BASAL CELL CARCINOMA

Sinonim: Basal cell epithelioma

Basalioma
Rodent ulcer (Jacobi ulcer)

Basal cell carcinoma:

Malignant tumor of the skin

Believed to arise from the external root sheat of Hair follicle or basal cells of the epidermis Most common malignancy in human

Typically occurs in chronic sun exposure area

 Rarely metastasizes. The incidence of metastatic 0,0028% - 0.1%. The most common sites of metastasis are the lymph nodes, lungs, and bones. Typically, enlarge slowly tendency tobe locally destructive.

History:

Complain of Patients slowly enlarging lesion, does not heal & bleeds when traumatized.
Hystory of chronic sun exposure:

- Recreational sun exposure (eg, sunbathing, outdoor sports) - Occupational sun exposure (eg, farming, construction)

 Occasionally have a history of exposure to ionizing radiation. or a history of arsenic intake Long term drug induced immune supression risk Develop within Associated with xeroderma pigmentosum, albinism, basal cell nevus syndrom

Clinical presentation
Nodular BCC Its the most common type usually a round, pearly, flesh colored papule,telangiectases. As it enlarges frequently ulcerates centrally ( Rodent ulcer ), leaving a raised, pearly border with telangiectases,.

Ulkus rodent; destruksi lokal luas pada lesi

 Most tumors are observed on the face, although the trunk and extremities also are affected. Deferensial diagnosis :
-Dermal nevus

-Amelanotic melanoma
-Tricoepithelioma -Fibrous Papul -Sebaseus hiperplasia

Cystic BCC: - An uncommon variant of nodular BCC, - It often is indistinguishable from nodular BCC clinically, - Polypoid appearance.

Difrensial diagnosis: Nevus intradermal; konsistensi lebih lunak, dan ukuran lebih stabil, Hiperperplasia sebaseus : berwarna kekuningan, dan disertai umbilikasi sentral. Hydrocystoma : kista pada kelenjar ekrin atau apokrin

Pigmented BCC

Uncommon variant of nodular BCC

Appears brown-black in some or all areas, it often difficult to differentiate from melanoma, seboroik keratosis, nevi. Areas often do not retain much pigment, and pearly, raised borders with telangiectases aids in diagnosis.

Morpheaform (sclerosing) BCC Morpheaform BCCuncommon variant Tumor cells induce fibroblast proliferation & collagen deposition (sclerosis) clinically resembling a scar, scleroderma . Appears as a white or yellow, waxy, sclerotic plaque, rarely ulcerates.

Karsinoma sel basal morfeaform; lesi menyerupai skar

 Tumor infiltrates in thin strands between collagen fibers treatment is difficult & the clinical margins are difficult to distinguish.

Mohs micrographic surgery is the treatment of choice for this type

Superficial BCC

Appears as an erythematous, well circumscribed patch or plaque, often with a whitish scale. The tumor appears multicentric.

Difrensial diagnosis: - Dermatitis nummular - psoriasis - bowen disease - keratosis seboroik - nevi - Actinic keratosis

Karsinoma sel basal superfisial pada punggung ; plak batas tegas, mirip psoriasis

Prognosis and staging Incidence metastases: 1:1000 Staging use UICC classification, Clinically useless because: T- too rough & N and M dont exist

The following information to ensure quality of therapy:

Tumor size(horizontal diameter) Localisation Vertical tumor diameter Therapeutical safety margin

Margin of surgical resection microscopically in health tissue

Therapy
The recommended treatment (standard procedure) surgical with histological confirmation.

Newer, nonsurgical therapeutic future possibilities, consider current medical modalities to be experimental cure rates << surgical modalities.

SURGICAL CARE

Surgical Care:

The goal of therapy removal of the tumor with the best possible cosmetic result.
Surgical modalities most used, most effective, and most studied treatments. Selection of the modality depends: tumor is primary or recurrent, location, size, and type.

Micrographically controlle surgery

recommended in all size of tumor,recurring tumor Procedure: 1. Border marker of the tumor

2. Local anesthetic .

3. Excision of the tumor (2-4 mm safety margin) with topographical marking 4. Complete histilogical examination of the whole outside surface. 5. If necessary, reexcision until outside is tumor free

Advantages:
highest cure rate of any treatment modality (99% for primary BCC, 9095% for recurrent BCC and is the treatment of choice for morpheaform BCC and recurrent BCC.

Disadvantages:
Micrographic surgery is time consuming,

Patients might require additional anesthesia before each stage.

Terapi alternatif

Bedah konvensional
Elektrodesikasi + kuretase

Crysurgery
Radioterapi 5-fluorourasil interferon alfa-2b

Follow-up
Follow-up is necessary.

Possibility of new tumors appearing (30 % of the cases)

Education & exact instruction for self examination greatest importance

A yearly clinical followup examination at least 3 year

Prevention: Avoid possible potentiating factors (eg, sun exposure,

ionizing radiation, arsenic

ingestion).

Special Concerns:

Tumor locations for high risk of recurrence, the nose or T-zone of the face have a higher incidence of recurrence.
Morpheaform (or sclerotic) type of BCC has a high risk of recurrence.

KARSINOMA SEL SKUAMOSA

 Merupakan proliferasi maligna sel keratinosit epidermis Etiologi: Sinar Surya, termal, sikatriks, radiasi kronik, virus, imunosupressant, tar, ulkus kronik.

Manifestasi klinis
Karsinoma sel skuamosa In situ

Mengenai full thickness intraepidermal

Dapat timbul pada lesi kulit: keratosis termal, keratosis radiasi kronik, sikatriks, keratosis solar, keratosis arsenik, kornu kutaneus

Dapat menetap dalam waktu lama didalam epidermis dan tanpa diprediksi melewati membrana basalis meluas ke dermis

Karsinoma sel skuamosa Invasif

invasif awal : nodul warna seperti warna kulit atau eritem ringan, batas tidak jelas, permukaan biasanya halus tetapi sering menjadi verukous atau papillomatous
Dapat timbul sebagai patch eritem disertai skuama persisten menyerupai dermatitis atau dermatofitosis

 Pertumbuhan tumor elevasi & diameter Invasi progresif ke jaringan dibawahnya memfiksir tumor ke jaringan dibawahnya

Ulserasi
Mudah berdarah , krusta

Difrensial diagnosis

Verruka vulgaris
Giant seboroic keratosis Giant keratoacanthoma

Deep mycosis
Granuloma pyogenic

Bowen disease

Diagnosis Berdasarkan gambaran klinis dan pemeriksaan histopatologi pada lesi yang dicurigai

Terapi

Bedah eksisi mohs micrographic surgery Terapi radiasi

Photodynamic therapy Immunoterapi

Kemoterapi

Pencegahan

Hindari paparan sinar surya berlebihan Pakai tabir surya khususnya pada resiko tingggi: burn scar, discoid lupus eritematosus, dan pada daerah X-ray demage