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Electrodesiccation and curettage
3%
3/86
Surgical excision
36%
31/86
Mohs surgery
57%
49/86
Topical 5-fluorouracil
2%
2/86
Imiquimod
0%
0/86
Select Answer to see Preferred Response
Given the size, location, and character of this patient's basal cell carcinoma (BCC), this lesion is at high risk for recurrence. In this scenario, Mohs surgery is the most appropriate treatment decision. Basal cell carcinoma is a very common form of skin cancer. While it rarely metastasizes to other tissues, these tumors are often locally invasive and cause significant damage to surrounding tissues. For these reasons, treatment is recommended. The specific treatment is dependent upon tumor size, location and pathology. Lesions larger than 6 mm in high risk areas (central face, nose, lips, eyelids, postauricular areas, hands, and feet) or larger than 10 mm on all other areas of the head and neck are considered high risk. Other high risk features include those with sclerosing, mixed infiltrative, micronodular, or basosquamous features, and those that are recurrent. Those lesions considered high risk should be treated with Mohs surgery. Firnhaber discusses treatment and efficacy of various treatment options of BCC. The benefits of Mohs surgery include preservation of normal tissue, microscopic control of the margins, and high cure rates. The recurrence rate following Mohs surgery is approximately 1% at 5 years while it is 5% with standard surgical procedures. Sehgal et al. discuss the pathophysiology of BCC. While the exact cause of BCC is unknown, the cancerous cells are believed to originate from pluripotent stem cells from the basal cell layer of the epidermis. The patched/hedgehog pathway is important for the regulation of cell growth. Disturbances in regulation of this pathway are associated with the development of BCC. Figure A demonstrates BCC with a central depression and overlying telangiectasia. Incorrect Answers: Answer 1: Electrodesiccation and currettage is not appropriate for BCC that has concerning clinical features. The procedure itself does not incorporate histological confirmation of tumor removal. Answer 2: While surgical excision can be performed faster than Mohs surgery, it often requires the sacrifice of significant amounts of uninvolved tissue to achieve acceptable cure rates. Mohs surgery is a better option. Answer 4,5: Topical 5-fluorouracil and imiquimod should only be used on superficial BCCs in low risk areas.
3.9
(7)
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