & Symptoms:** || Although SCC can from anywhere on the body the majority of these tumor sites arise in the heavily exposed area of the body (head, ears, shoulders, face, etc.). Typically BCCs often look like open sores, red patches, pink growths, shiny bumps, or scars [2/5].
 * Change in color. (Red, white, pink, blue/black)
 * Change in surface. (scaly, flaky, red patch, bleeding areas that don’t heal)
 * Change in texture. (hard or lumpy moles)
 * Change in surrounding skin. (near skin that pigmentation is changing)
 * Change in previously normal skin now scar like.
 * Shiny bump or nodule. ||
 * **Diagnostic Procedures:** || A routine Self-inspection is the best tool of detections, which should be done in a well lit room at regular intervals. Once an area of concern is established a dermatologist or other physician should be involved to perform an exam which may include. [2/5]
 * Physical exam focusing on changes in normal skin appearance
 * Notation of (mole, freckle or blemish) size, diameter and symmetry
 * Depth of invasion of tumor must be defined with a “dermatoscope” or other “epiluminescence microscopy” (ELM).
 * Once the diagnosis of SCC has been established and due to rapid growth of this type of cancer the course of action can include.[5]
 * Full physical exam to establish other sites (as well as nearby lymph nodes)
 * Motor skill assessment to detect brain involvement
 * Chest x-ray for lung involvement
 * Liver function test for liver involvement
 * CBC count
 * Alkaline phosphatase levers and bone scan
 * Biopsy of site (skin, punch or incisional/excisional)
 * Surgical excision or resection
 * Also (PET, CT, MR) if involvement has been established. ||
 * **Histology:** || Several histologic types of BCC exist. Distinctions are important because clinical detection of tumor margins is more difficult with certain histologic types.[6] Usually, BCCs are well differentiated and cells appear histologically similar to basal cells of the epidermis.[6]
 * **Lymph node drainage:** || Basal cell carcinomas can spread to lymph nodes.[6]The location of lymph nodes involved depends on the location of the original diagnosis. ||
 * **Metastatic spread:** || Basal cell carcinomas rarely metastasize.[6] The incidences of metastases is less tha 0.1%. The common sites of metastatic spread are lymph nodes, lungs and bones.[6] ||
 * **Grading:** || Depth and thickness are the greatest prognostic indicators along with anatomic location and differentiation. Depth and thickness are rated on anatomic levels called “Clark Levels”. [5] I. Intraepidermal tumor only
 * **Staging:** || The American Joint Committee on Cancer’s (AJCC) TNM system is used to stage basal and squamous cell skin cancers. ** T ** = tumor size, location, and spread in to nearby tissues.[2]
 * TX: primary tumor can’t be assessed.
 * TO: no evidence of primary tumor
 * Tis: Carcinoma in situ
 * T1: Tumor is 2cm across or smaller and has only one high risk feature.
 * T2: larger than 2cm across or has 2 or more high risk features.
 * T3: Invades facial bones
 * T4: invades bones of the body or base of skull
 * Thicker than 2mm
 * Invaded in to lower dermis or subcutis
 * Invaded tiny nerves if the skin
 * Originates from the ear or hair-bearing lip
 * Poorly differentiated or undifferentiated under microscope
 * N ** = Nodal involvement
 * NX: nearby nodes can’t be assessed
 * NO: No spread to nearby nodes
 * N1: 1 nearby node on the same side of the body as the primary and 3cm or less across
 * N2a: 1 node same side as primary and between 3 and 6cm across
 * N2b: more than 1 node on the same side as the primary, none larger than 6cm
 * N2c: spread to nodes on the opposite side of the body and none larger than 6cm
 * N3: any node is larger than 6cm across
 * M ** = Metastasis or spread to distant organs
 * M0: no spread to organs
 * M1: spread to organs
 * **Radiation side effects:** || * Erythema of the treated area is the earliest side effect
 * Dermatitis dependent of the dosage and energy used
 * Dry desquamation
 * Moist desquamation
 * Burning and itching symptoms
 * Radiation necrosis(usually in higher fractional doses)[3] ||
 * **Prognosis:** || How well a patient does depends on many different factors. The most important is how quick the cancer was diagnosed. Most basal cell cancers are cured when treated early. Some basal cell cancer’s come back, but they almost never spread to other parts of the body. [7] ||
 * **Treatments:** || Some treatments for basal cell cancer include: [7]
 * Excision
 * Curettage and electrodesiccation
 * Cryosurgery
 * Medication
 * Johns surgery
 * Photodynamic therapy
 * Radiation may be used if not removed with surgery
 * **TD 5/5:** || The TD 5/5 for a skin dose is: [8]
 * **References:** || # Drugs, Diseases & Procedures. Medscape. http://emedicine.medscape.com/article/. Accessed June 27, 2012.
 * 1) Cancer staging/ grading. Available at: []. Accessed on July 2,2012
 * 2) Chao KS, Perez CA, Brady LW. Radiation Oncology: Management Decisions. Philadelphia, PA: Lippincott Williams & Wilkins; 2002
 * 3) Protocol for Examination of Specimens from Patients With Squamous cell Carcinoma of the Skin. Available at: __[|http://www.cap.org]__. Accessed on July 5th, 2012.
 * 4) Washington, Charles, and Dennis Leaver. Principles and Practices of Radiation Therapy.St. Louis,Missouri: Mosby Elsevier, 2010
 * 5) Bader, R.Basal Cell Carcinoma Workup. Medscape.Feb 2012.Available at:[|http://emedicine.medscape.com/article/276624-workup#aw2aab6b5b4aa]. Accessed on: July 5, 2012.
 * 6) Basal cell carcinoma. MedlinePlus. Available at: []. Accessed on July 2, 2012.
 * 7) Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. //Int J Radiat Oncol Biol Phys. // 1991;109-122. ||

Back to Week 7