Radiation therapy involves long-term treatment, during which several courses of radiation are prescribed. The total radiation exposure that the patient receives during this time approaches 60-70 Gy. Radiation therapy is carried out in the postoperative period when the malignancy of the tumor is established, as well as in the presence of metastases.

Basal cell carcinoma chronic, the tumor grows slowly, rarely metastasizes. However, in severe cases, the tumor can lead to severe destruction of tissues, including cartilage, bones, and also take an aggressive course. The most aggressive course is scleroderma-like and ulcerative infiltrative basal cell carcinoma. Nodular non-ulcer and superficial basal cell carcinomas are less aggressive.

To the signs aggressive course of basal cell carcinoma include: a change in the size of nuclei, a decrease in amyloid synthesis and protein expression of the tcl-2 gene, which leads to a violation of apoptosis; violation of the continuity of the membrane; an increase in the synthesis of glycosaminoglycans by stromal fibroblasts, an increase in collagen synthesis and an increase in the level of stromal fibronectin; synthesis of metalloproteases, including collagenase IV, matrilisin, stromelysin-3, which are not detected in non-aggressive forms of basal cell carcinoma. In this case, the stroma of aggressive forms contains fibroblasts that resemble myo-fibroblasts. In aggressive subtypes of basal cell carcinoma, an increase in the expression of the c-fos oncogene is also noted; a decrease in the adhesion of tumor cells to fibroblasts, which is associated with a decrease in the number of E-cadherin molecules; a significant increase in the number of radially located microfilaments in tumor cells [PO]; aggressive forms of basal cell carcinoma may contain tetraploid DNA.

Usually basal cell carcinoma relapses much more often than metastases.

Basal cell carcinoma recurrence rate after surgical treatment ranges from 2 to 41% and depends on the size and shape of the tumor, its localization, etc. Micrographic surgery is more effective, which provides 96-98% cure for primary and 90-94% for recurrent basal cell carcinoma, but the method is laborious and is used in the localization of basal cell carcinoma in anatomically difficult areas, large tumor sizes (more than 2 cm) and in its relapses.

Rare metastasis of basal cell carcinoma they associate it with stroma dependence - in the absence of a stroma, the growth of tumor cells stops. The platelet growth factor also plays a role.

To the moment the development of metastases basal cell carcinoma exists on average for about 9 years and recurs repeatedly after treatment. If metastases do develop, the life expectancy of patients is short and on average does not exceed 8 months. There were no features foreshadowing possible metastasis. Neither localization, nor histological subtype, nor the patient's immune status, or the presence of multiple basaliomas in nevoid basal cell syndrome predispose to the development of metastases. By the time they appear, tumors are often large, but this is not necessary.

Basal cell cancer treatment

Choice basal cell cancer treatment and its effectiveness often depends on the nature of the tumor (primary, recurrent), its clinical and morphological characteristics, the number of foci and their localization, the size of the tumor and the depth of invasion, the age of patients and the presence of concomitant diseases, etc.

In the treatment of basal cell carcinoma In addition to surgical removal, they use close-focus X-ray therapy, cryodestruction, laser therapy, photochemotherapy, electrocoagulation and curettage, chemotherapy, immunotherapy and complex therapy. Close-focus X-ray therapy is usually used to treat solitary basal cell carcinomas up to 3 cm in size.However, the recurrence rate in this case is from 1.6 to 18%, and with the localization of basal cell carcinoma on the face - from 10 to 30% of cases, especially in anatomically complex areas (auricle , corners of the eyes, etc.). In this regard, a combination of surgical excision of the tumor and radiation therapy is possible, but this can lead to significant cosmetic defects.

Most common cryodestruction of basal cell carcinoma, effective in 70-98% of cases with limited forms of basal cell carcinoma.

Cryodestruction of basal cell carcinoma it is carried out by the contact method on devices "Cryoelectronics-2", etc. using applicators - copper discs or cotton swabs immersed in liquid nitrogen. Cryospraying is also used on devices KA-02, etc. The required exposure time varies from 30 to 180 s and depends on the form of basal cell carcinoma, its size and localization. Cryodestruction is not performed in morphe-like, scleroderma-like variants of basal cell carcinoma, as well as basal cell carcinoma of the nasolabial fold.

Gives a good therapeutic and cosmetic effect with a sparing local effect on the tumor in pulsed (neodymium laser) or continuous (carbon dioxide laser) modes, causing coagulation tissue necrosis with clear boundaries. Laser therapy is used mainly for superficial types of basal cell carcinoma. Recurrences of basal cell carcinoma with the pulsed method of therapy are 1.1-3.8% - with primary 4.8-5.6% in relapsed variants of basal cell carcinoma; with continuous exposure - respectively 2.8 and 5.7-6.9%.

One of the new methods is photodynamic basal cell cancer therapy, in which photosensitization using photoheme, etc. is used, followed by light radiation with a wavelength of 630-670 nm. This method of treatment is used both for superficial foci and for nodular ulcerative forms of basaliomas. both solitary and multiple.

When using electrocautery and curettage as independent methods relapses of basal cell carcinoma observed in 10-26% of cases.

From chemotherapeutic agents cytostatic ointments are used: 5% 5-fluorouracil, 5-10% fluorofuric, 30-50% - prospidin, etc. within 2-4 weeks. usually in the elderly, with multiple superficial basal cell carcinomas.

Complex method of treatment of basal cell carcinoma, including parenteral administration of prospidin and subsequent cryodestruction of the tumor, is used in multiple variants of basal cell carcinoma, large tumor sizes, and ulcerative forms.

Basal cell carcinoma laser therapy(argon laser) in combination with immunocorrectors (taktivin, sodium nucleinate) is used in the treatment of multiple basal cell carcinomas.

Can also be used in treatment and prevention basalioma isotretinoin and etretinate, drugs that normalize the activity of enzymes of the cyclase system, as well as injecting basaliomas with intron A every other day at a dose of 1.5 million IU (for a course of 13.5 million IU). The course, if necessary, is repeated after 6-8 weeks. with solitary superficial and ulcerative basaliomas. In some cases, it is supplemented with subsequent cryodestruction.

Basal cell carcinoma (synonyms for basalioma, basal cell carcinoma) is one of the most common tumors in the human population, accounting for up to 75% of non-melanoma epithelial skin neoplasms. According to the WHO definition, it is a locally destroying tumor from the cells of the basal layer of the epidermis / hair follicles with slow growth and rare metastasis (Fig. Below).

The most common sites are exposed skin areas that are directly exposed to sunlight. Basal cell skin cancer (BCC) often develops on the skin of the face (82–97% of cases), mainly in the area of ​​the nose and eyelids, temporal regions, cheeks and forehead, nasolabial folds, and upper lip. At the same time, basal cell carcinoma on the face often develops in the form of multiple tumors. The second most frequent localization is the skin of the neck, trunk, scalp and auricles (in 7.2% of cases). Basal cell carcinoma develops much less frequently on the skin of the back and extremities (in 3.7% of cases).

Basal cell skin cancer (photo)

Epidemiological studies indicate a steady increase in the incidence of CCC in the world by an average of 3-10% per year. The code for MKB-10 is C44. This type of cancer is a disease of the predominantly elderly / senile age, which accounts for 72-78% of cases, and is less common in relatively early age... The average age of patients is 64.4 years. It occurs more often in men, which is due to the large exposure to ultraviolet radiation due to the specifics of their professional activities. Despite the slow growth, rare cases of metastasis (0.051-0.15% of cases) and deaths, basal cell skin cancer can cause severe and extensive local destruction of soft tissues, cartilage and bone tissue causing disfigurement of cosmetically significant areas of the body. Metastasis occurs by the lymphogenous / hematogenous route, more often to the lungs, liver, pleura, esophagus, spleen, heart, peritoneum, kidneys, adrenal glands, dura mater.

The tumor occurs mainly in those individuals who are often / intensively exposed to solar radiation. In this case, for the development of a tumor, the more important factor is not the intensity of radiation, but the chronic nature of ultraviolet exposure. Accordingly, the most common basal cell carcinoma of the face and especially the basal cell carcinoma of the skin of the nose.

Photo. Basalioma of the nose

Despite the high incidence of basal cell carcinoma, the incidence of its detection remains extremely low, amounting to only 6–8%, which significantly delays its treatment.

Pathogenesis

The leading role in the pathogenesis of BCSC belongs to the so-called signaling pathway SHH(Hedgehog signaling pathway). Hedgehog signaling controls the activity of genes involved in morphogenesis, and it is its damage that is detected in BCSC. The Hedgehog complex (HSC) directly includes the Smo transmembrane protein, the Ci transcription factor and protein kinases.

The primary role is assigned to mutations in the PTCH gene, located on chromosome 9q, which is encoded by the SHH receptor. Specific mutations caused by UFOs in various oncogenes of the tumor suppressor gene p53, which occur in almost 50% of cases, are also of some importance. Other mutations (locus CDKN2A and genes (H-Ras, K-Ras, and N-Ras) are detected in significantly fewer sporadic cases of BCSCs (Fig. Below).

In the absence of ligands (neutral ions / molecules) in endosomes, the Path transmembrane receptor blocks the SMO transmembrane protein. Protein kinases with microtubules of the Hh complex are actively involved in the processes of partial proteolysis and phosphorylation of the transcription factor. As a result, a cleaved form of the GliR factor is formed, which penetrates the nucleus and blocks the transcription of target genes. In the presence of the Hh ligand, the blocking action of the Path receptor is terminated, SMO leaves the endosomes, which causes the dissociation of the Hh protein complex, the loss of its connection with microtubules, and the formation of an uncleaved (complete) form of the transcription factor Gli-act, which penetrates the nucleus and activates the process transcription of target genes. The mechanism of activation of the SHH signaling pathway is shown in Figures a and b below.

Figure a

Figure b

In general, the mechanisms of activation of the signaling pathway are shown in the figure below, where A is a mutational mechanism; B - autocrine; C and D - paracrine mechanism.

Classification

The classification is based on various features. According to the prevalence of basiloma, several stages are distinguished:

• the initial stage (pre-invasive carcinoma) - despite the presence of cancer cells, the tumor has not formed and it is extremely difficult to determine it;
• Stage 1 - the diameter of the tumor reaches 2 cm, the neoplasm is limited by the dermis and does not pass to the adjacent tissues;
• Stage 2 - the diameter of the basal cell carcinoma reaches 5 cm, grows through the entire thickness of the skin, does not spread to the subcutaneous tissue;
• Stage 3 - the diameter exceeds 5 cm, the surface ulcerates, grows deep into the skin, destroying the subcutaneous fatty tissue, tendons and muscles;
• Stage 4 - the tumor reaches 10 or more centimeters in diameter, damages the cartilage, bones and adjacent organs.

In accordance with morphological features and appearance tumors distinguish superficial, nodular (nodular), nodular-ulcerative, ulcerative, scleroderma-like, cicatricial-atrophic, warty, pigmented forms of basal cell carcinoma and other mixed variants.

In accordance with the International classification, several types of basiloma growth are distinguished: superficial, scleroderma and fibro-epithelial.

By clinical manifestation the initial stage is highlighted, expanded and terminal. As a rule, the basal cell carcinoma of the initial stage looks like a small nodule up to 2 cm in diameter, while there are no ulcerations. Photo of the basal cell carcinoma of the initial stage below.

Expanded stage - a tumor up to 5 cm with soft tissue lesions and primary ulceration (photo below).

Terminal stage - the tumor reaches 10 or more centimeters, ulcerates, grows into the underlying tissues. Photos of basal cell carcinoma of the face in the terminal stage can be found on specialized forums.

The reasons

The development of skin basiloma, as already noted, is based on genetic disorders. And the most important etiological factors in the development of BCCB include:

• Intense chronic ultraviolet exposure and especially short wavelengths (290-320 nm). At the same time, the latency period between the primary damage to the skin by ultraviolet rays and the clinical manifestation of the tumor can vary widely, reaching 20–50 years.
• An unfavorable family history (the presence in the family of hereditary syndromes such as Bazex syndrome, Gorlin-Goltz, basal cell nevus, Rhombo, skin types 1 and 2) in which there is a frequent development of basiloma.
• Acquired / congenital, including taking immunosuppressants, cytostatics.
• Skin pathologies (long-term non-healing ulcers / wounds, chronic dermatitis, scars from burns, inflammatory and degenerative processes, albinism, pigmented xeroderma and etc.).
• Exposure to toxic / carcinogenic substances (arsenic, hydrocarbons, soot).
• X-ray / radioactive and electromagnetic radiation.
• Age (after 60 years) and gender (male).

Symptoms

Basiloma is characterized by slow growth, develops most often over a number of months and even years. The most active tumor growth is observed on the periphery of the focus with pronounced phenomena of cellular apoptosis. Therefore, in the treatment of basiloma, it is important to clearly define the boundaries of the lesion and to fully influence the zones of peripheral growth.

The clinical picture of the disease and the biological behavior of the tumor are determined by its morphohistological type. Photos of basal cell carcinoma of the face of various shapes are shown below.

Surface form. It is characterized by the formation of a single pink spot with raised edges and a shiny surface, reminiscent of foci of mycosis, eczema, psoriasis (Fig. Below).

Its varieties include pigment BKRK, in which the color of the focus is brown. A benign course is characteristic. A spot can exist for a long time without increasing its size or with a slow and insignificant increase in its area. The frequency of this form is about 10% of all basaliomas.

The nodular (large-nodular) form is the most common form of basal cell carcinoma. It accounts for about 75% of all cases. It is an exophytic rounded formation, slowly growing, pink in color. In the ulcerative-nodular variant, the central part of the node often ulcerates and quickly becomes crusty. Less often, ulceration increases in size and acquires the shape of a funnel with the formation of a dense inflammatory infiltrate up to 1 cm wide along the periphery. Ulcerative-infiltrative BCSC can destroy tissues, especially when it is localized near natural openings (auricles, nose, eyes). - piercing BKRK (fig. Below).

Often, the nodular forms contain a brown or black color (pigmented BCRC) that gives the formation. The most common localization (more than 90%) is the skin of the neck and head.

Scleroderma-like (flat) shape. It is characterized by a plaque-like formation with ridged edges, flesh-colored and with a pearlescent sheen. Scleroderma-like resembles a scar. This form accounts for about 6% of all BKRC. In most cases, they are localized on the skin of the neck and head (Fig. Below).

This form is characterized by an aggressive course, rapid invasive growth in the underlying tissues (adipose tissue and muscles). Ulceration is possible in later stages of development.

Ulcerative form. The ulcer spreads not only along the surface, but also actively destroys all underlying tissues, including bones, accompanied by severe pain. The ulcer may be crusty and has smooth, firm, roller-like edges (photo below).

Infiltrative form (more often due to the progression of flat and nodular variants of BKRK - photo below).

It is characterized by a pronounced infiltrative component, a tendency to relapse and a poor prognosis.
There are many different variants of mixed forms, when, as the tumor develops, one form turns into another.

Analyzes and diagnostics

Diagnosis of basiloma is based on the detection of characteristic neoplasms on the skin and carrying out morphological verification of the process by histological examination of biopsy material or cytological examination of scrapings. To exclude the presence of metastases in internal organs / lymph nodes, if necessary, additional studies are carried out - ultrasound, radiography, computed tomography.

Basal cell carcinoma treatment

Treatment of basal cell carcinoma of the face provides for the complete removal of the tumor with minimization of the cosmetic defect and maximum preservation of functions. Treatment options mainly depend on the potential risk of recurrence of one or another form of tumor, which in turn depends on the aggressiveness of the clinical course and histological signs. An equally important factor in the choice of the method is the localization of the tumor, since the preservation of function and the minimization of the cosmetic defect for the operation are paramount, especially when it is located in open areas of the skin, such as the face.

Drug treatment can be used for forms of BCSC with low risk relapse. Despite the low efficiency, the advantages of local drug treatment are the preservation of surrounding tissues and a cosmetic effect, the possibility of treatment at home. For this, a 5% cream is used topically. Imiquimod, Kuraderm, Ingentol mebulat, 5-fluorouracil (5-FU), Ftorafur and Prospidine ointment, which are applied in a thin layer for a day to the affected area of ​​the skin with the capture of 5-7 mm of clinically unchanged skin under an occlusive dressing for 2-3 weeks.

Systemic drug therapy is carried out with a metastatic variant of a basiloma or with an inoperable locally advanced variant of a tumor. Sometimes it is prescribed before surgical excision of a tumor, systemic chemotherapy, holding cryodestruction... For this purpose, a drug, an inhibitor of Hedgehog signaling, Vismodeglib, is prescribed, which has a selective mechanism of action and low toxicity. Drugs with a similar effect include Sonidegib.

Treatment of basal cell cancer also includes immunotherapy, which consists in the systemic / local use of immunomodulatory drugs, in particular, recombinant interferons - (suppositories), alpha-2b-reaferonomy, Intron. Reaferon and Intron used to inject the tumor for 2-3 courses. The drugs are quite effective, since there are marked reductions in the size of the tumors, and some of them were resolved by cicatricial atrophy.

Basalioma - folk remedies

There are various folk methods for treating basalioma (celandine juice, decoction of burdock root, plantain leaves, bee products, etc.), but almost all folk remedies do not have any evidence base and are not recommended to be used as the main method of treatment.

The main treatments for basiloma are:

• surgery;
• (used in the initial stages of the disease, a carcinocidal dose of at least 70 g.);
• electrocoagulation;
• photodynamic therapy (destruction of a tumor occurs through the implementation of a photodynamic reaction);
• cryodestruction(removal of the tumor with liquid nitrogen).

The doctors

Medicines

• Preparations for local therapy: Imiquimod, Kuraderm, Ingentol mebulat, 5-fluorouracil(5-FU), Ftorafur ointment, Prospidine ointment.
• Systemic therapy drugs: Vismodeglib, Sonidegib.
• Immunomodulatory drugs: (suppositories), Reaferon.

Procedures and operations

Surgical excision is performed under local anesthesia and includes elliptical surgical removal of the basal cell carcinoma with an offset of 4 mm from its edge. It is carried out in cases where tissue preservation is not a priority (on closed body surfaces). Efficiency for tumors less than 2 cm in size is 90-95%. Below are photos: basal cell carcinoma of the nose - before and after treatment and basal cell carcinoma of the skin of the face (before and after treatment).

Diet

There is no special diet for skin basiloma.

Prevention

The prevention of reducing the risk of developing basiloma is based on protection, especially in childhood and adolescence, from UFOs and other unfavorable factors impact, including:

• Avoiding direct long-term exposure to the sun and sunburn, frequent use of tanning beds, wearing protective clothing and glasses, using sunscreen.
• Timely treatment of long-term non-healing fistulas / ulcers.
• Protection of rough scars on the skin from mechanical injury.
• Compliance with personal hygiene and the use of personal protective equipment when working with substances containing carcinogens, chemical reagents and radiation sources.

Consequences and complications

Basal cell carcinoma is characterized by a relatively benign course. The main complications are its ability to spread to adjacent tissues, causing their destruction and the formation of a cosmetic defect on the skin.

Forecast

In general, with timely adequate treatment of basal cell carcinoma and the absence of metastasis, the prognosis of the disease is favorable and a stable cure is observed in 95-98%. In advanced cases, there can be severe destruction of underlying tissues, including muscle, cartilage, and bone. When the tumor spreads to the underlying tissues, there is a high risk of a significant cosmetic defect. In cases of tumor metastasis, especially in vital organs, the prognosis for life is unfavorable with an overall 5-year survival rate of about 10-15%.

List of sources

• Savoskina V.A. Basal cell carcinoma: epidemiology, pathogenesis, clinical picture, diagnosis, modern methods treatment // Clinical immunology, allergology infectology., 2016., p. 15-22.
• Khlebnikova A.N. Clinical, morphological and immunohistochemical features of various forms of basal cell skin cancer and a complex method of its treatment. Abstract of thesis. dis. ... Dr. med. sciences. Moscow: 2007.
• Vasilevskaya E.A., Vardanyan K.L., Dzybova E.M. Modern methods of treatment of basal cell skin cancer // Clinical Dermatology and Venereology 3, 2015 p. 4-11.
• Gamayunov S.V., Shumskaya S.V. Basal cell carcinoma of the skin - an overview of the current state of the problem. // Practical Oncology. 2012; 13 (2): 92-106.
• A.G. Novikov Clinical and morphological characteristics, diagnosis and treatment of basal cell skin cancer. Clinical Dermatology and Venereology. 2012; 3: 106-108.

Basal cell carcinoma or basalioma is the most common type of skin cancer. Developing from atypical cells of the basal layer of the epidermis, this tumor occupies an intermediate position between benign and malignant skin formations.

The main reason for this classification is the absence of tumor metastasis in other organs. However, the structural characteristics of basal cell carcinoma contribute to its rapid spread over the surface of the skin with the capture and subsequent destruction of surrounding tissues such as muscles, nerves, and skull bones.

Characteristics of the disease

Basalioma refers to skin neoplasms with a predictable nature and predictable course. Affecting mainly the open skin of people of both sexes over 50 years old, the tumor is localized mainly on the face, in particular, on the wings of the nose, on the upper lip and nasolabial region, temples, etc. However, the disease also affects the scalp and neck; very rarely, tumor foci (often multiple) are localized on the body.

The onset of the disease is facilitated, as a rule, by the continuous exposure to carcinogenic substances on the patient's exposed skin, as well as the use of certain substances in food.

Factors provoking the development of basal cell carcinoma:

• ultraviolet radiation;
• ionizing radiation;
• exposure to carcinogenic substances (arsenic, tar, soot, etc.);
• genetic predisposition.

So, for example, constant exposure to ultraviolet radiation on the skin leads to the formation of the so-called dimeric thymine - a special form of damage in the structure of the DNA molecule. These damages activate mutagenic processes in the cell and provoke tumor development.

Basalioma description

Forecast

The prognosis for timely and qualified treatment of basal cell carcinoma is favorable in 99% of cases. Due to the fact that the tumor is not prone to metastasis, healing occurs within a few weeks after the operation.

Difficulties in treatment, as well as a significant deterioration in the prognosis for cure, appear at the advanced stages of the development of the disease, when areas of muscle and bone tissue were already involved in the lesion. However, even in this case, a fatal outcome is very rare, as modern methods of treating basal cell skin cancer are quite effective at any stage of the disease.

Removal of neoplasms in Lasmed Clinic

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