A 67-year-old man comes to the office due to a "sore" on the right side of his face. The sore has been growing slowly over the past year, and it bleeds and oozes at times. The patient recently retired from his job as a mail carrier and spent his entire career delivering mail outdoors. He is otherwise healthy and has a 30-pack-year history. Skin examination reveals a 1.5-cm lesion, as shown in the exhibit. Biopsy shows basal cell carcinoma. Which of the following is the best next step in management of this patient?

Question

A 67-year-old man comes to the office due to a "sore" on the right side of his face.  The sore has been growing slowly over the past year, and it bleeds and oozes at times.  The patient recently retired from his job as a mail carrier and spent his entire career delivering mail outdoors.  He is otherwise healthy and has a 30-pack-year history.  Skin examination reveals a 1.5-cm lesion, as shown in the exhibit.  Biopsy shows basal cell carcinoma.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d8b6_5ed0_bc81_c3a6dcc7c61d_MD0003_00 This patient has a large (ie, >1 cm) basal cell carcinoma (BCC) in the periorbital region, a cosmetically sensitive area that has a high risk for cancer recurrence after treatment. The management of BCC is determined largely by the risk of lesion recurrence, which is based primarily on the location and size of the cancer: Low-risk BCC includes most lesions <2 cm in size on the trunk or extremities, excluding the hands and feet. High-risk BCC includes lesions on the face, neck, hands, feet, or genitalia, especially those ≥1 cm; lesions ≥2 cm in any location; and lesions with an aggressive histology or poorly defined borders. First-line treatment for high-risk BCC is Mohs micrographic surgery. This technique is characterized by sequential removal of thin skin layers with intraoperative microscopic margin inspection to ensure complete removal of the cancer. This procedure allows for the highest cure rate and maximal preservation of normal tissue, an ideal choice for treating nonmelanoma skin cancers of the face, where the recurrence risk is high and cosmesis is a concern. (Choice A) BCC can be locally invasive (eg, invade nearby bone, nerves) but rarely metastasizes. A staging CT scan is not typically needed. (Choice B) Curettage and electrodesiccation destroy the cancer mechanically and electrically without histologic margin evaluation but have inferior cosmetic outcomes; this treatment is generally reserved for low-risk tumors in non-cosmetically sensitive areas (eg, trunk, extremities). (Choice D) A standard elliptical excision with 4-mm margins is used primarily to treat low-risk cancers in non-cosmetically sensitive areas. It is typically not recommended for the face because of the technical difficulties associated with certain locations (eg, periorbital/eyelid areas, nasolabial folds) and because it leaves a large scar. (Choice E) Monotherapy with topical 5-fluorouracil is reserved for small (eg, <1 cm), low-risk lesions when surgical removal is not an option. Educational objective: Mohs micrographic surgery is the first-line treatment for nonmelanoma skin cancers that have a high risk for recurrence. It allows for the highest cure rate and maximal preservation of normal tissue, making it an ideal option for facial lesions. References: Guidelines of care for the management of basal cell carcinoma. (http://www.ncbi.nlm.nih.gov/pubmed/29331385)

A 67-Year-Old Man Comes to the Office Due to a "Sore