An elderly woman who complained of pain and progressive erosive lesion measuring 5cms * 4cms eroding the ear lobe. Duration 2-3 years. Complained of pain down the neck. urface was rough with erosion at places, margins elevated uniform with a distinct line of black color, soft to touch, tenderness was present.
No lymph nodes were palpable, hearing was good, no vertigo, no diabetes, mild hypertension was told.
History of moderate sun exposure noted.
Probable diagnosis of basal cell carcinoma was made.
She is poor, and single.
Can I get some inputs regarding the case? Open for any questions
les
Satyaprasad
Superficial basal cell carcinoma. You must destroy it.
Do you have or may try topical imiquimod ?
yes we have imiquimod. how effective would radiofrequency removal be.?
I think I'll try first imiquimod.
I'll see what happen or if I can destroy most of the lesion. And in the area in which it doesn't work I'll try other mean of destruction like radio frequency; cryosurgery; CO2 Laser ....or other.
Clearly BCC.
Due to its relative depth (see histographs) this lesion will probably not respond sufficiently to Imiquimod. I would prefer surgical resection or radiotherapy, the latter maybe being more convenient, however somewhat lower response rate and a little higher relapse rate.
Dr Micheal, radiotherapy may be prescribed, but how effective would it be, since any failure may make it difficult for surgical excision. so which one should be the first to recommend.
Success rate for RT has been described between 90 % and 98 %. There is a RCT comparing both ( Avril MF, Auperin A, Margulis A, et al. Basal cell carcinoma of the face: surgery or radiotherapy? Results of a randomized study. British journal of cancer. 1997; 76(1): 100) showing the same.
Since RT is a little inferior to surgery - I agree that you would firt see to have her operated.
It is necessary a very well prepared surgeon to do this work. I think also that all lesion don't have the same depth. So, I maintain my first choice and I'll see after.
If I have the capacity in surgery of my Department I would think different ?! I really don't know. I want to know what is necessary to destroy with surgery or other destroying means !
Sir as a part of discussion may I ask you whether all the cells or tissues involved should be removed enmass or is there any chance of recurrence either by intravascular seeding or remnants left behind due to unequal growth of tumor.
Because of the size and depth of this basal-cell carcinoma, my first choice of therapy
would be Mohs surgery.
Surgery. Mohs would be ideal. Otherwise excision with 3 to 5 mm of clear margin with-possibly-graft reconstruction. If the patient is unwilling or the surgery cost is an issue radiotherapy is the second best choice. Some centers may have good experience with Photodynamic therapy. Of course recurrence or residual tumor may be an issue for both open surgery and radiotherapy, minimized only by Mohs.
BCC and Mohs
Photodynamic therapy for superficial lesion not the case on histopathology;
repeated cryotherapy
radiotherapy but with experience
The usual treatment for Basocellular Carcinoma is the surgical resection with Mustardé Flap or the resection with a Free Flap
Due to its depth, I would firstly consider surgery after imaging techniques. If not possible try RT.
Dear Collegue, in my experience RTT on parothid area may cause some problem, like nerve palsy, lesion to salivary glands, pain and distortion of skin and, some times may induce squamous cell carcinoma. I agree with Dr. Rapoport: wide excision (i.e with free margin of 0,5 cm ) and reconstruction (if not possible to perform a free flap I suggest the use of large cervical rotation flap, if necessary with a z-plasty at his base to allow better wound closure). (see "Local flaps in facial reconstruction"Shan R. Baker, second edition - Mosby Elsevier).
This is a case of long standing sclerosing BCC . Wide excision with 5 mm margin and partial thickness skin graft might be the best possible choice for this lady. Any enlarged node in the area should be excised for pathologic study. MOH surgery should be gold standard but might not be available.
Should have parotido-masseteric anatomic region's MRI to be sure the about the deep surgical safe margins. If there is any tumor invasion or very near to the parotid gland, superficial parotidectomy should be added to the operative procedure; then a local or free flap may close the soft tissue defect (assuming BCC).
If we manage with a SCC,the suggestion of a MRI to define the surgical margin is excellent
I would suggest Radiotherapy if there is an experienced radiotherapist who can assume the treatment because it is important to dedde and design the total dose, and the dose fractionation..
..
may be Basal cell carcinoma, probably post PAWN CHEWING.
AS nodes are not involved, excision with chemotherapy may help,alternative is radiotherapy
if the histopathological diagnosis is suggestive of early stage Ca, localized excision with chemotherapy will be sufficient. As the nodes are free, it can be diagnosed as WELL DIFFERENTIATED Ca. it does not require extensive surgery including mandible.
Surgery is option of choice if not invading into deeper structures, otherwise radiotherapy.
There is no establshed role for chemotherapy in the given case. Hedgehog inhibitors are a -however expensive- option in non-resectable cases which are not eligible or refractory to radiotherapy.
This neoplasia is not amenable to irradiation due to involvement of cartilage.
micrographic excsion followed by plastic surgery reconstruction best option
Dear Venkata is it erosion or ulcer, what about the margin-rolled, underminded? tuberculin test done?
No need for Moh's Micrographic Surgery. It is usually carried out for lesions around the canthal regions. But first of all, an incisional biopsy must be performed. It looks like morphea type BCC.