Diagnosis

History

History of Presenting Complaint

  • When the lesion was first noticed
  • How it has progressed since noticed (important to identify speed of progression)
  • What symptoms is the lesion causing - bleeding, itchy, smell
  • Symptoms of perineural invasion - numbness, burning pain
  • Any other symptoms temporally related - other lumps, etc

Past Medical History

  • Immunosuppressive conditions or treatments (eg AIDS, chemotherapy, transplant)

Past Surgical History

  • Previous BCCs

Past Radiotherapy History

  • Any previous BCCs treated with radiotherapy
  • Any other radiotherapy

Medications

  • Any immunosuppressive medications

Allergies

  • Nil important

Family History

  • Gorlin's Syndrome

Social History

  • Transport - will the patient be able to get themselves to treatment easily?
  • Home - Is the patient located near to the radiotherapy department or will they need admission

Physical Examination

Primary Lesion

  • Site - particularly important for high risk areas and for adjuvant treatment after surgery
    • Examination of adjacent structures is particularly important in the head and neck area.
    • For instance, the conjunctival surface of the eyelid for eyelid-based lesions, or the external auditory canal for lesions near the external auditory meatus
  • Size and Shape - Important for future comparison as well as determining treatment modality / fractionation
  • Depth and Tethering - Depth of invasion can be judged by attachment to deep structures
  • Neurological exam may be helpful in locally advanced cases with perineural invasion to the base of skull

Regional Nodes

  • Examine regional lymph nodes

Distant Disease

  • Almost unheard of for basal cell carcinoma

Concurrent disease

Examine the remaining skin for evidence of other BCCs.

Imaging

Large tumours may benefit from imaging with CT or MRI. If perineural invasion is present MRI is useful to assess base of skull extension or involvement of cranial nerves.

Pathology

Histological confirmation necessary.
Options:

  • Excisional biopsy (full set of information but then radiotherapy is not usually required!)
  • Punch biopsy (no information about lateral margins)
  • Shave biopsy (no information about lateral margins, depth of invasion or histological subtype)

Staging [1]

Staging of skin tumours is based off the TNM guidelines released by the AJCC. The seventh edition bases the stage of the primary tumour on size as well as on high risk features.

High Risk Features

  • Local invasion: Depth of Invasion > 2 mm, Clark Level IV, or perineural invasion
  • Site: Located on the ear or non-hair bearing lip
  • Differentiation: Poorly differentiated or undifferentiated

Primary Tumour (T)

  • T0 - No evidence of primary tumour
  • Tis - Carcinoma in situ
  • T1 - < 2 cm in greatest dimension with no more than 1 high risk feature
  • T2 - > 2 cm in greatest dimension, or with 2 or more high risk features
  • T3 - Tumour with invasion of the orbit, mandible, maxilla or temporal bone
  • T4 - Tumour with invasion of other bones, or perineural invasion of the skull base

Regional Nodes (N)

  • N0 - No evidence of nodal disease
  • N1 - Metastasis in a single, ipsilateral lymph node less than 3 cm in size
  • N2 - Metastasis in multiple ipsilateral or contralateral lymph nodes, not greater than 6 cm in size
    • N2a - Single metastasis, between 3 and 6 cm in size
    • N2b - Multiple ipsilateral metastases, no greater than 6 cm in size
    • N2c - Multiple ipsilateral and contralateral metastases, no greater than 6 cm in size
  • N3 - Lymph node metastasis over 6 cm in size

Distant Metastasis (M)

  • M0 - No evidence of distant metastatic disease
  • M1 - Metastatic disease

Final TNM Stage

  • Stage 0 - Tis N0 M0
  • Stage I - T1 N0 M0
  • Stage II - T2 N0 M0
  • Stage IIIA - T3 N0 M0 — T1-3 N1 M0
  • Stage IVA - T1-3 N2 M0 — T4 NANY M0 — TANY N3 M0 — TANY NANY M1

Links

Bibliography

Bibliography
1. AJCC Cancer Staging Manual, 7th Edition