Standard of care for BCC diagnosis and management

Hi All

Just wondering about whether there was any consensus or views about the following:

1. All suspected BCC’s need a biopsy to guide management

2. If you have a biopsy diagnosis of BCC, you should submit the treatment (curette or excision) specimen.

3. BCC’s can be treated without histological confirmation at any point.

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  1. #1 by Dr Ian Katz on March 1, 2011 - 4:35 am

    1. I do believe so as there is little correlation between clinical impression and subtype. Love to get a reference for this.
    2. I do believe so as there is poor correlation between biopsy subtype and final specimen subtype, so there may be morphoeic BCC that is not treated appropriately
    3. I do not believe so as there is a huge overlap between the clinical diagnosis of BCC and many things including melanoma
    But I am a biased pathologist

  2. #2 by shaun on March 1, 2011 - 5:08 am

    my view all BCC’S need a biopsy, as we are scientists and management options depend on pathology, a superficial bcc may be treated with aldara/pdt
    nodular or morpheic bcc more likely to need excision
    Once biopsied and surgically treated all histology must be checked for margins or for a mixed picture which may warrent further treatment.
    I do not agree that Bcc’s can n=be treated at any point without histological confirmation, as how can you be 100% sure with a clinical/dermoscopic picture=
    ie histological verse dermascopical results are often different

  3. #3 by Tony Dicker on March 1, 2011 - 5:45 am

    1. Some BCCs need histological confirmation of the suspected clinical diagnosis, but others can be managed directly from clinical opinion.

    2. The second excision specimen should be submitted to histology for examination of the margins (excision)

    3. Many, but not every BCC can be diagnosed by clinical impression. Histological confirmation at some point relieves any future doubt about the original lesion if recurrence occurs later.

  4. #4 by hein vandenbergh on March 1, 2011 - 6:24 am

    1. An obvious nodular BCC gets excised by me without prior Bx, but always sent for histo, of course.

    2. If a suspected BCC is biopsied – or if a biopsy of never-mind-what comes back as BCC – ‘all of every subsequent definitive treatment’ gets reviewed by path (sub-type and margin), UNLESS it looked like an sBCC, was so confirmed, and is treated with imiquimod (obviously).

    3. I suppose they can, but it would be very unwise. In any case, for imiquimod to be obtained on NHS one needs a Bx; also, not all obvious BCCs are benevolent, esp on the facial triangle, or are indeed a BCC. Basic premise: the ONLY things which I remove from pts which do NOT go for histo are ingrown toenails. And the run-o’the-mill obvious SK curetted, unless they feel a bit more adherent than they should: that is usually a sign of it being Bowenoid SCC, not unusual at all.

  5. #5 by mark burton on March 1, 2011 - 7:30 am

    I recall at one of the SCCANZ conferences a medicare expert saying that they did not expect all bcc’s to be biopsied because most can be identified by naked eye and or dermoscopy.Strange they don’t take the same stance on 30202

  6. #6 by Jim Wall on March 1, 2011 - 7:47 am

    Yes, but no, but yes. It is interesting but not surprising that there is so little evidence available on which to base our treatment of the commonest human cancer. I have been misled both ways many times – it is an obvious BCC, but histo says it’s not, or it’s something entirely different, but histo says BCC.

    Ian, you will be receiving a specimen from me tomorrow which I first saw two weeks ago – it was a typical BCC with arborising telangiectasia, those alleged maple leaf areas of pigment, ulceration centrally and the fibre sign. I looked at it again today prior to excision and it is clearly a melanoma.

    We probably should biopsy them all, but time is against us and if we do the skin cancer bill will be even greater than it is now.

    I’m also struck by how often I hear stories of dermos removing lesions unbiopsied which turn out to be nothing important. Time after time after time.

  7. #7 by Dr Ian Katz on March 2, 2011 - 7:03 am

    Stewart Percians comment:
    Ian
    1 Biopsy neede for less obvious BCCs, small or superficial or morphoeic; obvious nodular biopsy no help
    2 Submit excisions for histopath. especially for margins and exclude sometimes non-pig. melanoma
    C&C for sBCC after already biopsy shows superficial BCC, not much help as not going to do more treatment
    3 only if numerous BCCs in an area, especially superficial, and at least one been biopsied…. then others C&C done without histo.

    Stewart

  8. #8 by Dr Ian Katz on March 2, 2011 - 7:04 am

    Cliff Rosendahl wrote
    1. Yes but that can be in the form of definitive excision

    2. Yes – Re excision to confirm margin. No point if curette (or PDT,Cryo,Aldara obviously)

    3. This is dangerous because as we all know the odd curetted BCC comes back as an AMM

    4. Regards,

  9. #9 by Hilton Beck on March 2, 2011 - 12:27 pm

    Essentially agree with Cliff.
    Ian would you care to comment on whether nodular BCC’s are clinically obvious or not? I am of the impression that the “nodularity “is a histological appearance rather than a macro appearance of the typical raised and thus named nodular appearing bcc. The nomenclature of subtypes of BCC is confusing , and varies so much from one pathologist to another that it is difficult to interpret reports at times , (superficial multifocal, nodular superficial, nodular, morpheic, sclerosing, infiltrating). My weirdest one arrived yesterday, patient requesting a second opinion- a second time incomplete excsion of a bcc nasal tip (general surgeon-no dermoscopic assessment) I noted dermoscopically obvious substantial persisting tumour, but the pathology reports were unhelpful with regard to formulating further mx- first report called it incompletely excised “incipient BCC”, the second made no mention of subtype, or depth of the tumour.Perhaps we should consider a clinicopathological classification of bcc designed to influence management , rather than the current classification , which seems to vary widely, and causes a lot of confusion. This is critical to the management .
    So is dermoscopy, how can anyone excise a bcc without at least a dermoscopic assessment of margins. This also touches a bit on a previous post with regard to item numbers, audits etc.- the medicare assessors will compare the patholgy report on size vs stated size recorded by the treating doctor – in many instances, particularly with bcc, the margins of the tumour are dermoscopically substantially larger than the macro measurements. I bill according to the actual size of the lesion, not the macro size, the patholgist reports the macro size. Sometime you can look at the margins and these can show that there is an obvious inconsistancy, but not always……. how do I justify this when the officials move in?

  10. #10 by Dr Ian Katz on March 2, 2011 - 9:36 pm

    Hilton, I think nodular BCC’s are the most diagnosable and if they are being excised may not need prior histo.
    I agree with the clinicopath classification – hopefully I do help in that regard.
    I think Medicare goes on clinical size as long as it is documented and roughly in correlation with the histo size – obviously cant bill for > 2 cm and then have histo sample of <0.5cm

  11. #11 by Hilton Beck on March 3, 2011 - 6:11 am

    Thanks, but the term nodular applies to the histological appearance rather than macro? I agree they are probably easiest to recognize clinically, but that is partly my point regarding nomenclature. I went to a GP focused dermatology conference a few years back, where a significant number of doctors believed that the term superficial bcc applied to the macroscopic appearance, hence were quite happy to treat with cryo etc. In my experience,most of the aggressive subtypes of BCC are relatively flat/superficial in their macro appearance, and I regularly see these types after they have been suboptimally treated based on this appearance.
    Suppose we just have to make sure things are well documented re billing.

  12. #12 by andrew Montanari on March 3, 2011 - 7:03 am

    Looks like we nearly have consensus.
    I used to think I could confidently diagnose a BCC just clinically.
    Now I almost always get a bx first.
    My lesson was when a couple of clinically obvious sBCCs (curetted) turned out to be melanomas.
    A less frightening lesson came after a ‘BCC’ excision on the cheek showed chronic folliculitis.

    The unexpected happens. Perhaps rarely, but even so, the patient sees your mistake and does not know or care that you got it right the other 99% of the time.

    “Specilaists’, however, is somewhat shielded his ‘automatically’ good reputation. The public tend to forgive them. We GPs do not have the luxury of being able to make half the mistakes that specialists do.

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