Basal Cell Carcinoma: A Patient and Physician's Experience.

In this article, the first coauthor, a patient with a basal cell carcinoma on her upper lip, discusses her experience with Mohs micrographic surgery for the treatment of the skin cancer. The second coauthor, who is the patient's physician (a dermatologist who shares her last name but is not a relative), diagnosed her skin cancer and referred her for Mohs surgery. The third coauthor, who is the patient's son and not only a dermatologist, but also a dermatopathologist and a Mohs surgeon (and also shares her last name), summarizes the presentation and treatment of the basal cell carcinoma.

Patient’s Experience

When I was a young girl my parents thought it was healthy to put baby oil on one’s skin before going outside to be in the sun. Little did they know that this action would cause so many problems for me once I grew up and became an adult.

Being fair-skinned and a redhead with blue eyes, I had many sunburns followed by big water blisters due to exposure to the sun’s rays. As I became older, the dermatologist froze many areas of my body to correct the damage caused by the sun’s rays in my youth.

I had my first Mohs surgery more than 50 years ago. This was on my face, and I remember having the doctor cut the affected area, cover it with a bandage, and send me back to the waiting room until the skin sample could be checked to make certain that all of the cancerous cells had been removed. Another time, again on another part of my face while I was still living in upstate New York, another Mohs surgeon did the same procedure. Fortunately, both of these men were excellent; I did not suffer from any discomfort and the scars were not noticeable.

Now, I am an 82-year-‘young’ patient. My son—Philip R. Cohen, MD—is a dermatologist; however, he practices in California. Recently, my current dermatologist—in Florida (where I live)—referred me to my third Mohs surgeon.

It was the strangest thing as I thought I had scratched my face just above the right side of my upper lip. The scratch did not go away. I made an appointment to see my dermatologist and showed it to Dr. Eli Cohen; although we share the same family name, we are not relatives. He took a biopsy of the lesion and sent it to a dermatopathologist (Fig. 1). I was shocked when I received the call from his office; it was not a scratch, but a basal cell carcinoma.

Fig. 1

a–d An 82-year-old woman developed a basal cell carcinoma on the right side of her upper lip. The upper lip, right side, was the site of the non-healing scratch. a Photograph of the site after a shave biopsy had been performed to determine the diagnosis of the persistent skin lesion (below the purple triangle and between the purple linear lines); the surface of the lesion has been cauterized. b The residual basal cell carcinoma, which is located at the biopsy site (circled in purple ink), appears as a flesh-colored nodule. c Mohs surgery (with the tumor being cleared after taking one surgical stage) was performed to excise the skin cancer; purple ink (extending from the surgery-created tumor-free wound) marks the vermillion border between the cutaneous and mucosal upper lip. d The surgical wound was modified into an ellipse; the wound was subsequently sutured in a side-to-side manner

Dr. Cohen said he was going to send me to the Mohs surgeon who had previously done several procedures on my husband.

I went to the Mohs surgeon thinking this would be a simple procedure just like my other two experiences. Wrong. The Mohs surgeon explained that the cancer area began above my lip and extended into my lip; therefore, this time the procedure would be bit more difficult and a bit more uncomfortable. He knew I was on a blood thinner and told me I had to stop it a few days before the operation so that I would not bleed profusely. I then became aware that I would have many stitches on my face, but the lip itself had to be handled differently. The doctor explained that I would need a pressure bandage since there would be small area that he would not stitch.

Naturally I was concerned and nervous. I was assured that everything would be all right, but that I would experience discomfort for a period of time.

The day of the surgery arrived. The area of my lip containing the skin cancer was anesthetized; I felt no discomfort from the procedure (Fig. 1). It was explained to me that I would feel pain later and that I could take acetaminophen for the pain. A huge area was bandaged and I felt quite awkward when I left the office (Fig. 2). I was told to make two appointments to see the Mohs surgeon: the first visit in 1 week for some of the stitches to be removed and the second visit the following week for the remaining stitches to be removed.

Fig. 2

Photograph of the patient taken postoperatively showing a bulky pressure dressing on her upper lip

Later that day, I realized that being on a blood thinner made my surgery more difficult. Unfortunately, after I went home, I noticed that I had bled through the bandage. I called the Mohs surgeon’s office; his staff told me to come back to the office the next day and they would change my bandage. When I arrived at the Mohs surgeon’s office the next day his assistant carefully and gently removed the bandage. She said that the healing after the procedure was progressing nicely and that I should continue to do much better. She was correct; although I still was having significant discomfort and tightness in the area, I was no longer bleeding. Indeed, my biggest problem was that I am a person who smiles a great deal and it was painful to smile during this time.

When I returned to the office after the first week some of the stitches were removed. This was done in such a caring manner that I felt no discomfort from the procedure.

The following week the remainder of the stitches were removed; sure enough, I was able to smile without any pain. I could hardly tell I had an operation. I was healing so well and my face looked natural (Figs. 3, 4).

Fig. 3

Distant view of the patient’s face shows the upper lip following complete healing of the surgical site

Fig. 4

Closer views of the upper lip—no smiling (a) and smiling (b)—show that the surgical site has healed nicely and that the scar is well placed among the other skin folds on the upper lip

My only problem now is that I am a bit numb at the surgical site on the right side of my upper lip. However, I was informed that it could take up to 1 year for the normal sensation in that area to spontaneously return. I was also told to massage the area twice a day for 5 min at a time until my next appointment that will be in 1 month.

I have seen other people who had similar operations for skin cancer. Some of them did not have the wonderful outcome that I experienced. I feel very fortunate that I have had such excellent doctors.

In addition to my basal cell carcinoma, I also had several actinic keratoses that Dr. Cohen ‘froze’ with liquid nitrogen. Therefore, I have my skin examined by the dermatologist every 3–6 months. In addition, I will continue to apply sunscreen to my face, neck, and arms each day.

Physician’s Perspective

Basal cell carcinoma is the most common type of skin cancer [1]. Similar to Mrs. Cohen’s tumor, it most frequently presents as a flesh-colored papule or nodule on a sun-exposed site, such as the face. Excision, using microscopically controlled margins (Mohs micrographic surgery), is a very effective management strategy for these tumors. However, the clinical presentation of basal cell carcinoma can vary, and there are several potential treatment modalities available for patients.

This article does not contain any new studies with human or animal subjects performed by any of the authors.

Sun exposure (ultraviolet A and ultraviolet B radiation) is the most common risk factor for developing basal cell carcinoma. Indeed, basal cell carcinoma occurs more frequently in individuals with certain physical features: blue or green eyes, freckles, blond or red hair, fair or light skin color, and always burning and never tanning after being exposed to the sun. Genomic analysis of basal cell carcinoma tumors has associated the cancer with an aberration of the Hedgehog pathway, with mutations affecting the PTCH1 (patched 1) gene [2-5].

Other risk factors also contribute to the pathogenesis of basal cell carcinoma. These include exposure to either an environmental toxin (such as arsenic, coal tar, and paraffin) and or to other sources of radiation, such as tanning beds and ionizing radiotherapy. Injuries to the skin (such as burns or chronic trauma) can also promote the development of this skin cancer. In addition, immunosuppression is a risk factor that can predispose an individual to develop basal cell carcinoma—either iatrogenic-related secondary to the medications to prevent rejection in the recipients of solid organ transplants or viral-associated in individuals with human immunodeficiency virus infection. Also, basal cell carcinoma is more prevalent in patients with certain inherited disorders; some of these genodermatoses include basal cell nevus syndrome, Bazex syndrome, epidermolysis bullosa simplex (Dowling Meara subtype), oculocutaneous albinism, Rombo syndrome, and xeroderma pigmentosa [3, 4, 6–9].

In addition to nodular basal cell carcinomas—similar to that of Ms. Cohen’s skin cancer—that appear as telangiectatic or flesh-colored, smooth or ulcerated smaller papules of < 5 mm or as larger nodules of > 6 mm, the clinical presentation of these cancers can be variable (Table 1) [5, 6, 10–19]. They also frequently appear as red plaques (superficial basal cell carcinomas) or white indurated scar-like flat lesions (infiltrated basal cell carcinomas) [3]. Less commonly, they present as pedunculated tag-like lesions often on the abdomen (fibroepithelioma of Pinkus) [14, 17] or red flat macules frequently on the face that mimic telangiectasias (red dot basal cell carcinomas) [11, 12, 15] or brown or black papules or patches that mimic melanocytic tumors (pigmented basal cell carcinomas) [6, 18]. In seldom cases, basal cell carcinomas are linear in morphology [18] or advanced cancers [5] or giant-sized tumors [19]; metastatic basal cell carcinomas with tumor that has spread to other organs, such as the lung or liver, are extraordinarily rare [10, 13].

Table 1

Clinical types of basal cell carcinoma

Clinical types of basal cell carcinoma
Advanced
Fibroepithelioma of Pinkus
Giant
Infiltrating (morpheaform or sclerosing)
Linear
Metastatic
Nodular
Pigmented
Red dot
Superficial

Mrs. Cohen’s basal cell carcinoma occurred on her upper cutaneous lip and extended beyond the vermillion border into her mucosal lip. Indeed, similar to her tumor, most basal cell carcinomas occur on skin that has been directly exposed to the sun. However, albeit less common, basal cell carcinomas can occur at usual sites, at locations that have been shielded from the sun, or both; these include the axilla [6, 16], breast and nipple [20], buttock and perianal area [21], foot, groin, penis and scrotum, periungual and subungual area (adjacent and beneath the nail) [22, 23], umbilicus [24], and vulva.

Each of the clinical variants of basal cell carcinoma has corresponding pathologic features (Table 2) [3, 6, 14, 17–19, 25–33]. Tumors with fibroepithelioma of Pinkus, keratotic, infundibulocystic, nodular, and superficial pathologic growth patterns are at lower risk for persistence following treatment as compared to those tumors with a more aggressive pathology subtype, such as basosquamous, infiltrative, micronodular, and mixed [3, 26, 27, 30]. Less common pathologic variants (such as pigmented [6, 18], granular [28] and pleomorphic [29, 31] subtypes) and tumors with either associated amyloid [32] or myoepithelial differentiation [25] or osteoma cutis [33] typically demonstrate less aggressive biologic behavior.

Table 2

Histologic types of basal cell carcinoma

Histologic types of basal cell carcinoma
Amyloid deposit-associated
Fibroepithelioma of Pinkus
Granular cell
Infiltrative (morpheaform or sclerosing)
Infundibulocystic
Keratotic
Nodular
Metatypical (basosquamous)
Mixed
Micronodular
Myoepithelial differentiation
Ossification-associated
Pigmented
Pleomophic
Superficial

A combination of clinical characteristics and pathologic features of the tumor are consistent with basal cell carcinomas that have a higher risk for persistence (which is manifested clinically by recurrence) following treatment (Table 3) [3, 34]. The therapeutic intervention of choice for high-risk basal cell carcinomas is Mohs micrographic surgery—the treatment that Mrs. Cohen received [34, 36]. Traditionally, the surgeon who removes the cancer also performs the microscopic evaluation of that surgical specimen. This technique allows for evaluation of the entire peripheral margin of excision during the surgical process in order to confirm that the cancer has been completely removed; if residual tumor is noted, addition layers of tissue—at the sites indicated from examination of the prior skin specimen—are taken until a tumor-free border is achieved. Then, the surgical wound is repaired.

Table 3

Features of high-risk basal cell carcinomas

Features of high-risk basal cell carcinomas
Aggressive pathologic growth pattern
Borders of tumor: poorly defined
Immunosuppressed patient
Location and corresponding size of tumor
Trunk and extremities (excluding hands, feet, nail units, pretibial and ankles): ≥ 20 mm
Cheeks, forehead, scalp, neck and pretibial : ≥ 10 mm
Central face, eyelids, eyebrows, periorbital skin, nose, lips, chin, mandible, preauricular and postauricular skin/sulci, temple, ear, genitalia, hands and feet: ≥ 1 mm (all of these locations constitute high-risk basal cell carcinoma independent of the tumor size)
Perineural tumor involvement microscopically
Radiation therapy previously at the tumor site
Recurrent tumors

In addition to Mohs micrographic surgery, there are other surgical, nonsurgical, and systemic treatments for basal cell carcinoma (Table 4) [5, 10, 13, 34, 35, 37–41]. Systemic treatments are considered for individuals with either giant, advanced, or metastatic basal cell carcinomas [5, 10, 13]. Radiation therapy may be considered for patients for whom surgery is not feasible or is contraindicated; in addition, adjuvant radiotherapy may be recommended for some individuals with high-risk basal cell carcinomas—such as patients whose tumors have perineural invasion or have not been able to achieve a tumor-free margins of excision, or both [34, 35, 41]. Nonsurgical topical interventions may be considered in patients with superficial basal cell carcinomas [34, 35, 37, 38, 40]. However, the cure rates of other treatment modalities are lower than those observed in patients whose tumors have been excised using Mohs micrographic surgery.

Table 4

Treatment of basal cell carcinoma

Treatment of basal cell carcinoma
Nonsurgical intervention
Cryosurgery
Photodynamic therapy
Radiation therapy
Topical therapies: 5-fluorouracil, imiquimod
Surgical intervention
Curettage and electrodessication
Excision (standard)
Mohs micrographic surgery
Systemic interventions
Immune checkpoint inhibitors: nivolumab
Smoothened inhibitors: sonidegib, vismodegib

Our Patient

Mrs. Cohen presented to me with a persistent lesion on her upper lip. She has the phenotypic features that have been associated with an increased risk for the development of skin cancer, two prior basal cell carcinomas on her face, and a history of actinic keratoses that have regularly been treated with liquid nitrogen cryotherapy. Mrs. Cohen was convinced this was only a scratch that was slow to heal; indeed, non-neoplastic conditions can mimic a basal cell carcinoma [42]. Also, bacterial or mycobacterial infection and basal cell carcinoma can be present in the same lesion [43]. However, I suspected that Mrs. Cohen had a new basal cell carcinoma and performed a biopsy to establish the diagnosis.

The report from the dermatopathologist confirmed the diagnosis of a nodular basal cell carcinoma. I referred Ms. Cohen to a Mohs surgeon to have the cancer removed. Her tumor was cleared after one stage of excision, and the Mohs surgeon was able to repair the surgical wound with a side-to-side closure.

Mrs. Cohen has achieved an excellent functional and cosmetic result following the treatment of her upper lip basal cell carcinoma. She and I have discussed that after a patient develops a basal cell carcinoma, there is between a 30–70% cumulative risk of developing another basal cell carcinoma within the next 3 years [44-47]. Therefore, I will continue to regularly see Mrs. Cohen for total body skin checks.