The correct answer is ED&C (choice “a”); see below for discussion. Imiquimod cream (choice “b”) is indicated in such cases, although it is not without shortcomings as a treatment choice (more information below).
Given the size of the lesion, one could argue that two-stage excision (choice “c”), in which two-thirds of the lesion is removed initially, the wound allowed to heal, then the rest of the lesion removed later, would be a good option. Again, however, it is not perfect.
Mohs surgery (choice “d”) is the only option offered that takes care of the entire lesion in one step, with microscopically controlled margins to ensure complete removal and primary closure all in one session.
There are at least five types of BCC; of these, the superficial BCC is the one that looks the least like a skin cancer. The back is one of the more common areas for a BCC to appear, where it is often mistaken for fungal infection. The latter condition is actually quite uncommon on the back; furthermore, this patient had no particular reason to be exposed to such an organism or to be susceptible to it. Lack of response to treatment for fungal infection was further evidence against such a diagnosis.
Knowing that BCCs can look like this is a priceless piece of information. Corroboration for the diagnosis of this sun-caused skin cancer comes readily from the presence of sun damage elsewhere on the skin. Superficial BCCs are so common that biopsy is often unnecessary, although insurance providers frequently require it before excision can be done.
ED&C, a perfectly acceptable mode of treatment for many minor BCCs, is not a good choice in this area and with a lesion of this size, as it is likely to produce a large, nonhealing, raw wound covered by inappropriate granulation (so-called pyogenic granuloma).
Treatment with imiquimod cream, two to four times a week for at least a month, has the potential to be curative, but involves the creation of a large oozing site while it’s working. Even after several months’ treatment on a lesion of this size, biopsies may still be necessary to check for residual cancer. In selected patients and lesions, cases in which surgery is problematic, imiquimod can be an excellent treatment choice.
Two-stage excision does ensure the complete removal of the lesion but has the obvious disadvantage of taking several weeks and requiring two surgery sessions.
Even if the patient is sent for Mohs surgery, closure will be problematic with a lesion this size and in this keloid-prone area.
But job #1 in such cases is to make a correct diagnosis, then select from among the various treatment choices. Without a biopsy, that diagnosis is uncertain. But without the suspicion of BCC, biopsy may not appear to be indicated.