Basal Cell Carcinoma (BCC)

Casebank History
1

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3 scenarios

  1. One on the back of the head
  2. One on face
  3. On Hair line

Above Neck- Any non-pigmented lesion is BCC
Below Neck - Non-pigmented is SCC
Pigmented - Melanoma

It is hard to say what is it exactly, but the fact that it is recurring is a bit concerning to me, unfortunately, it looks suspicious to me and I do suspect that the cause among other things could be skin cancer (called basal cell carcinoma)

  • Will have a previous history of it
  • Are types of skin cancer
  • Routine referral to Dermatology if the lesion is on the back of the head for surgical excision or cryotherapy/freezing therapy
  • 2-week referral to suspected cancer pathway to derma if the lesion is on the face for surgical excision or Cryotherapy.

Concern:
P: Am I going to die?
D: Such type of cancer doesn’t spread and responds well to treatment

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2

The reason why basal cell carcinoma (BCC) on the face warrants an urgent referral, while one on the back of the head may lead to a routine referral, relates to several factors including the lesion’s location, risk of progression, and potential impact on vital structures.

  • Urgent referral on the face: The skin on the face is thinner, and BCC in this area can grow more aggressively, potentially affecting important structures like the eyes, nose, or mouth. Cosmetic outcomes and function are also a significant concern, as surgery to remove BCC from the face can lead to visible scarring or functional impairment, especially in areas like the eyelids or lips.

  • Routine referral for the back of the head: The back of the head is usually considered a lower-risk area. BCCs here are often slow-growing and less likely to cause immediate functional or cosmetic concerns. Therefore, a routine referral is appropriate unless the lesion is large, ulcerated, or causing other specific issues.

  • BCC on the neck: The neck can be considered a borderline area. If the BCC is located on the front or side of the neck, closer to important structures like the throat, an urgent referral might be considered due to similar reasons as the face. However, for more posterior (back of the neck) lesions, a routine referral may suffice, depending on the size and appearance of the lesion.

In summary, the urgency of the referral is influenced by the lesion’s location, with areas involving cosmetic, functional, or vital structures (like the face and sometimes the neck) often requiring faster assessment to avoid complications.

3

Where are you:
You are FY2 in GP surgery.

Who the patient is:
Donna Branson is a 55-year-old lady who came with some concerns.

Other information you have about the patient:
He has Rheumatoid Arthritis and has been on Methotrexate and paracetamol for 5 years.

What you must do:
Talk to the patient and address her concerns.

Patient’s information:

  • You noticed a lump on your forearm two months ago.
  • It is just below the elbow.
  • It has been increasing in size.
  • It is pinkish, it itches sometimes.
  • It bleeds on touch.
  • You like sunbathing
  • You work outdoors
  • You work in a construction company as a supervisor.
  • You had travelled on a vacation and you were sunbathing.
  • You have Rheumatoid Arthritis for the past 5 years.
  • You are on Methotrexate and paracetamol.
  • You have no allergies.
  • Social history (you live alone, but you are coping well with day to day activities)
  • You think that the cause of the swelling is infection.

Questions:

  1. What is the cause of this swelling?
  2. What are you going to do for me?

Emotions and attitudes: Normal emotions initially.

Approach:

  • GRIPS
  • Purpose of consultation
  • History taking of skin lesion:
    • Duration
    • Size
    • Colour
    • Change in size
    • Margin, regular or irregular
    • Change in colour
    • Colour, regular or irregular
  • Symptoms of cancer:
    • Weight loss
    • Tiredness
    • Fatigue
  • PMAFTOSA
  • Risk factors:
    • Sunbaths
    • Immunocompromised
    • Immunosuppressant drugs
  • Examinations:
    • Skin lesion
    • Systemic exam
    • Observation
  • Summarize
  • Ideas: is there anything you feel could be the cause of the lump? (patient thinks it is infection)

Diagnosis:

  • After looking at your lump, unfortunately, I feel that it could be what we call a Basal cell carcinoma. It is a type of skin cancer but these types of skin cancer are usually treatable.
  • Unfortunately, if you have rheumatoid arthritis, there is an increased risk of developing skin cancer.
  • Concerns: is there anything you are worried about?

Management:

  • Urgent referral to the dermatologist to be seen within 2 weeks.
  • Skin biopsy (The specialist will remove the lump and send it to the lab)
  • Sometimes they may need to perform further investigations to make sure it has not spread.
  • Wide local excision: and if it is confirmed they can suggest further removal of the skin around the lump.
  • Radiotherapy: sometimes after surgical skin removal, they may use radiotherapy.

Summarize the discussion:

  • We will do the blood test today to make sure there is nothing else going on.
  • I will make an urgent referral to the dermatologist (the skin specialist) who will see you within 2 weeks.
  • I have explained that the lump is likely to be what we call basal cell carcinoma which is a type of skin cancer.
  • I have also explained that these types of cancer are usually treatable but the specialist may want to perform further investigations like scans to make sure it has not spread anywhere else.