Infiltrating Basal Cell
Carcinoma
Laura S. Gilmore, MD
Department of Ophthalmology
October 8, 2004
Discussant: Kenn Freedman, MD
Case Presentation
• CC: growth on right side of nose
• HPI: 81 yo HF who first noted growth on
right side of nose “last December”,
progressively growing.
• PMH: arthritis
• SH: ½ ppd smoker X 25 years
• ROS: denies F/C, significant weight loss
• FH: non-contributory
Physical Exam
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General: AAO, VSS and good
VA: 20/80 OD, 20/50 OS
Pupils: 3mm OU, no APD
External: extensive ulcerative lesion from
bridge of nose to RLL and R cheek, with almost
complete destruction of RLL and nearly
complete ptosis of RUL
• IOP, CVF, DFE normal OS, unobtainable OD
Differential Diagnosis
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Malignant melanoma
Squamous cell carcinoma
Basal cell carcinoma, infiltrative
Infectious
Basics of BCC
• Background
– Most common cutaneous malignancy (~8090%)
– Typically slow-growing, rarely metastasizes
– Sun-exposed skin, mostly face and scalp, esp
nose, cheek, and periorbital regions (~80%)
• Frequency
– 900,000 Dx in US/year
– estimated lifetime risk of 33-39% for
men and 23-28% for women
• Sex
– Men 2X over women
Basics of BCC
• Mortality/Morbidity
– <0.1% metastasize
– Very low mortality
– Significant morbidity with direct invasion of
adjacent tissues, especially when on face or
near an eye
• Age
– Likelihood increases with age
– Rare in <40 yo
• Race
– Most often in light-skinned, rare in darkskinned races
Variants of Basal Cell
Carcinoma
• Superficial
• Nodular
• Micronodular
• Infiltrating (5%)
• Sclerosing/
morpheaform (5%)
• Metatypical
• Infundibulocystic
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Nodulocystic
Adenoid
Clear cell
Follicular
Sebaceous
• Perineurally
invasive
Perineural Invasion
• May be seen in 3% of pts with infiltrating
and morpheaform types
– Most often infiltrating type, which has
highest rate of local recurrence
• Requires CT scan for full work-up
• Causes? inherently aggressive behavior
vs inadequate early management?
Treatment Options
• Electrodessication and curettage
• Curettage alone
• Surgical excision
• Mohs micrographically controlled
surgery
• Cryosurgery
• Ionizing radiation
• Surgical excision plus radiation
• Exenteration
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Factors Considered in
Treatment Planning
Pt preference to keep eye
Pt age
Surgical excision-considered definitive tx
“Careful frozen section controlled excision of
periocular BCCs yields cure rates comparable to
Mohs micrographic surgery at 5-year follow-up”
– 5 year recurrence of 2.2% in one study
– Wong, et al. “Management of Periocular Basal Cell
Carcinoma with Modified En Face Frozen Section
Controlled Excision.” Ophthalmic and Plastic
Reconstructive Surgery. 2002. Vol 18 (6): 430-435.
• Therefore, avoiding exenteration was considered a
good possibility
Conclusion
• Basal cell carcinomas are not always as
innocent as we tend to believe
• In formulating treatment course:
– Strong pt preference and
other pt factors
– Current research