As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education series provides a comprehensive and contemporary review of basal cell carcinoma. The second article in this series will present both the current standard of care and newly developed approaches to diagnosis, treatment, and prevention of this disease.

Basal cell carcinoma: Contemporary approaches to diagnosis, treatment, and prevention.

Background
Basal cell carcinoma (BCC) recurrences, especially in the facial region, represent a complex cosmetic problem To date the possibility of predicting recurrence is supported solely by the histologic subtype

Objective
To evaluate the relationship between BCC histologic subtypes linked to high and low risk of recurrence and the presence of hyperechoic spots on sonography

Methods
Retrospective analysis of the pre-surgical ultrasound examinations of primary BCC tumours with visualization and counting of intra-tumoural hyperechoic spots The data were then correlated with the corresponding histologic subtype

Results
Thirty one patients with histologically proven BCC were included in the study Hyperechoic spots were detected in all cases and there was a positive, statistically significant association between hyperechoic spots count and high recurrence risk histologic subtypes Higher hyperechoic spots count was found in the recurrence-prone micronodular, sclerosing variant and morpheiform BCC subtypes Low risk and high risk of recurrence showed a significant difference on the mean hyperechoic spots count of 55 (range: 3–25) and 8 (4–81) A cut-off point ≥7 hyperechoic spots presented a sensitivity of 79% and specificity of 53% for predicting the high risk of recurrence subtypes

Conclusion
The presence and count of hyperechoic spots within BCC lesions may help predicting the high risk of recurrence histologic subtypes

Ultrasound as predictor of histologic subtypes linked to recurrence in basal cell carcinoma of the skin

Background
Multi-beam optical coherence tomography (OCT) is a novel method of non-invasive skin imaging allowing the evaluation of tissue at high level of lateral and axial resolution. It permits the horizontal and vertical evaluation of the extent of diseases.

Objective
Herein, we aimed to validate diagnosing basal cell carcinoma (BCC) by OCT using a newly developed scoring system (‘Berlin Score’-BS). This was based on the predetermined criteria such as dark border underneath the tumour and ovoid structures. Their frequency and distribution in subtypes of BCC were evaluated.

Methods
The study was conducted in two phases, in which the experience of examiner differed. A total of 127 BCC and 50 other skin diseases were examined. In phase one, students performed the evaluation of skin lesions using the BS, while in phase two an expert performed the scoring in a different subset of patients.

Results
Application of BS by students revealed sensitivity and specificity of 92.8% (95% CI 85.4–96.8) and 24.1% (95% CI 11.0–43.4) when reaching the lower threshold BS≥8. The most common BCC subtypes were superficial (28.7%) and nodular (22.6%) BCC. Second phase was carried out to verify collected data by a dermatological specialist and expert in using OCT. Increased sensitivity and specificity for OCT amounted to 96.6% (95% CI 80.4–99.8) and 75.2% (95% CI 52.5–90.9). Thereby 88% of all diagnoses were correctly classified confirmed by histopathology.

Conclusion
Multi-beam optical coherence tomography revealed to be a fast and promising device for assessing lesions by means of BS. Both students, who benefit from practice in handling OCT, and experts are able to perform this procedure. However, experience and training in the interpretation markedly increased sensitivity and specificity of the BS in our study. Moreover, redefinition and refining of the criteria seems necessary and may further increase the diagnostic value of OCT for NMSC.

Assessment of a scoring system for Basal Cell Carcinoma with multi-beam optical coherence tomography.

Basal cell carcinoma (BCC) is the world’s leading skin cancer in terms of frequency at the moment and its incidence continues to rise each year, leading to profound negative psychosocial and economic consequences. UV exposure is the most important environmental factor in the development of BCC in genetically predisposed individuals, this being reflected by the anatomical distribution of lesions mainly on sun-exposed skin areas. Early diagnosis and prompt management are of crucial importance in order to prevent local tissue destruction and subsequent disfigurement. Although various noninvasive or minimal invasive techniques have demonstrated their utility in increasing diagnostic accuracy of BCC and progress has been made in its treatment options, recurrent, aggressive, and metastatic variants of BCC still pose significant challenge for the healthcare system. Analysis of gene expression and proteomic profiling of tumor cells and of tumoral microenvironment in various tissues strongly suggests that certain molecules involved in skin cancer pathogenic pathways might represent novel predictive and prognostic biomarkers in BCC.

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Gene Expression and Proteome Analysis as Sources of Biomarkers in Basal Cell Carcinoma.

Mitochondrial D310 D-Loop instability and histological subtypes in radiation-induced cutaneous basal cell carcinomas

Background Basal cell carcinoma (BCC) of the skin is now the most common malignancy in the human population. One of the most negative features of this disease is frequent tumor recurrence. Unfortunately, all of the traditional diagnostic criteria have failed to definitively predict which patients should be considered at high risk of recurrence. Objective The aim of this study was to evaluate the prevalence, topographical localization, and histomorphological features of recurrent BCCs. Methods Biopsy samples and clinical data from 30 consecutive patients (15 women and 15 men) with 31 recurrent BCCs diagnosed from January 2007 to September 2010 were analyzed retrospectively. The mean age of the individuals at the time of diagnosis of recurrence was 68.2 years (range 32 to 97 years). Histological types and other pathological findings of original and relapsing BCCs, as well as the time between them, were able to be compared in 24 cases. Results Recurrent carcinomas represented 4.9% of all diagnosed cases during the observed period. Recurrence time varied from 4 to 105 months with a mean time of 31.2 months. The majority of recurrences occurred within 3 years after the primary treatment. The topographic localization of tumors was as follows: auricles (n = 5), cheeks (n = 4), medial canthus (n = 4), periauricular regions (n = 3), temporal areas (n = 3), paranasal regions (n = 3), nose (n = 3), forehead (n = 1), lower eyelid (n = 1), mandible (n = 1), chin (n = 1), neck (n = 1), and back (n = 1). Histologically, 50% of primary and 54.8% of recurrent BCCs demonstrated at least partial aggressive-growth features. Comparing primary and corresponding relapsing BCCs, 50% of them showed an identical type, in 16.7% the recurrent tumor had developed a more aggressive histological picture, and in 20.8% the histomorphology had became more benign. Of all primary tumors previously removed by total extirpation, 54.5% were resected completely and 45.5% incompletely. Conclusions BCC recurrences may vary considerably with respect to various tumor- and host- -related factors, and so it is impossible to predict them precisely. Although aggressive histological types and positive excision margins are considered the strongest predictors, we demonstrated that half of the primary cancers had shown an indolent character, and that more than half of them had appeared to be completely resected. We can conclude that all patients that have had BCCs removed should be re-examined regularly even after microscopically adequate excisions, or lesions with an indolent histomorphology. Careful monitoring must be undertaken for at least 3 years; however, the most appropriate course is a lifetime of regular follow-up.

Recurrent basal cell carcinoma: a clinicopathological study and evaluation of histomorphological findings in primary and recurrent lesions.

Basal cell carcinoma (BCC) is recently the most common cancer in humans characterized by several histopathological subtypes. Fibroepithelioma of Pinkus (FEP) is traditionally classified as a very rare variant of BCC, however, it manifests clinical and morphological differences that distinguish it from most other types BCCs. This study was performed to evaluate the incidence of FEP and clinical-pathological characteristics of patients diagnosed with this tumor. Four cases of primary FEP (3 females, 1 male, mean age 53.4 y) were analyzed retrospectively. The prevalence of FEP was 0.7 % of all diagnosed BCCs. Topographically, tumors were localized on the right brachium, right gluteal region, left mesogastrium, and right side of the abdomen. Histological examination showed typical anastomosing cords of basaloid cells extending from the overlying epidermis into the loose fibrous stroma in the dermis. Mitotic activity or significant cellular atypia, as well as sign of solar dermatosis were absent. Mean horizontal and vertical diameter of the lesions were 7.7 and 2.8 mm, retrospectively. We did not observe infiltration of deeper skin structures. All lesions were removed completely and classified as pathological stage pT1. Three cases manifested typical picture of a "pure" FEP, one lesion had partially a feature of nodular type BCC, too. Although FEP is conventionally considered as indolent BCC variant with a favorable clinical outcome, recent evidences also favors its classification as a form of trichoblastoma. This is appropriate example how some types of cutaneous tumors can overlap in terms of dignity and clinical-morphological characteristics. This should be taken into account in differential diagnosis and in predicting of biological behaviour of the individual tumors of the skin (Tab. 2, Fig. 3, Ref. 26).

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Fibroepithelioma of Pinkus.

Basal cell carcinoma (BCC) of the skin is generally characterised by a favourable clinical outcome. The slow and mostly local character of growth helps in its early recognition, thus the vast majority of cases are diagnosed in the early phase of disease. However, in cases of long-term neglect of clinical symptoms, certain cancers may reach huge proportions and may significantly destroy surrounding tissue. BCCs larger than 5 cm are called giant BCCs. The authors of the article present a case report of woman suffering from a giant BCC of the head with a history of 15 years of lasting growth, during which she had refused a medical examination. Finally, she was forced to go into hospital due to episodes of unconsciousness and convulsions. Clinical investigations revealed a huge ulcerating tumour in the fronto-parietal region infiltrating the skull and penetrating into the cranial cavity with compression of the brain. A surgical extirpation of the tumor-affected soft tissue and the calva was performed with plastic reconstruction of dura mater and skin. Microscopic examination of biopsy specimens confirmed a diagnosis of mixed BCC with nodular, infiltrative and metatypical features, which had completely infiltrated calva and dura mater. It was not possible to surgically remove a part of the tumour-affected bones of the left orbita, thus the patient is going to undergo local radiotherapy. This case report emphasizes the fact that BCC, in spite of its usually "benign" biological behaviour, should never be underestimated because it may progress to the advanced stage of the disease, for which treatment is much more difficult with a larger negative impact and a significantly worse prognosis for the patient.

[Giant cutaneous basal cell carcinoma of the head with intracranial propagation--a case report].

Klippelov-Trenaunayov syndrom je zriedkave vrodene vaskularne ochorenie, u ktoreho jednu z hlavných diagnostických cŕt predstavuju od narodenia sa vyskytujuce kapilarne malformacie kože charakteru naevus flammeus. Klinicka symptomatologia choroby vsak býva pomerne variabilna s castými inkompletnými formami, pri ktorých je diagnosticky najdoležitejsou crtou prave jej kožna manifestacia. Okrem kapilarnych anomalii sa možu vyskytovať pocetne hemangiomy, lymfangiomy, angiokeratomy a výnimocne boli opisovane aj zhubne nadory kože. Autori v praci opisuju pripad 12-rocneho chlapca s Klippelovým-Trenaunayovým syndromom so zameranim sa na dermatologicku manifestaciu ochorenia, u ktoreho boli biopticky diagnostikovane benigne cievne nadory kože. V diskusii rozoberaju problematiku histomorfologickeho vysetrenia nadorových a nenadorových vaskularnych kožných lezii v detskom veku, uskalia ich diferencialnej-diagnostiky a vyzdvihuju nutnosť uzkej spoluprace klinika a patologa v diagnostickom procese.

O. Zacharova

Papers

Recurrent basal cell carcinoma: a clinicopathological study and evaluation of histomorphological findings in primary and recurrent lesions.

Fibroepithelioma of Pinkus.

[Giant cutaneous basal cell carcinoma of the head with intracranial propagation--a case report].

Vaskulárne kožné lézie u dieťaťa s Klippelovým-Trénaunayovým syndrómom