Nonsuperficial Basal Cell Carcinoma Research Articles

Comparison of Sonographic Characteristics Between Superficial Basal Cell Carcinoma and Non-Superficial Basal Cell Carcinomas.

To compare the sonographic characteristics of superficial basal cell carcinoma (sBCC) and non-superficial basal cell carcinomas (nsBCC). The ultrasound characteristics of 73 basal cell carcinoma (BCC) confirmed by surgical pathology were retrospectively analyzed, and the cases were divided into 11 cases of sBCC and 62 cases of nsBCC according to pathological subtypes. Ultrasound characteristics between groups were compared. Among all the ultrasound characteristics, lesion thickness (P=.000), shape (χ2 =39.293, P=.000), basal changes (χ2 =8.473, P=.037), infiltration level (χ2 =46.140, P=.000), and distribution of intralesional hyperechogenic spots (χ2 =15.699, P=.000) of the lesions had statistically significant correlation with pathological diagnosis of sBCC. While no significant differences were shown in surface morphology, keratinization, maximum diameter, intralesional echogenicity, posterior echogenic changes, and intralesional color Doppler flow of the lesions. Small lesion thickness, oblate shape, superficial dermal local infiltration, and <3 internal hyperechogenic spots distribution of BCC determined by high frequency ultrasound may positively correlate with pathological diagnosis of sBCC. This is beneficial for treatment planning.

The Feasibility of Immunocryosurgery in the Treatment of Non-Superficial, Facial Basal Cell Carcinoma That Relapsed after Standard Surgical Excision: An Experience Report from Two Centers.

In this retrospective, chart review study, we evaluated the feasibility of immunocryosurgery in facial, non-superficial basal cell carcinomas (BCC) that had relapsed after standard surgery. Inclusion criteria were (a) 'biopsy confirmed relapse of facial BCC', (b) known 'calendar year of surgical excision(s)', and (c) 'relapse within 10 years after the last surgical excision'. Tumors treated from 1 January 2011 to 31 December 2020 with a standard 5-week immunocryosurgery cycle (daily imiquimod application for 5 weeks and a cryosurgery session at day 14) were included. Descriptive statistics, Kaplan-Meier method, and Cox proportional hazards model were calculated with significance at p < 0.05. From the n = 27 BCC evaluated, n = 20 (74.1 ± 8.4%) cleared after one immunocryosurgery cycle. Two of the remaining cases cleared completely after a repeat cycle, one patient favored surgery, and four BCC did not clear despite additional immunocryosurgery cycles (feasibility 81.5 ± 7.5%). Of the 22 tumors with clinical outcome 'complete clearance with immunocryosurgery', three BCC relapsed at 9, 28, and 50 months. Overall, the 5-year treatment efficacy rate was 60.2 ± 13.4% (mean follow-up 94.6 ± 15.1 months). In total, 20/27 BCC relapses after surgery (74.1%) were tumor-free at the end of personalized follow-up times (66.7 ± 12.4% tumor free patients at 5-year follow-up). Number of tumor relapses before immunocryosurgery was the single predictor of tumor progression after immunocryosurgery (p = 0.012). Conclusively, immunocryosurgery could be further evaluated as an alternative, definitive treatment of selected facial BCC relapsing after surgery.

A cohort study on detection and subtyping of basal cell carcinoma with optical coherence tomography: The additional value of distant diagnosis by an expert

To the Editor: Optical coherence tomography (OCT), a non-invasive technique for diagnosis of basal cell carcinoma (BCC) could potentially replace standard biopsy, thereby, enabling physicians to diagnose and initiate treatment during the same consultation.1,2 The ability of OCT assessors to discriminate between BCC and non-BCC, and between BCC subtypes (superficial BCC vs non-superficial BCC) must be high. However, the discriminative ability of assessors varies due to differences in experience level.

Superficial basal cell carcinoma, think deeper: Step sectioning of skin biopsy specimens yields 14% more aggressive subtypes.

IntroductionBecause of different therapeutic regimens for superficial and non-superficial basal cell carcinomas (BCCs), accurate histopathological examination of a punch biopsy to determine its subtype is essential. The aim of the current study was to evaluate the additional yield of a more extensive step-section method to that of a standard histologic examination at 4 levels.Material and methodsData for this prospective study was obtained from the Pathology department of a Dutch tertiary hospital. Biopsy specimens of subsequent patients from March 2019 to June 2020 were sectioned to 8-levels instead of the regular 4-levels. Only patients with a superficial BCC subtype in the first 4-levels of sectioning were included (n = 100). After 8-level sectioning, it was recorded in which level (5–8) a more aggressive BCC component was found (i.e. nodular, infiltrative, or micronodular). Patients were followed-up to evaluate further treatment, and in case of excision, the excision specimen was reviewed to determine the BCC subtype. A logistic regression was performed to assess characteristics associated with a more aggressive BCC component in levels 5–8.ResultsIn 14 patients (14%) a more aggressive component was found in levels 5–8, all with a nodular component. Thirteen of these patients underwent excision, confirming a more aggressive BCC subtype. Of the 86 patients that had no deeper BCC component in levels 5–8, 26 (30.2%) underwent excision; In 4 patients no residual BCC was found, in 15 patients superficial BCC, and in 7 a more aggressive BCC subtype (1 nodular and 6 a combination of superficial/nodular/infiltrative). In multivariable analysis, head&neck localization was associated with finding a more aggressive BCC subtype in levels 5–8 (OR 6.41 (95%CI 1.56–26.30), p = 0.01)).ConclusionsMore extensive sectioning of superficial BCC biopsy specimens, especially in the head&neck area, leads to a more accurate BCC subtype diagnosis requiring different clinical management strategies.

Diagnostic Value of Optical Coherence Tomography Image Features for Diagnosis of Basal Cell Carcinoma.

Optical coherence tomography (OCT) is a non-invasive diagnostic method. Numerous morphological OCT features have been described for diagnosis of basal cell carcinoma (BCC). The aim of this study is to evaluate the diagnostic value of established OCT features and to explore whether the use of a small set of OCT features enables accurate discrimination between BCC and non-BCC lesions and between BCC subtypes. For each lesion, the presence or absence of specific OCT features was recorded. Histopathology was used as a gold standard. Diagnostic parameters were calculated for each OCT feature, and multivariate logistic regression analyses were performed to evaluate the loss in discriminative ability when using a small subset of OCT features instead of all features that are characteristic for BCC according to the literature. The results show that the use of a limited number of OCT features allows for good discrimination of superficial BCC from nonsuperficial BCC and non-BCC lesions. The prevalence of BCC was 75.3% (225/299) and the proposed diagnostic algorithm enabled detection of 97.8% of BCC lesions (220/225). Subtyping without the need for biopsy was possible in 132 of 299 patients (44%), with a predictive value for presence of superficial BCC of 84.3% vs 98.8% for presence of non-superficial BCC.

Dermoscopic Features of Basal Cell Carcinoma and Their Association with Histological Types in A Chinese Population: A Perspective Study

Abstract Objective: The treatments and prognoses of high-risk and low-risk basal cell carcinomas are quite different. This study aimed to examine the dermoscopic features of basal cell carcinomas and assess the association between the features and basal cell carcinomas recurrence risks in a Chinese population. Methods: Patients with histopathologically confirmed basal cell carcinomas examined from March 2016 to April 2020 were enrolled. The dermoscopic features were evaluated, and the correlations between these features and the histological types and recurrence risks were assessed. Results: The study cohort comprised 119 Chinese patients with a total of 119 skin lesions. The most common dermoscopic feature of basal cell carcinomas was the absence of a pigment network (119/119, 100%), followed by shiny white streaks (105/119, 88.24%), blue-gray ovoid nests (99/119, 83.19%), multiple blue globules (78/119, 65.55%), and arborizing vessels (78/119, 65.55%); yellow-white structures were present in 29/119 lesions (24.37%). Leaf-like and spoke-wheel areas were significantly associated with superficial basal cell carcinomas (P &lt; 0.001), while arborizing vessels (P &lt; 0.001), blue-gray ovoid nests (P &lt; 0.001), and ulceration (P &lt; 0.05) were significantly associated with nonsuperficial basal cell carcinomas subtypes. The dermoscopic features of the high-risk and low-risk groups exhibited considerable overlap; however, the respective independent predictive factors for a high and low risk of basal cell carcinomas recurrence were short fine telangiectases (P &lt; 0.05) and blue-gray ovoid nests (P &lt; 0.05). Conclusion: Dermoscopy provides important information about basal cell carcinomas and is helpful in differentiating superficial basal cell carcinomas from other subtypes. The dermoscopic vascular structures and blue-gray ovoid nests play a crucial role in evaluating the basal cell carcinomas risks preoperatively.

Surgeon Experience Level and Number of Mohs Stages: A Prospective Observational Study of In-training Surgeons

Background&#x0D; Comparisons of Mohs surgeons by experience level (early-, mid-, late-career) and their respective number of stages taken during Mohs have not detected any difference. However, data comparing the number of stages for attending Mohs surgeons to Mohs fellows is non-existent.&#x0D; Objective&#x0D; To prospectively observe and compare the mean number of Mohs stages taken for attending Mohs surgeons and fellows.&#x0D; Methods/Materials&#x0D; Procedural data from 2,140 Mohs cases over 24 months was collected and divided into an attending or fellow surgeon cohort.&#x0D; Results&#x0D; The attending cohort had a higher mean number of stages for all nonmelanoma skin cancer when compared to the fellow cohort (p=0.005). The attending cohort demonstrated a higher mean number of stages for non-aggressive, non-superficial basal cell carcinoma (p&lt;0.001), but no difference was found for other cancer subtypes. No difference was detected when comparing the two cohorts’ performance at high, medium, and low risk surgical areas.&#x0D; Conclusion&#x0D; The attending cohort had a higher mean number of stages overall for combined types of skin cancer and for non-aggressive, non-superficial basal cell carcinoma specifically when stratified by diagnosis as compared to the fellow cohort. No difference existed in the mean number of stages between the cohorts based on surgical area.

Dermoscopy in Basal Cell Carcinoma: An Updated Review

Dermoscopy is a noninvasive technique that has been demonstrated to improve diagnostic accuracy in basal cell carcinoma (BCC). The first dermoscopic model for the diagnosis of BCC, based mainly on the identification of pigmented structures, was described by Menzies and colleagues, and since then dermoscopy has generated an abundance of literature useful to routine clinical practice. From a practical perspective, dermoscopic structures associated with BCC can be classified as pigmented, vascular, or nonpigmented/nonvascular. One of the most recent applications of dermoscopy in BCC is as an aid to predicting histologic subtype and essentially differentiating between superficial and nonsuperficial BCC. It can also, however, help raise suspicion of more aggressive variants with a higher risk of recurrence. A thorough dermoscopic examination during follow-up of patients with actinic damage or a history of multiple BCCs can facilitate the detection of very incipient lesions and significantly impact treatment and prognosis.

Dermatoscopia del carcinoma basocelular: revisión actualizada

Dermoscopy is a noninvasive technique that has been demonstrated to improve diagnostic accuracy in basal cell carcinoma (BCC). The first dermoscopic model for the diagnosis of BCC, based mainly on the identification of pigmented structures, was described by Menzies et al., and since then dermoscopy has generated an abundance of literature useful to routine clinical practice. From a practical perspective, dermoscopic structures associated with BCC can be classified as pigmented, vascular, or nonpigmented/nonvascular. One of the most recent applications of dermoscopy in BCC is as an aid to predicting histologic subtype and essentially differentiating between superficial and nonsuperficial BCC. It can also, however, help raise suspicion of more aggressive variants with a higher risk of recurrence. A thorough dermoscopic examination during follow-up of patients with actinic damage or a history of multiple BCCs can facilitate the detection of very incipient lesions and significantly impact treatment and prognosis.

Biopsy outperforms reflectance confocal microscopy in diagnosing and subtyping basal cell carcinoma: results and experiences from a randomized controlled multicentre trial.

SummaryBackgroundReflectance confocal microscopy (RCM) is a noninvasive method for skin assessment, allowing entire lesion evaluation up to the papillary dermis. RCM is a potentially attractive alternative to punch biopsy (PB) in basal cell carcinoma (BCC).ObjectivesTo determine the diagnostic accuracy of RCM vs. PB in diagnosing and subtyping BCC, and to study patient satisfaction and preferences.MethodsPatients with a clinically suspected primary BCC were randomized between RCM and biopsy. Conventional surgical excision or follow‐up were used as reference. Sensitivity and specificity for BCC diagnosis and subtyping were calculated for both methods. BCC subtype was stratified based on clinical relevance: aggressive (infiltrative/micronodular) vs. nonaggressive (superficial/nodular) histopathological subtype and superficial vs. nonsuperficial BCC. Data on patient satisfaction and preferences were collected using a questionnaire and a contingent valuation method.ResultsSensitivity for BCC diagnosis was high and similar for both methods (RCM 99·0% vs. biopsy 99·0%; P = 1·0). Specificity for BCC diagnosis was lower for RCM (59·1% vs. 100·0%; P < 0·001). Sensitivity for aggressive BCC subtypes was lower for RCM (33·3% vs. 77·3%; P = 0·003). Sensitivity for nonsuperficial BCC was not significantly different (RCM 88·9% vs. biopsy 91·0%; P = 0·724). Patient satisfaction and preferences were good and highly comparable for both methods.ConclusionsBiopsy outperforms RCM in diagnosing and subtyping clinically suspected primary BCC. This outcome does not support routine clinical implementation of RCM, as a replacement for PBs in this patient group.

Optical Coherence Tomography for Noninvasive Diagnosis and Subtyping of Basal Cell Carcinoma: A Prospective Cohort Study

Noninvasive diagnostic strategies such as optical coherence tomography (OCT) enable detailed examination of skin tissue architecture and have potential for identification and subtyping of basal cell carcinoma (BCC). To evaluate the additional diagnostic value of OCT, a prospective cohort study was performed in 182 patients with 250 lesions suspected for non-melanoma skin premalignancies requiring a biopsy. Accuracy of BCC diagnosis and subtype on the basis of clinical examination (CE) of patients was compared with that on the basis of OCT scans in conjunction with clinical images of lesions (cOCT). Confidence levels were recorded on a 5-point scale, where score 0 indicated absence of BCC and scores 1-4 indicated increasing suspicion of BCC. Diagnostic performance parameters were compared using histopathologic diagnosis as gold standard. The patient-based area under the receiver operating characteristic curve (AUC) increased from 85.6% for CE to 91.2% for cOCT (P= 0.061) and the lesion-based AUC from 82.7% to 91.3% (P < 0.001). When confidence scores 1-4 were defined as positive, patient-based specificity increased from 47.5% (CE alone) to 76.8% (cOCT) at similar sensitivity (97.6% and 95.2%, respectively). cOCT slightly improved the ability to discriminate between superficial and nonsuperficial BCC subtypes and seemed to be a valuable addition to CE alone in the diagnosis and subtyping of BCC.

Single versus Multiple Level Sectioning for the Subtyping of Basal-Cell Carcinoma: A Retrospective Study

Background: The histological subtype of basal-cell carcinoma (BCC) is often based on a punch biopsy; only a small part is evaluated, possibly leading to misclassification. Consensus on the optimal approach to process punch biopsies is lacking, though accurate subtyping is important for appropriate treatment. Objective: The aim is to investigate whether evaluating 4 levels of a punch biopsy instead of 1 or 2 levels leads to more accurate subtyping of BCC. Methods: In a retrospective study we evaluated 87 punch biopsies of histologically confirmed BCCs. The primary outcome was the proportion of “more aggressive” BCCs (nonsuperficial vs. superficial, infiltrative vs. nodular subtype) that was missed by evaluation on 1 or 2 levels, using 4-level diagnosis as reference standard. Results: Eighty-five cases were available for analysis. Subtyping based on 1 level resulted in discrepancies with 4-level diagnosis in 16.5% of all cases. Underdiagnosis occurred in 14 of 58 nonsuperficial BCCs (24.1%, 95% CI: 13.9–37.2). Seven of 38 nodular BCCs (18.4%, 95% CI: 7.74–34.3) were diagnosed as superficial in 1 level, and 7 of 20 infiltrative BCCs (35%, 95% CI: 15.4–59.2) were diagnosed as superficial (n = 2) or nodular (n = 5) in 1 level. Conclusion: In order to maximize correct subtyping and plan appropriate treatment, we advise to evaluate at least 2, but preferably more, levels of a punch biopsy to determine the BCC subtype.

Non-genetic and genetic predictors of a superficial first basal cell carcinoma.

BackgroundSeveral observational studies have suggested differences in the risk factor profile between patients with superficial basal cell carcinomas (BCCs) and non‐superficial BCCs.ObjectiveTo test the reproducibility of previous study findings and to find new genetic and non‐genetic predictors for patients with a superficial first BCC.MethodsA total of 14.628 participants of northwestern European descent aged 45 years or older from a prospective population‐based cohort study (Rotterdam Study) were linked with the Dutch Pathology Registry (PALGA) of whom 1528 were identified as BCC patients. After exclusion, 948 eligible BCC patients remained for further non‐genetic analyses and 1014 for genetic analyses. We included 11 phenotypic, environmental and tumour‐specific characteristics, and 20 candidate single nucleotide polymorphisms (SNP) as potential predictors for patients with a superficial first BCC. We performed binary logistic multivariable regression analyses.ResultsWe found that patients with a superficial first BCC were significantly younger, almost two times more often female and 12–18 times more likely to have their BCC on the trunk or extremities than patients with a non‐superficial first BCC. One SNP (rs12203592), mapped to IRF4, looked promising (OR 1.83, 95% CI 1.13–2.97, P‐value <0.05), but after adjustment for multiple testing, no significant differences in genetic make‐up between superficial BCC and non‐superficial BCC patients were found.ConclusionWe conclude that patients with a superficial BCC differ from non‐superficial BCC patients with respect to environmental factors (tumour localization as a proxy for UVR exposure) and phenotypic characteristics (age and sex), but we found no difference in genotype. As superficial BCC patients develop their first BCCs at a younger age, they could be at higher lifetime risk for subsequent skin cancers and therefore be an important group for secondary prevention.

Immunocryosurgery for non-superficial basal cell carcinomas ≤ 20 mm in maximal diameter: Five-year follow-up.

To report the five-year follow up results of a prior prospective clinical trial (NCT01212562) on immunocryosurgery for the treatment of non-superficial basal cell carcinoma (BCC) ≤20 mm in diameter. Immunocryosurgery consists of five weeks daily 5% imiquimod cream and a cryosurgery session on day fourteen. This combination cleared 95 ± 2% of BCCs at the eighteen month follow up. Herein, we present the results of the five year follow-up or per last available information of the aforementioned cohort. The primary study outcome was treatment failure (non-complete response or relapse); failure rates were calculated per intention to treat and per protocol. Data for at least five years after initial treatment were available for 55% of the patients (53.4% of per protocol treated tumors) as actualized up to 31th July 2016. Age at recruitment was the only significant predictor of follow-up availability. Nine treatment failures were documented after one immunocryosurgery cycle. The five-year tumor free rate after one immunocryosurgery cycle was 91.4 ± 2.8% and 87.7 ± 3.1% according to per protocol and per intention to treat analysis, respectively. Sex, tumor size or high-risk anatomical localization within the 'H-area' of the face did not affect treatment outcome. With repeat immunocryosurgery cycles only 3 sites were not tumor free at last follow up (effectiveness: 97.1 ± 1.6% per protocol or 93.2 ± 2.3% per intention to treat analysis). Immunocryosurgery is an effective, minimally invasive treatment alternative to surgical modalities for most BCC ≤20 mm in diameter, including those in high risk localizations.

Immunocryosurgery for Non-superficial Basal Cell Carcinoma: A Pro­spective, Open-label Phase III Study for Tumours ≤ 2 cm in Diameter

Cryosurgery and topical imiquimod are established mono-therapies for superficial basal cell carcinoma (BCC) but are often insufficient for thicker BCCs. We present here a phase III, prospective, interventional, single-arm (cases only) study (trial registration: NCT01212562) to evaluate the feasibility and efficacy of cryosurgery (liquid nitrogen, open spray, 2 × 15 s; day 14) during 5 weeks' imiquimod ("immunocryosurgery") for primary, non-superficial BCC, ≤ 2 cm in diameter. Ninety-one consecutive patients with 134 basal cell carcinoma were evaluated. A total of 83 patients (124 tumours) started treatment, and 79 patients (119 tumours) completed at least one cycle of immunocryosurgery (feasibility: 95.2%; follow-up: 18-60 months). The efficacy after one treatment cycle was 95 ± 2% stable complete remissions (116/119 tumours cleared, 3/116 tumours relapsed: 6 treat-ment "failures"). Neither tumour size (p = 0.865) nor localization (p = 0.233) predicted outcome. Repeat immunocryosurgery controlled 5/6 treatment failures (overall efficacy: 99%). Lack of a conventionally treated control group is a limitation of this study. However, the results show a high therapeutic efficacy of immunocryosurgery in a large series of primary non-superficial BCC.

Cryosurgery is more effective in the treatment of primary, non-superficial basal cell carcinomas when applied during and not prior to a five week imiquimod course: a randomized, prospective, open-label study

Combinational cryosurgery during daily imiquimod application ('immunocryosurgery') efficiently cures invading basal cell carcinoma (BCC). Since timing of the cryosurgery is considered crucial for effectiveness, our aim was to compare efficacy of two different timing schemes of the combination of cryosurgery and topical imiquimod: Cryosurgery (a) 2 weeks after (Arm I) vs (b) prior to the initiation of a 5 week daily imiquimod course (Arm II). 16 patients with 21 BCC were recruited in this prospective, randomized, open-label trial. 14 patients with 17 BCC were evaluated (Arm I: 7 patients/10 tumors vs Arm II: 7 patients/7 tumors) during scheduled interim analysis at 6 month follow-up (two patients dropped out, one non-compliant and one lost to follow up). The trial was revoked because study Arm I ('immunocryosurgery') was significantly superior to Arm II (adjuvant imiquimod) in achieving tumor clearance (10/10 vs 3/7 tumors; p=0.0147) and by overall treatment efficacy (9/10 vs 2/7 relapse-free tumors; p=0.0345). The same overall efficacy persisted after at least 18 months follow-up for those patients with tumor clearance after the trial treatment. The timing of cryosurgery during imiquimod application substantially determines the efficacy of this combinational approach in the treatment of BCC.

FC26 Efficacy of immunocryosurgery in 105 consecutive, non-superficial basal cell carcinomas

FC26 Efficacy of immunocryosurgery in 105 consecutive, non-superficial basal cell carcinomas

Evaluation of the penetration of 5-aminolevulinic acid through basal cell carcinoma: a pilot study.

Aminolevulinic acid (ALA) is a charged, hydrophilic molecule that penetrates poorly through cellular structures. This property has been implicated in the poor clinical response of non-superficial basal cell carcinomas (BCCs) to photodynamic therapy (PDT). Release of ALA hydrochloride from a 20% w/w formulation was found to be incomplete and that approximately 36.8% of the total dose is released during the application period of 4 h. Using scintillation spectroscopy and a precise tissue sectioning protocol, it was demonstrated that depths of penetration of at least 2 mm from the lesion surface had been reached. Using cumulative stratal ALA concentrations, it was found that 10% of the total applied dose permeated into the lesion. In spite of this, comparisons drawn with photodynamic concentrations used in tissue culture work reported elsewhere revealed that estimations of the ALA concentration at 2 mm were sufficient to elicit a possible therapeutic response. Results from this work question the reasons given for poor outcomes of PDT in nodular BCC based solely on depth as a hindering factor.