Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 53-year-old woman is evaluated for a slowly enlarging, telangiectatic, pearly, ulcerated 1-cm plaque on the left temple. It bleeds periodically when traumatized. Medical history is significant for atrial fibrillation. She takes warfarin daily. She is otherwise in good health.

On physical examination, vital signs are normal. Cardiac examination shows an irregular heart rate but is otherwise normal. The remainder of the examination is unremarkable.

Biopsy of the lesion reveals a basal cell carcinoma with micronodular and infiltrative features.

Which of the following is the most appropriate treatment for this lesion?

A: Cryotherapy
B: Electrodesiccation and curettage
C: Mohs micrographic surgery
D: Radiation therapy
E: Topical imiquimod

MKSAP Answer and Critique

The correct answer is C: Mohs micrographic surgery.

Mohs micrographic surgery is the most appropriate treatment for this patient’s basal cell carcinoma (BCC). Many modalities are available for the treatment of BCCs. Selection of the most appropriate technique depends on a number of factors, including the size of the lesion, the location, the patient’s age and comorbidities, the histologic subtype of the tumor, and the cost of the procedure. Although standard surgical therapy is appropriate treatment with high cure rates (>95%) for tumors and a low risk of recurrence, micrographic surgery (Mohs) is preferred for tumors with high-risk pathology (micronodular, infiltrative, or sclerosing) or lesions in sites where a cosmetic outcome is important. For this patient, the size of the lesion and location on the temple indicate that a tissue-sparing procedure would be desirable because of cosmetic considerations. The histologic subtype indicates that this lesion has a relatively high risk of recurrence, and given the patient’s age, she will presumably live long enough for recurrence to be likely. Mohs micrographic surgery offers a very high cure rate (>98%) coupled with the likelihood of a good cosmetic result. It is also a cost-effective choice in this setting. The fact that the patient is on anticoagulation therapy is not a contraindication to surgery.

Cryotherapy may be used to treat superficial BCCs and some nodular BCCs, but it is not generally used for other histologic subtypes because of an unacceptably high risk of recurrence. It also has an unpredictable cosmetic result and is not generally used for tumors on the head and neck.

Electrodesiccation and curettage is a reasonable treatment for nodular and superficial BCCs that occur on the trunk and extremities. It is not appropriate for more infiltrative subtypes since the recurrence rate is quite high. It is rarely used for tumors on the face because of a relatively high recurrence rate and an unpredictable cosmetic result.

Radiation therapy is a reasonable choice for BCCs in patients who are either not surgical candidates or who refuse surgery. It carries the risk of chronic radiation skin changes in subsequent years, and given the patient’s age, this makes it a less desirable option. Radiation therapy is also less cost-effective and less convenient for the patient, since it requires multiple treatments over the course of several weeks.

Topical imiquimod treatment is often used for superficial BCCs and sometimes used off-label for nodular BCCs, but it is generally not used for other subtypes of BCC because of an unacceptably high risk of recurrence. This is particularly true for lesions on the head and neck.

Key Point

• For basal cell carcinoma, Mohs micrographic surgery offers a very high cure rate coupled with good cosmetic results.

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