About one year ago, this 48-year-old woman noted the appearance of a tiny papule on her left maxilla. It has grown in the interim, becoming of considerable concern to the patient and her husband.

They live in the same high desert country where they both were born and raised. As a result, they have been extensively exposed to a great deal of sunlight, and that exposure has been poorly tolerated in both of them. Several family members have been diagnosed with skin cancer, a fact that finally prompts the patient to have this lesion evaluated. She presents to her primary care provider, who in turn refers her to dermatology.

The patient is otherwise fairly healthy. However, she is overweight and has hypertension, which is controlled with medication.

On examination, the patient’s red hair, blue eyes, and fair skin are noted, along with signs of past sun damage, including solar lentigines and telangiectasias. The lesion in question is a fairly impressive planar 7.5-mm glassy, telangiectatic nodule with a central area of erosion. It is located on the lower left maxilla, about 3 mm above the vermillion border. The lesion is not tender to palpation but is quite firm. Systematic evaluation of the rest of the patient’s face, ears, and neck reveals no other suspicious findings.

Shave biopsy is performed, with the results verifying the suspected diagnosis of basal cell carcinoma. The patient is then presented with treatment options—at which point she expresses great concern over the cosmetic outcome of the lesion’s removal and her desire to be rid of all the cancer.

ANSWER
The one inappropriate choice—and therefore, the correct answer—is ED&C (choice “a”). Of all the choices, this option has the greatest potential for an unacceptable scar and for a recurrence of the cancer. All the other choices are entirely appropriate.

DISCUSSION
Had this been a far older patient with little concern about appearance, ED&C would have been a perfectly acceptable choice. But this patient made her expectations clear enough, effectively ruling out such an approach. A plastic surgeon (choice “b”) could be expected to not only obtain adequate margins around this cancer, but to be able to close the defect with an acceptable cosmetic outcome. Mohs surgeons (choice “d”) have the unique ability to examine the excised tissue margins at the surgical bedside, closing only when those margins are determined microscopically to be clear. They also have the ability to close larger defects in difficult areas such as this, obtaining an acceptable final result.

Had the patient or situation contraindicated surgery, at least two options would remain. The first is imiquimod (choice “c”) cream, which has a proven ability to destroy basal cell carcinomas (when applied several times a week over a period of six weeks to three months). Uncertain results can, and often do, necessitate a biopsy to confirm total destruction, and the patient has to endure weeks of redness and irritation at the site during treatment.

The other option is radiation therapy (choice “e”), an extremely effective nonsurgical alternative. However, it requires multiple treatment sessions over several weeks and can damage surrounding skin.