A 62-year-old woman comes to the office due to a skin lesion. For the last 6 weeks, she has noticed a slowly enlarging nodule on the back of the neck; it is not associated with pain, itching, or discharge. Medical history is unremarkable. The patient has worked for the last 30 years as a landscape designer. Examination reveals a 7-mm lesion, as shown in the exhibit. Which of the following is the most appropriate next step in management of this patient's lesion?
Basal cell carcinoma | |
Risk factors |
|
Clinical |
|
Diagnosis |
|
Treatment |
|
C&E = curettage & electrodesiccation. | |
This patient has an enlarging, pearly nodule with telangiectatic vessels on sun-exposed skin, concerning for basal cell carcinoma (BCC). BCC is the most common skin cancer in the United States, with the nodular type accounting for 80% of cases. Risk factors include fair skin and a history of heavy sun exposure.
Generally, when BCC is suspected a biopsy (eg, punch, shave, excisional) is done initially to confirm the diagnosis and assess for high-risk histologic features. In an excisional biopsy, the entirety of the visible lesion is removed, usually without excising a margin of surrounding skin. If the biopsy confirms BCC, additional excision with 4-mm margins is done with the goal of completely removing cancerous tissue, including microscopic tumor extensions surrounding the visible lesion. Excision with 4-mm margins is associated with a low risk of recurrence and is a common definitive treatment strategy for BCC.
(Choice B) In contrast to an excisional biopsy, an incisional biopsy removes only a portion of a lesion. It is typically used for large lesions for which excision is impractical. Due to its size, this patient's lesion is easily excised, and sampling only a portion of the lesion might miss areas with more aggressive tumor histology.
(Choice C) An enlarging lesion suspicious for skin cancer should always be biopsied for definitive diagnosis. Reassurance and follow-up can delay diagnosis and treatment.
(Choice D) Sentinel lymph node biopsy is used to detect subclinical nodal metastasis in invasive melanoma. However, BCC has very low metastatic potential, and the procedure typically is not done.
(Choice E) Surgical excision with 0.5- to 1-cm margins is indicated to remove melanoma in situ. Although amelanotic melanoma can present as a pink nodule, a biopsy to diagnose the lesion should be the initial step.
Educational objective:
Nodular basal cell carcinoma typically presents as an enlarging, pearly nodule with telangiectatic vessels on sun-exposed areas. A biopsy (eg, shave, punch, excisional) is obtained first to confirm the diagnosis and assess for high-risk histologic features.