6.1 Prognosis of basal cell carcinoma

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


Background

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 sclerosingscar-like (morphoeic) [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)

Recurrent tumours

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

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

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

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

Sclerosingscar-like (morphoeic) (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 basosquamousshowing evidence of squamatisation (descriptor applicable to basaloid tumours and indicating aggressive subtype) or metatypicalshowing evidence of squamatisation (descriptor applicable to basaloid tumours and indicating aggressive subtype) 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

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

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

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 specialistMedical practitioners who through training, experience and peer opinion specialise in the management of keratinocyte cancers opinion on its clinical significance and optimal treatment (e.g. discuss with radiation oncologist).

Naevoid basal cell carcinoma syndrome

Naevoid BCC syndrome (Gorlin’s syndrome)(naevoid BCC syndrome) an autosomal dominant syndrome characterised by multiple BCCs 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

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

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