TEXTBOOK DISCUSSION

Basal cell carcinoma is the most common cutaneous tumor. Composing 70% of the primary skin cancer, BCC is most commonly found on the face, the neck, and

the hands and arms, but it can occur anywhere.

The BCCs can grow in size and result in significant cosmetic and functional morbidity. Although they can be any size, lesions typically range between 3 and 15 mm in dimension at initial presentation. A large BCC can become very destructive. Large lesions are more likely to erode into muscles, cartilage or bone. BCC is derived from the same cell line as SCC, the keratinocytes. These basal cells or keratinocytes, are situated at the lowest layer of the epidermis, just above the basement membrane that attaches the epidermis to the dermis. When one basal cell divides, one daughter cell advances slowly upward through the epidermis as a keratinocyte, while the other remains a basal cell into the basal layer to reproduce again. Basal cells that fail to mature into keratinocytes retain their capacity for mitotic division, later forming a tumor.

Etiology and Risk Factors

The risk of BCC and SCC increases with age, this type of skin cancer is relatively uncommon (although it is becoming more common) in persons younger than the age of 40. Individuals who freckle easily or who have fair skin, red or blonde hair, blue or green eyes are at the greatest risk for the development of BCC. Several inherited syndromes make early onset of BCC more likely: these include albinism, xerodema pigmentosum or nevoid BCC syndrome. There is growing evidence that psoralen and ultraviolet A (PUVA) therapy for psoriasis increases the risk for NMSC.

Sunlight exposure (ultraviolet (UV) radiation) causes almost all cases of basal and squamous cells cancer and is amajor cause of melanoma. Ultraviolet radiation initiates and promotes carcinogens by (1) DNA point mutations, (2) oncogene activation, (3) tumor suppressor gene inactivation, (4) cellular proliferation, (5) inflammation. Disruption of the earth’s ozone layer and the relationship of that phenomenon to skin cancer are both complicated and numerous. Further studies are needed to determine the varying effects that ozone layer depletion may have on skin cancer development and trends.

Indoor training. Some people believe tans that are a result of artificial light (tanning beds and lamps) are safer tans and will protect them from the skin damage and skin cancer. A study done in 2002 revealed that participants who used tanning devices were 1.5 times more likely ro develop BCC and 2.5 times more likely to develop SCC than people who did not use tanning beds and lamps.

There are five types of Basal Cell Carcinoma

Nodular- the most common type of basal cell cancer, most often appears on the face, neck, and head. The tumor is made up of masses of cells that resemble epidermal basal cells and grow in a bulky, nodular form from lack of keratinization. In early stages, the tumor is a papule that looks like a smooth pimple. It is often pruritic and continues to grow at a steady rate, doubling in size every 6 to 12 months. As the tumor grows, the epidermis thins,but it remains intact. The skin over the tumor is shiny, and either pearly white, pink, or skin colored. Telangectasis may be visible over the area of the tumor. As the tumor continues to increase in size, the center or periphery may ulcerate, and the tumor develops well-circumscribed borders. It bleeds easily from mild injury.

Superficial- found most often on the trunk and extremities, is the second most common type of basal cell cancer. This tumor is a proliferating tissue that attaches to the under surface of the

epithelium. The tumor is a flat papule or plaque, often erythematous, with well defined borders. The tumor may ulcerate and be covered with crusts or shallow erosions.

Pigmented- found on the head, neck, and face, is less common. This tumor concentrates melanin pigment in the center of the basal cancer cells, giving it a dark brown, blue, or black appearance. The border of the tumor is shiny and well defined.

Morpheaform- the rarest form of basal cell cancer, usually develops on the head and neck. The tumor forms finger-like projections that extends in any directions along dermal tissue planes. The tumor resembles a flat ivory or flesh-colored scar. This form is more likely to extend into and destroy adjacent tissue, especially muscle, nerve, and bone. It is often more difficult to diagnose because of its appearance.

Keratotic(basosquamous)- found on the preauricular and postauricular. It contains both basal cells and squamoid-appearing cells that keratinize. Its appearance is much like that of nodular basal cell cancer. This type of basal cell cancer tends to recur locally and also is the type most likely to metastasize.

Clinical Features

Basal cell Cancer may start as a transluscent growth that has pink and white tones, a shiny border, giving it a pearly appearance, and a tendency to crust. This pearly like lesion can have an overlying telangiectasis. Often these nodules become quite friable and may develop a hemorrhagic ulceration. If left untreated, they can severely damage underlying tissue and the skin. As the lesion enlarges, the center may flatten or ulcerate, but the border is still raised, giving a rolled edge appearance.

Diagnosis and Staging

A complete skin examination is the key diagnostic component. Once suspected clinically, basal cell carcinoma must always be definitely diagnosed by histology. Evaluate and suspicious cutaneous lesions or lymph adenopathy with biopsy to rule out metastasis or new primary lesions. Typical techniques used to perform the biopsy include a small punch biopsy or shave biopsy. A shave biopsy (top lesion into depth of middermis) is performed using local anesthesia. Punch biopsy (sharp, small circular “punc” similar to a cookie cutter approach) is used if the tumor is suspected to be deeper layers of the skin. The tissue sample is examined to determine the clinical diagnosis and identifying features of the various classifications.

Histologic grading for BCGs and SCCs is similar to the grading system for other cancers. G1 signifies well-differentiated tumor cells, G2 refers to moderately well-differentiated, G3 signifies poorly differentiated cells and G4 signifies undifferentiated cells. Confirmation of cutaneous or subcutaneous spread and the extent of disease by biopsy is imperative.

Metastases and Recurrence

Metastatic BCC is extremely rare. It usually occurs via hematologic or lymphatic spread. The malignant characteristic of the tumor are based on the destructive growth of the primary tumor rather than metastasis. A patient who develops one BCC has 35% to 50% chance of developing a second BCC lesion within the next 3.5 to 5 years, as well as other skin cancers. Close observation of the patient for the recurrence is recommended.

Management

A. Medical management

1. Use of cefazolin 1g IVTT q8h.

2. A complete skin examination should be done and regional lymoh nodes checked for evidence of possible metastasis.

B. Surgical management

Surgical excision

Both basal cell and squamous cell cancers are excised surgically. The surgery may be minor or major, depending on the size and location of the tumor. Surgery for small tumors is most often performed in the outpatient surgery department or in the surgeon’s office. Surgical excision allows a rapid healing and yields good cosmetic result carries the risk of infection.

The goal of surgical excision is to remove the tumor completely, so some surrounding tissue is excised along with the tumor. If the tumor is on the face, the incision is made along normal wrinkle or anatomic lines so that the scars will be less obvious. The incision is closed in layers to leave the smallest possible scar. A pressure dressing is usually applied over the incision to provide support.

If a large tumor is removed, a skin graft or skin flap may be performed to cover the excised area. It grafting is necessary, the client is hospitalized.

Mohs micrographic surgery

It is a technique used to excise advanced, recurrent or poorly defined basal cell or squamous cell carcinoma of the skin with minimal excision of normal tissue. The bulk of the clinically evident tumor is excised initially. Then the lesion is resected by serial tangential excision.

C. Nursing management

Maintaining tissue integrity

Provide careful skin care to prevent further skin irritation, drying and damage. Handle skin over the affected area gently; avoid rubbing and use of hot or cold water, soaps, powders, lotions and cosmetics.

Instruct patient to wear loose-fitting clothes and avoid clothes that constrict, irritate or rub the affected area.

Provide aseptic wound care on area of moist desquamation.

Watch for excessive bleeding and tight dressings that compromise circulation.

Dental works should be avoided until the area is completely healed.

Managing malignant skin lesions

Carefully assess and cleanse the skin, reducing superficial bacteria, controlling bleeding, reducing odor and protecting skin from pain and further trauma.

Assist and guide the patient and family regarding care for these skin lesions at home

Preventing infection

Assess factors that can promote infection, such as impaired skin, chemotherapy, radiation and other therapy; malignancy; medications; age, etc.

Monitor laboratory studies such as WBC count for leukopenia or neutropenia.

Monitor patient for sepsis, particularly if invasive catheters or infusion lines are in place.

Teaching self-care

The wound is usually covered with a dressing to protect the site from physical trauma, external irritants and contaminants. Advise the patient when to report for a dressing change or is given written and verbal information on how to change dressing.

Instruct patient to seek treatment for any moles that are subject to repeated friction and irritation and to watch for indications of potential malignancy in moles.

SIGNS AND SYMPTOMSBased on Textbook Manifested by ClientTelangiectasiaPearly, shiny appearanceInflammationThickening/LumpingUlcerationWeight LossBladder/ bowel changesUnusual discharges/ bleedingIndigestion or difficulty swallowing

-+ 2004, pearly, shiny appearance,1 cm in diameter+May 2009, after hit by a bamboo+2004, approx 1 cm; May 2009 approx 2cm+May 2009, ulceration after hit by a bamboo----

SCHEMATIC DIAGRAMPredisposing PrecipitatingAge—below 40 Sun exposure: fishermanGender—Male (3:2, compared to female) Alcohol drinking

Sunburn Smoking

Daughter cells 1 fail to mature into keratinocytes (to be developed into keratin)

Daughter cells 2 continue to produce more basal cells

Basal Cell Mitosis

Daughter cell 1 do not enter G0 phase of cell cycle

Daughter cells 1 remain as basal cells

DNA cross-linking between thymidine residues

While DNA repair removes most UV-induced damage, not all crosslinks are excised

cumulative DNA damage leading to mutations

Uncontrolled production of basal cells

TUMOR GROWTH

Tumor develops own blood supply and receives nutrition by diffusion

Tumor grows to 1 cm, however diffusion is efficientPearly, shiny appearance

approximately 1 cm

Thickening/Lumping

Cells in the center of the tumor becomes hypoxic and starts to die

Tumor develops tumor angiogenesis factor (TAF) which triggers capillaries and other

blood vessel in the area to grow new branches into the tumor for continued

nourishment

As tumor cells continue to divide, they change features from the original cells

The changes/ differences allow them to live and divide no matter the condition:

selective advantage

As tumor cells continue to have fewer and fewer normal cell features, they

become malignant

BASAL CELL CARCINOMA

Inflammation

TelangiectasiaWeight LossBladder/ bowel changesUnusual discharges/ bleedingIndigestion or difficulty swallowing

Ulceration