In 2012, the American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery, and the American Society for Mohs Surgery published appropriate use criteria (AUC) for Mohs micrographic surgery (MMS). The recommendations were based on the expert opinion and consensus of a rating panel of 17 Mohs surgeons and non-Mohs dermatologists. [77]
The report deemed MMS appropriate for all basal cell carcinomas—regardless of location, size, and histologic subtype—in the following:
-
Previously irradiated skin
-
Traumatic scars
-
Areas of osteomyelitis
-
Areas of chronic inflammation or ulceration
-
Patients with genetic conditions such as xeroderma pigmentosum, basal cell nevus syndrome, or other syndromes that increase risk for skin cancer
MMS was also considered appropriate for all primary and recurrent BCCs in Area H (central face, eyelids [including inner/outer canthi], eyebrows, nose, lips [cutaneous/mucosal/vermilion], chin, ear and periauricular skin /sulci, temple, genitalia [including perineal and perianal], hands, feet, nail units, ankles, and nipples/areola).
MMS was endorsed for the following BCCs in Area M (cheeks, forehead, scalp, neck, jawline, pretibial surface):
-
All recurrent basal cell tumors
-
Primary histologically aggressive and nodular tumors
-
Primary superficial tumors in non-immunocompromised individuals with lesions ≥0.6 cm in diameter
MMS was also deemed appropriate for the following BCCs in Area L (trunk and extremities, excluding pretibial surface, hands, feet, nail units and ankles):
-
Recurrent histologically aggressive and nodular basal cell cancers
-
Primary, histologically aggressive tumors ≥0.6 cm
-
Primary nodular tumors >2 cm
-
Prmary nodular tumors ≥1.1 cm in immunocompromised patients
Use of MMS was considered inappropriate solely in Area L for the following [77] :
-
Recurrent superficial BCCs
-
Primary nodular tumors ≤1 cm
-
Primary nodular tumors ≤0.5 cm in immunocompromised patients
-
Superficial BCCs in healthy individuals
-
Superficial tumors ≤1 cm in immunocompromised patients
The NCCN prefers MMS for high-risk tumors and as adjuvant therapy if margins are positive after excision. [7]
-
A pink, scaly lesion on the skin. Superficial basal cell carcinoma (BCC) is often misdiagnosed as eczematous dermatitis or guttate psoriasis and is often difficult to distinguish clinically from Bowen disease (squamous cell carcinoma in situ). Features that suggest the diagnosis of superficial BCC are the absence of significant white, adherent scale and a history of the lesion remaining unchanged for several months or years. Treatment options for this tumor include electrodesiccation and curettage, surgical excision, cryosurgery, 5-fluorouracil, 5% imiquimod cream, and superficial radiotherapy. Electrodesiccation and curettage is the modality most commonly used, with a cure rate of approximately 95%.
-
Basal cell carcinoma.
-
A 68-year-old patient presenting with an advanced basal cell carcinoma (BCC) of the right periorbital region, frontal view. Courtesy of M Abraham Kuriakose, DDS, MD.
-
Lateral view of face showing extent of tumor. Courtesy of M Abraham Kuriakose, DDS, MD.
-
Basal cell carcinoma of the right lower lid.
-
Biopsy-proven basal cell carcinoma of the upper lid margin. Note the loss of cilia (madarosis) in the area of the tumor.
-
Medial canthal/lower lid basal cell. Note the pearly nodular surface with characteristic telangiectatic vessels. Proximity to the lacrimal system will impact its treatment and reconstruction.
-
Nodular basal cell carcinoma.
-
Nodular basal cell carcinoma appearing as a waxy, translucent papule with central depression and a few small erosions.
-
Scale, erythema, and a threadlike raised border are present in this superficial basal cell carcinoma on the trunk.
-
Large, superficial basal cell carcinoma.
-
Basal cell carcinoma. Courtesy of Hon Pak, MD.
-
Pigmented basal cell carcinoma.
-
Pigmented basal cell carcinoma.
-
Pigmented basal cell carcinoma has features of nodular basal cell carcinoma with the addition of dark pigmentation from melanin deposition. The pigmentation often has the appearance of dark droplets in the lesion, as shown here.
-
This infiltrating basal cell cancer has ill-defined borders and telangiectases.
-
This translucent pink papule has telangiectases and a crusted erosion, characteristic of nodular basal cell carcinoma.
-
Large, scarlike morpheaform basal cell cancer.
-
Nodular basal cell carcinoma. Nodular aggregates of basalioma cells are present in the dermis and exhibit peripheral palisading and retraction artifact. Melanin is also present within the tumor and in the surrounding stroma, as seen in pigmented basal cell carcinoma.
-
Histologic pattern of a well-differentiated basal cell carcinoma (original magnification X140). Courtesy of Prof Pantaleo Bufo, University of Foggia, Italy.
-
Histologic pattern of a well-differentiated basal cell carcinoma (original magnification X250). Courtesy of Prof Pantaleo Bufo, University of Foggia, Italy.
-
Micronodular basal cell carcinoma often has an absence of retraction artifact. The characteristic histology is small size and uniformity of the tumor nodules. Courtesy of Shang I Brian Jiang, MD.
-
Infiltrative basal cell carcinoma. Tumor cells are arranged in narrow strands, and mucin-rich stroma is often present. Courtesy of Shang I Brian Jiang, MD.
-
Keratotic basal cell carcinoma. Rare type characterized by keratocysts. Courtesy of Shang I Brian Jiang, MD.
-
Basosquamous basal cell carcinoma. Foci of neoplastic cells with squamous differentiation are present. Courtesy of Shang I Brian Jiang, MD.
-
Histology of superficial basal cell carcinoma. Nests of basaloid cells are seen budding from the undersurface of the epidermis. Courtesy of Michael L Ramsey, MD.
