Keratinocyte cancer

6.1 Prognosis of basal cell carcinoma

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Clinical practice guidelines for keratinocyte cancer > 6.1 Prognosis of basal cell carcinoma


Guideline contents > [[Guidelines:Keratinocyte carcinoma/Prognosis BCC|]]

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Speakman, D, Stephen Shumack, Helena Rosengren, Cancer Council Australia Keratinocyte Cancers Guideline Working Party. Guidelines:Keratinocyte carcinoma/Prognosis BCC . In: Clinical practice guidelines for keratinocyte cancer. Sydney: Cancer Council Australia. [Version URL: https://wiki.cancer.org.au/australiawiki/index.php?oldid=208376, cited 2023 Nov 29]. Available from: https://wiki.cancer.org.au/australia/Guidelines:Keratinocyte_carcinoma.


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25 November 2019 21:12:01




Background[edit source]

Unless stated otherwise, tumour stage is according to the American Joint Committee on Cancer (AJCC) cancer staging manual 8th edition [1] and Union for International Cancer Control (UICC) TNM classification of malignant tumours 8th edition.[2]

The prognosis for patients with basal cell carcinoma (BCC), including recurrence, 5-year survival and treatment-related morbidity, is influenced by tumour characteristics, the site, and the treatment modality (Table 4.1).

Table 4.1. Factors associated with recurrence of basal cell carcinoma

Tumour-specific factors

Size (higher risk for >2cm)

Stage (higher risk for T4; deep invasion beyond subcutaneous tissue)

Subtype (higher risk for sclerosing [morphoeic], or micronodular subtypes)

Presence of perineural invasion

Anatomical site (higher risk for nose, eyelids, temple, pre- and post-auricular/ear, lower legs, lip)

Recurrence status (higher risk for recurrent tumours)

Patient-related factors

History of skin cancers (higher risk if history of multiple tumours)

Treatment-related factors

Treatment modality (lower risk for surgical excision)

Completeness of excision (lower risk for complete excision)


Overview of evidence (non-systematic literature review)[edit source]

Recurrent tumours[edit source]

Rates of control are lower after treatment for recurrent BCC than after treatment for primary BCC.[3][4][5][6]

For early-stage tumours, reported recurrence rates after standard surgical treatment of previously treated (recurrent) BCC are in the range of 15–30%, compared with previously untreated (primary) BCC of 1–10%.[7][8] Mohs micrographic surgery (MMS) can be an effective treatment for these tumours (see: Criteria for selecting Mohs micrographic surgery). However, most series also report excellent salvage results with radical surgery[8][9] (or, less commonly, using radiotherapy).[10][11]

These recurrence figures increase with increasing tumour stage,[12] and salvage becomes harder to achieve. Furthermore, control rates are likely to progressively diminish with each successive episode of recurrence and salvage treatment.[9][13]

Stage[edit source]

Control rates diminish with increasing size and depth of invasion (T stage; Table 4.2). See Appendix A TNM staging.


Table 4.2. Overall estimated control rates of treated primary BCC by T stage[14][15][16][17][18][19][20][21][22][23]

T stage Size (maximum diameter) 5-year control rates
T1 ≤2cm 95%
T2 >2cm but ≤5cm 88%
T3 >5cm 80–85%
T4 Tumour deeply invaded beyond subcutaneous tissues 40–50%

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Cartilage and bone invasion are surrogate markers of more advanced stage, deeper invasion and/or recurrent BCC.[24] It is very difficult to control BCC that has infiltrated cartilage or bone because it is not possible to define the extent of spread, the tumour burden may be large, and radical treatment may not be possible or may involve significant morbidity that may not be acceptable to or tolerated by the patient.[17][18]

Rarely, patients present with very large primary BCCs (>10–20cm) due to patient neglect or denial. These usually occur on the trunk, where they remain hidden. Due to their large size they are usually deeply invasive and consequently may be very difficult to treat.[25]

Site[edit source]

Higher recurrence rates have been observed for all treatment modalities in the facial region, particularly in and around the nose, eyes and ears, compared with non-facial sites.[6][26]

The spectrum of morphological subtypes of BCCs occurring on the trunk and limbs tends to differ from that of BCCs occurring on the head and neck.[27] The subcutaneous anatomy of the face and scalp is far more complex and critical than in non-facial sites, posing potentially graver consequences for deep invasion of BCC and greater risk of morbidity from injudicious treatment.

Morphological and histological subtype[edit source]

Superficial and nodular BCCs are usually clinically and histologically well circumscribed and curable with all established treatment modalities.[5][19]

Sclerosing (morphoeic), micronodular and infiltrative (deeper induration) BCCs are harder to define macroscopically, and microscopically are associated with lower clearance rates following excision. They are associated with higher recurrence rates.[28][29][19][30]

Tumours that show histological features intermediate between BCC and cutaneous squamous cell carcinoma (cSCC), formerly called basosquamous or metatypical BCCs, are also more likely to recur.[31][19] These represent less than 5% of all BCCs.[19]

However, the quality of data supporting all the observed associations between morphological and histological subtype and prognosis is poor.

Treatment modality[edit source]

Surgical excision remains the treatment of first choice. Complete excision (particularly MMS) delivers the highest and most prognostically reliable control rates (see: Surgical treatment).[7][8][4][9][28][32][33][34][23][35]

Radiotherapy, electrodessication and curettage, and cryotherapy each deliver lower control rates than surgical excision, in descending order (see: Radiotherapy, cryotherapy and electrodessication and curettage).[7][10][9][6][20][36][23][37]

Incomplete excision[edit source]

Incomplete excision is associated with an overall recurrence rate of 30%. This finding emphasises the importance of achieving complete excision at the primary procedure.[13][38][36][39][40][41][42][43][44]

The risk of recurrence is highest in lesions where both lateral and deep margins are involved.[45][46][30]

Approximately one-third of incompletely excised BCCs are found to recur, with the proportion depending on the length of follow-up.[41][46][43][44]
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Perineural invasion[edit source]

Perineural invasion (PNI) is uncommon among patients with BCC and even rarer than among patients with cSCC (see also Perineural invasion in Prognosis of cutaneous squamous cell carcinoma). It most often occurs in patients with BCC of the head and neck.[47][48][49][50]

Clinicians managing BCC with PNI should seek a specialist opinion on its clinical significance and optimal treatment (e.g. discuss with radiation oncologist).

Naevoid basal cell carcinoma syndrome[edit source]

Naevoid BCC syndrome (Gorlin’s syndrome) is a rare inherited disorder with early onset and a relentless, lifelong, high frequency of BCC.[51][52][53]

Diminishing reserves of normal skin with increasing age can eventually compromise control in these patients (see: Epidemiology).[52]

Measuring success of basal cell carcinoma treatment[edit source]

The endpoint for measuring the success of BCC treatment (excluding cosmetic, functional and patient convenience factors) is not universally defined.

Survival (overall survival or disease-specific survival) is a poor measure of treatment success because BCC is rarely fatal and BCCs can have a very long history in recurrence pattern; commonly 10 to more than 20 years.[3][4][13]

The best available endpoint is a chronologically defined local control rate (e.g. 5-year and 10-year control or recurrence).

Completeness of excision is a useful surrogate measure because incomplete excision is associated with an overall recurrence rate of 30%.[13][38][36][39][41][42][43][44]


Key point(s)
  • Patients with basal cell carcinoma without high-risk features can be reassured that the prognosis is generally excellent.
  • When a patient has a basal cell carcinoma that is larger than 2cm, is on the face, or has recurred after a previous treatment, the clinician should explain that there is a risk of recurrence or spread. The clinician should offer follow-up or further treatment as appropriate, and carefully explain the risks and benefits of each management option.
  • When incomplete excision of a basal cell carcinoma is reported, the surgeon or treating clinician should explain to the patient that there is a significant risk of the cancer recurring, and should offer further treatment as appropriate, carefully explaining the risks and benefits of each management option.


Note: Follow-up of patients after treatment is individually tailored according to patient factors, tumour factors, anatomic site and the perceived adequacy of treatment.

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References[edit source]

  1. ↑ Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK, Gershenwald JE, Compton CC, Hess KR, et al. (Eds.). AJCC Cancer Staging Manual (8th edition). Springer International Publishing: American Joint Commission on Cancer; 2017 [cited 2016 Dec 28].
  2. ↑ Brierley JD, Gospodarowicz MK, Wittekind C. TNM Classification of Malignant Tumours, 8th Edition. Wiley-Blackwell; 2017.
  3. ↑ 3.0 3.1 Silverman MK, Kopf AW, Grin CM, Bart RS, Levenstein MJ. Recurrence rates of treated basal cell carcinomas. Part 1: Overview. J Dermatol Surg Oncol 1991 Sep;17(9):713-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1890243.
  4. ↑ 4.0 4.1 4.2 Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 1989 Mar;15(3):315-28 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2646336.
  5. ↑ 5.0 5.1 RANK BK, WAKEFIELD AR. Surgery of basal-cell carcinoma. Br J Surg 1958 Mar 18;45(193):531-47 Available from: http://www.ncbi.nlm.nih.gov/pubmed/13536360.
  6. ↑ 6.0 6.1 6.2 Menn H, Robins P, Kopf AW, Bart RS. The recurrent basal cell epithelioma. A study of 100 cases of recurrent, re-treated basal cell epitheliomas. Arch Dermatol 1971 Jun;103(6):628-31 Available from: http://www.ncbi.nlm.nih.gov/pubmed/5555851.
  7. ↑ 7.0 7.1 7.2 Silverman MK, Kopf AW, Grin CM, Bart RS, Levenstein MJ. Recurrence rates of treated basal cell carcinomas. Part 2: Curettage-electrodesiccation. J Dermatol Surg Oncol 1991 Sep;17(9):720-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1820764.
  8. ↑ 8.0 8.1 8.2 Silverman MK, Kopf AW, Bart RS, Grin CM, Levenstein MS. Recurrence rates of treated basal cell carcinomas. Part 3: Surgical excision. J Dermatol Surg Oncol 1992 Jun;18(6):471-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1592998.
  9. ↑ 9.0 9.1 9.2 9.3 Rowe DE, Carroll RJ, Day CL Jr. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 1989 Apr;15(4):424-31 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2925988.
  10. ↑ 10.0 10.1 Silverman MK, Kopf AW, Gladstein AH, Bart RS, Grin CM, Levenstein MJ. Recurrence rates of treated basal cell carcinomas. Part 4: X-ray therapy. J Dermatol Surg Oncol 1992 Jul;18(7):549-54 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1624628.
  11. ↑ Corbett Jr. Recurrence of Rodent Ulcers After Radiotherapy. Br J Surg 1965 May;52:347-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/14286979.
  12. ↑ Dubin N, Kopf AW. Multivariate risk score for recurrence of cutaneous basal cell carcinomas. Arch Dermatol 1983 May;119(5):373-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6847215.
  13. ↑ 13.0 13.1 13.2 13.3 Taylor GA, Barisoni D. Ten years' experience in the surgical treatment of basal-cell carcinoma. A study of factors associated with recurrence. Br J Surg 1973 Jul;60(7):522-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/4577594.
  14. ↑ Petrovich Z, Parker RG, Luxton G, Kuisk H, Jepson J. Carcinoma of the lip and selected sites of head and neck skin. A clinical study of 896 patients. Radiother Oncol 1987 Jan;8(1):11-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3809597.
  15. ↑ Mazeron JJ, Chassagne D, Crook J, Bachelot F, Brochet F, Brune D, et al. Radiation therapy of carcinomas of the skin of nose and nasal vestibule: a report of 1676 cases by the Groupe Europeen de Curiethérapie. Radiother Oncol 1988 Nov;13(3):165-73 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3146781.
  16. ↑ Lovett RD, Perez CA, Shapiro SJ, Garcia DM. External irradiation of epithelial skin cancer. Int J Radiat Oncol Biol Phys 1990 Aug;19(2):235-42 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2394605.
  17. ↑ 17.0 17.1 Lee WR, Mendenhall WM, Parsons JT, Million RR. Radical radiotherapy for T4 carcinoma of the skin of the head and neck: a multivariate analysis. Head Neck 1993 Jul;15(4):320-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8360054.
  18. ↑ 18.0 18.1 Mendenhall WM, Parsons JT, Mendenhall NP, Million RR. T2-T4 carcinoma of the skin of the head and neck treated with radical irradiation. Int J Radiat Oncol Biol Phys 1987 Jul;13(7):975-81 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3597161.
  19. ↑ 19.0 19.1 19.2 19.3 19.4 Sexton M, Jones DB, Maloney ME. Histologic pattern analysis of basal cell carcinoma. Study of a series of 1039 consecutive neoplasms. J Am Acad Dermatol 1990 Dec;23(6 Pt 1):1118-26 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2273112.
  20. ↑ 20.0 20.1 Avril MF, Auperin A, Margulis A, Gerbaulet A, Duvillard P, Benhamou E, et al. Basal cell carcinoma of the face: surgery or radiotherapy? Results of a randomized study. Br J Cancer 1997;76(1):100-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9218740.
  21. ↑ McKenna RJ, Macdonald I. Carcinoma of The Eyelid Treated by Irradiation-Analysis Of 157 Primary And 22 Recurrent Cases. Calif Med 1962 Mar;96(3):184-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18732494.
  22. ↑ Abbatucci JS, Boulier N, Laforge T, Lozier JC. Radiation therapy of skin carcinomas: results of a hypofractionated irradiation schedule in 675 cases followed more than 2 years. Radiother Oncol 1989 Feb;14(2):113-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2710943.
  23. ↑ 23.0 23.1 23.2 Thissen MR, Neumann MH, Schouten LJ. A systematic review of treatment modalities for primary basal cell carcinomas. Arch Dermatol 1999 Oct;135(10):1177-83 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10522664.
  24. ↑ Del Regato JA, Vuksanovic M. Radiotherapy of carcinomas of the skin overlying the cartilages of the nose and ear. Radiology 1962 Aug;79:203-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/13884985.
  25. ↑ Randle HW, Roenigk RK, Brodland DG. Giant basal cell carcinoma (T3). Who is at risk? Cancer 1993 Sep 1;72(5):1624-30 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8348493.
  26. ↑ Ashby MA, Smith J, Ainslie J, McEwan L. Treatment of nonmelanoma skin cancer at a large Australian center. Cancer 1989 May 1;63(9):1863-71 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2702595.
  27. ↑ Goudie D. Non-melanoma skin cancer In: WD Foulkes, SV Hodgson. Inherited Susceptibility to Cancer: Clinical, Predictive and Ethical Perspectives Cambridge, UK: Cambridge University Press; 1998.
  28. ↑ 28.0 28.1 Emmett AJ. Surgical analysis and biological behaviour of 2277 basal cell carcinomas. Aust N Z J Surg 1990 Nov;60(11):855-63 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2241644.
  29. ↑ Sloane JP. The value of typing basal cell carcinomas in predicting recurrence after surgical excision. Br J Dermatol 1977 Feb;96(2):127-32 Available from: http://www.ncbi.nlm.nih.gov/pubmed/843446.
  30. ↑ 30.0 30.1 Armstrong LTD, Magnusson MR, Guppy MPB. Risk factors for recurrence of facial basal cell carcinoma after surgical excision: A follow-up analysis. J Plast Reconstr Aesthet Surg 2017 Dec;70(12):1738-1745 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28579037.
  31. ↑ THACKRAY AC. Histological classification of rodent ulcers and its bearing on their prognosis. Br J Cancer 1951 Jun;5(2):213-24 Available from: http://www.ncbi.nlm.nih.gov/pubmed/14869590.
  32. ↑ Mohs FE. Micrographic surgery for the microscopically controlled excision of eyelid cancers. Arch Ophthalmol 1986 Jun;104(6):901-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3718316.
  33. ↑ Mohs F, Larson P, Iriondo M. Micrographic surgery for the microscopically controlled excision of carcinoma of the external ear. J Am Acad Dermatol 1988 Oct;19(4):729-37 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3053805.
  34. ↑ Julian CG, Bowers PW. A prospective study of Mohs' micrographic surgery in two English centres. Br J Dermatol 1997 Apr;136(4):515-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9155950.
  35. ↑ Murray C, Sivajohanathan D, Hanna TP, Bradshaw S, Solish N, Moran B, et al. Patient Indications for Mohs Micrographic Surgery: A Systematic Review. J Cutan Med Surg 2019;2019 Jan Feb;23(1):75-90 Available from: http://www.ncbi.nlm.nih.gov/pubmed/30033747.
  36. ↑ 36.0 36.1 36.2 Rintala A. Surgical therapy of basal cell carcinoma. Correlation of the macroscopic and microscopic control of excision with recurrence. Scand J Plast Reconstr Surg 1971;5(2):87-90 Available from: http://www.ncbi.nlm.nih.gov/pubmed/5136061.
  37. ↑ Hall VL, Leppard BJ, McGill J, Kesseler ME, White JE, Goodwin P. Treatment of basal-cell carcinoma: comparison of radiotherapy and cryotherapy. Clin Radiol 1986 Jan;37(1):33-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3514075.
  38. ↑ 38.0 38.1 HAYES H. Basal cell carcinoma: the East Grinstead experience. Plast Reconstr Surg Transplant Bull 1962 Aug;30:273-80 Available from: http://www.ncbi.nlm.nih.gov/pubmed/13905648.
  39. ↑ 39.0 39.1 Shanoff LB, Spira M, Hardy SB. Basal cell carcinoma: a statistical approach to rational management. Plast Reconstr Surg 1967 Jun;39(6):619-24 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6026420.
  40. ↑ Pascal RR, Hobby LW, Lattes R, Crikelair GF. Prognosis of "incompletely excised" versus "completely excised" basal cell carcinoma. Plast Reconstr Surg 1968 Apr;41(4):328-32 Available from: http://www.ncbi.nlm.nih.gov/pubmed/5647401.
  41. ↑ 41.0 41.1 41.2 De Silva SP, Dellon AL. Recurrence rate of positive margin basal cell carcinoma: results of a five-year prospective study. J Surg Oncol 1985 Jan;28(1):72-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3968892.
  42. ↑ 42.0 42.1 Park AJ, Strick M, Watson JD. Basal cell carcinomas: do they need to be followed up? J R Coll Surg Edinb 1994 Apr;39(2):109-11 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7520063.
  43. ↑ 43.0 43.1 43.2 Sussman LA, Liggins DF. Incompletely excised basal cell carcinoma: a management dilemma? Aust N Z J Surg 1996 May;66(5):276-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8634041.
  44. ↑ 44.0 44.1 44.2 Rippey JJ, Rippey E. Characteristics of incompletely excised basal cell carcinomas of the skin. Med J Aust 1997 Jun 2;166(11):581-3 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9201177.
  45. ↑ Richmond JD, Davie RM. The significance of incomplete excision in patients with basal cell carcinoma. Br J Plast Surg 1987 Jan;40(1):63-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3814899.
  46. ↑ 46.0 46.1 Liu FF, Maki E, Warde P, Payne D, Fitzpatrick P. A management approach to incompletely excised basal cell carcinomas of skin. Int J Radiat Oncol Biol Phys 1991 Mar;20(3):423-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1899855.
  47. ↑ Hanke CW, Wolf RL, Hochman SA, O'Brian JJ. Chemosurgical reports: perineural spread of basal-cell carcinoma. J Dermatol Surg Oncol 1983 Sep;9(9):742-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6886188.
  48. ↑ Morris JG, Joffe R. Perineural spread of cutaneous basal and squamous cell carcinomas. The clinical appearance of spread into the trigeminal and facial nerves. Arch Neurol 1983 Jul;40(7):424-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6860179.
  49. ↑ McCord MW, Mendenhall WM, Parsons JT, Amdur RJ, Stringer SP, Cassisi NJ, et al. Skin cancer of the head and neck with clinical perineural invasion. Int J Radiat Oncol Biol Phys 2000 Apr 1;47(1):89-93 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10758309.
  50. ↑ McCord MW, Mendenhall WM, Parsons JT, Flowers FP. Skin cancer of the head and neck with incidental microscopic perineural invasion. Int J Radiat Oncol Biol Phys 1999 Feb 1;43(3):591-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10078643.
  51. ↑ Gorlin RJ. Nevoid basal cell carcinoma syndrome. Dermatol Clin 1995 Jan;13(1):113-25 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7712637.
  52. ↑ 52.0 52.1 Shanley S, Ratcliffe J, Hockey A, Haan E, Oley C, Ravine D, et al. Nevoid basal cell carcinoma syndrome: review of 118 affected individuals. Am J Med Genet 1994 Apr 15;50(3):282-90 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8042673.
  53. ↑ Hahn H, Wicking C, Zaphiropoulous PG, Gailani MR, Shanley S, Chidambaram A, et al. Mutations of the human homolog of Drosophila patched in the nevoid basal cell carcinoma syndrome. Cell 1996 Jun 14;85(6):841-51 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8681379.

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scar-like (morphoeic)

scar-like (morphoeic)

showing evidence of squamatisation (descriptor applicable to basaloid tumours and indicating aggressive subtype)

showing evidence of squamatisation (descriptor applicable to basaloid tumours and indicating aggressive subtype)

Medical practitioners who through training, experience and peer opinion specialise in the management of keratinocyte cancers

(naevoid BCC syndrome) an autosomal dominant syndrome characterised by multiple BCCs

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