6.1 Prognosis of basal cell carcinoma
Unless stated otherwise, tumour stage is according to the American Joint Committee on Cancer (AJCC) cancer staging manual 8th edition  and Union for International Cancer Control (UICC) TNM classification of malignant tumours 8th edition.
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
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)
History of skin cancers (higher risk if history of multiple tumours)
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]
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%. 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 (or, less commonly, using radiotherapy).
These recurrence figures increase with increasing tumour stage, and salvage becomes harder to achieve. Furthermore, control rates are likely to progressively diminish with each successive episode of recurrence and salvage treatment.
Control rates diminish with increasing size and depth of invasion (T stage; Table 4.2). See Appendix A TNM staging.
|T stage||Size (maximum diameter)||5-year control rates|
|T2||>2cm but ≤5cm||88%|
|T4||Tumour deeply invaded beyond subcutaneous tissues||40–50%|
Cartilage and bone invasion are surrogate markers of more advanced stage, deeper invasion and/or recurrent BCC. 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.
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.
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. 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]
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.
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. These represent less than 5% of all BCCs.
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).
Radiotherapy, electrodessication and curettage, and cryotherapy each deliver lower control rates than surgical excision, in descending order (see: Radiotherapy, cryotherapy and electrodessication and curettage).
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.
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.
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]
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.
The best available endpoint is a chronologically defined local control rate (e.g. 5-year and 10-year control or recurrence).
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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