Basal cell carcinoma: What does basalioma look like and why does it occur?

Basal cell carcinoma (BCC) is currently the most common malignancy in the human population with a continuously increasing annual incidence.

Basalioma = Basal Cell Carcinoma = Basal Cell Carcinoma = BCC.

More than one in three new cases of cancer is skin cancer. Most of these are basal cell carcinoma (basalioma, BCC), which is a non-melanoma skin cancer (NMSC).

It is an epithelial skin cancer with an unusually large clinical and historiopathological diversity. It is approximately 2-4 times more common than squamous cell carcinoma.

Basal cell carcinoma (BCC) is currently the most common malignancy in the human population. Up to 85% of BCC occurs in sun-exposed areas of the head and neck. Despite medical advances, surgical excision and radiotherapy (radiation treatment) remain the first-line treatment for most high-risk BCC lesions.

The geographic distribution of basalioma varies with latitude due to the effect of sunlight on the skin.

The highest incidence of BCC is recorded in northern Australia.

It occurs in:

• approximately 1.1 to 1.9 times more common in males than females
• in pale-skinned people - phototype I and II
• people with blue eyes
• people with light or red hair
• people over 40 years of age (highest incidence between 60 and 80 years of age)
• most commonly (85%) on the head and neck, which are chronically exposed to the sun
• 25-30% of lesions occur on the nose
• on the back of the hand, and in men on the calva (upper part of the skull) and lower lip.

If basalioma is caught early, it is easily treatable with available therapies.

Basaliomas rarely metastasize (between 0.0028% and 0.5%) and therefore rarely lead to death. However, they can lead to significant morbidity if not diagnosed early and treated correctly.

For malignant tumours (carcinomas), so-called staging, i.e. the determination of the extent of the tumour using the TNM system, is determined. Because of the low metastatic potential of basal cell carcinoma, the classical TNM classification (tumour, nodules, metastases) is not given for localised tumours.

For interest we present.

T (tumor, size designation)

1. _Tx (size cannot be determined)
2. _T0 (none)
3. _T1
4. _T2
5. _T3
6. _T4 (overgrows into surrounding tissue - skin...)
7. _Tis (carcinoma in situ - invasive carcinoma that spreads further)

N (nodus, involvement of regional lymph nodes)

1. _Nx (cannot be determined)
2. _N0 (regional lymph nodes not affected)
3. _N1
4. _N2
5. _N3

M (metastases, distant metastases)

1. Mx₍ cannot be determined)
2. M0₍ metastases not present)
3. T1₍ metastases present)

Basalioma (Dg C44.1) is the most common tumour in the region of the eye, eyelashes and inner corner.

It is an epithelial malignancy that arises from the basal cells of the epidermis (hence the name) and hair follicles.

It is a tumour resembling the basal layers of squamous epithelium. Macroscopically it is very varied. It starts as a small resistance of the eyelashes or inner corner, later exulcerates (ulceration, ulcerative breakdown) and infiltrates the surrounding area.

The highest incidence is recorded:

• after the age of 50
• in the first and second stages (T1, T2), when good cosmetic results can still be achieved with surgical treatment

Tumours overgrowing the entire thickness of the eyelash can still be successfully treated in most cases by resection of the entire eyelash.

In the T3 stage, when the process overgrows into the orbit and sinuses, destruction and loss of the eye occurs. In some cases, exenteration (removal) of the orbit or more extensive radical procedures are necessary.

Based on the biological behaviour, we generally distinguish between indolent (non-aggressive) types (superficial, nodular) and aggressive types (infiltrative, micronodular, metatypical - basosquamous) of basal cell carcinoma of the skin.

BCC is divided into two main subtypes with different clinical behaviour (Table)

Different types of basaliomas have different biological behaviour and prognosis, and from a practical point of view they are divided into...

low-risk:

• localization of the tumor on the trunk
• on the extremities except hands, feet, nail beds, pretibial region (tibia) and ankles

high-risk - "high-risk":

• facial area (cheeks, forehead, scalp, neck)
• pretibial area (tibia)
• central facial area, periorbital, nose, lips, chin, jaw, ear, preauricular and retroauricular area
• genitalia
• hands
• legs

The most important aetiological factors of BCC (factors causing its occurrence) are:

• actinic (solar) radiation - UVB (290-320 nm), which is capable of damaging cellular DNA and causing its mutations with the appearance of thymidine dimers
• UVA radiation (320-400 nm) - capable of penetrating glass, responsible for photoaging and photoimmunosuppression
• ionising radiation
• genetic influences
• Human papillomavirus (HPV) infection
• chemical substances
• carcinogens
• immunosuppression (reduced activity of the body's defences, e.g. after organ transplantation)
• PUVA therapy (P for psoralen, U for ultra, V for violet and A for the part of the solar spectrum between the wavelengths of 320 and 400 nanometres. Psoralens are chemicals found in certain plants that have the ability to absorb ultraviolet light in the UVA part of the solar spectrum. So PUVA is a combination of an oral drug and subsequent exposure to ultraviolet light)
• scars
• chronic skin damage

The macroscopic appearance of the BCC tumour is varied. It resembles a small persistent ulceration or has the appearance of a pearly line with fine atelectasis.

All histopathological variants of basalioma have a pearly, waxy or translucent character.

In the early stage, this tumour appears as a slowly growing greyish-white, shiny papule (vesicle) to nodule of skin colour with thinned epidermis and telangiectasias (localised dilated small blood vessels - hair cells).

It is rigid and has a pearly appearance, as if composed of tiny nodules (tumour plugs).

In the centre, ulceration with crust (scab) may form. A beaded rim with telangiectasias forms in the surrounding area.

It is not possible to make a definitive diagnosis without histological examination.

Histological examination can be performed after surgical extirpation of the tumour (removal) or during diagnostic biopsy (tissue sampling), as several histopathological forms of basalioma are known.

Local growth is characterised by painless progression of the lesion into the surrounding tissues. Untreated, the tumour doubles in size every year.

On the eyelashes, the tumour grows into the dermis (skin), later affecting the tarsus (cartilaginous base of the eyelash) and progressing through the septum to the orbit.

Because of the painless onset of basalioma growth, many patients seek medical attention after five years.

After collection, tissue samples must be on the tube for histopathological examination:

• patient's nationality
• the exact location of the sampling
• anamnestic data (duration of manifestation, bleeding, wetting, pain, tumour recurrence)
• clinical picture of the lesion (size, shape, staining, surface exulceration, localization of the manifestation)
• type of surgical procedure (excision, biopsy...)
• presumed diagnosis of the tumour

The result of the histopathological examination must be included in the macro description of the lesion:

• length, width, thickness (in mm or cm)
• symmetry or asymmetry
• staining
• topography (flat, nodular, exulcerated, crusted, bloody)
• tumour localisation
• type of surgical procedure (excision, re-excision, biopsy...)
• comment on the question of primary or secondary type (recurrence)

The microdescription must state:

• definitive diagnosis
• histopathological type
• presence or absence of ulceration
• the lateral and inferior margin of the excision in millimetres (important information when deciding on scar re-excision or post-operative radiotherapy)
• presence of perineural invasion.

MR (magnetic resonance imaging), CT (computed tomography) scans are used for more accurate diagnosis.

Treatment of basalioma requires an interdisciplinary approach (dermatologist, plastic surgeon, otorhinolaryngologist, radiation oncologist, clinical oncologist) to be effective.

Are patients with basalioma followed up after treatment? What is the process of dispensation?

Dispensary (follow-up - regular monitoring of the patient)

After surgery for basal cell carcinoma, the patient should have at least one follow-up appointment to check:

• the scar after surgery
• discuss his diagnosis and treatment
• the need for UV protection is stressed
• the importance of self-examination if there is a risk of tumour recurrence or new primary BCC

There is no evidence that intensive follow-up of patients with low-risk BCC yields better treatment outcomes (disease burden, cosmetic outcomes).

Does the patient qualify for disability recognition?

Temporary disability can be counted on in the treatment of BCC until satisfactory compensation of the clinical condition and the necessary functional capacity is achieved.

Can I protect myself from developing basalioma? What is the prevention of basalioma?

Basal cell carcinoma can be successfully prevented and its incidence can be significantly reduced with consistent prevention.

The role of primary prevention is through prevention campaigns with the aim of:

• inform and educate the population about the harmful effects of UV radiation.
• emphasising photoprotection habits (sunscreen, clothing)
• observing the principles of correct sunbathing
• control of sunbeds
• correct indication of phototherapy
• consistent recording of UV doses
• not exceeding the annual and lifetime cumulative dose (annual cumulative dose 150 ^J/cm2, lifetime dose 1000 ^J/cm2)
• educate the population about the need for self-examination of the skin

BCC most commonly occurs in humans:

• with a positive family history of malignant melanoma and non-melanoma skin cancer
• after surgery for malignant melanoma and NMSC
• immunocompromised, for example after organ transplantation
• HIV positive
• working outdoors
• with phototype I and II

Phototype I is characterized by:

• skin is very fair with freckles, hair is reddish, eyes are blue
• skin is not tanned, always red, burns
• the burns tend to be severe and painful
• without the use of a protective agent, the skin turns red within 5-10 minutes
• it is recommended to use sunscreens with SPF 50 and SPF 50+

Phototype II is characterised by:

• skin is fair but less often freckled, hair is fair, eyes are blue, green or grey
• the skin is red, tans very poorly, often burns and peels off quickly
• without the use of sunscreen, the skin turns red within 10-20 minutes
• it is recommended to use sunscreens with SPF 30 and SPF 50+

Preventive measures include, in particular, protection from UV rays.

The main task of secondary prevention is the early diagnosis of skin tumours in the early stages of the disease.

A full-body skin examination by a dermatologist is recommended once a year. In case of changes in moles and the appearance of new non-healing, swollen and scaly manifestations, the examination is urgent.

Educational programmes focus on proper self-examination of the skin and what to do if a skin tumour is suspected.

It appears that systemic administration of vitamin D3 could have a preventive effect.

What is the prognosis for basal cell carcinoma?

The prognosis of BCC has improved in recent decades worldwide. This is probably due to early diagnosis, better access to health services and increased public awareness through various educational campaigns.

In BCC, the aggressiveness of the tumor depends on the location. Especially tumors on the auricle and eyelid are more likely to metastasize.

The larger the size of the tumour and the higher the pathological staging of the disease, the more challenging the removal and treatment. The risk of recurrence increases.