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STAGING BASAL CELL CARCINOMA:
A PRACTICAL DESCRIPTION

One of the first steps in determining your treatment plan is establishing the stage of your cancer. Because basal cell carcinoma (BCC) has a low risk of spread but does tend to recur, it has a unique staging system (see SCIENCE SIDEBAR). It is based primarily on risk features and whether the BCC is difficult to treat.

 

Low-risk, Local BCC

Smaller BCC with no high-risk features

 

High-risk, Local BCC

Localized tumors that have one or more high-risk features

 

Advanced BCC

BCC that is localized and difficult to treat or that has spread (metastasized). Approximately 1%-10% of BCCs are considered advanced. Locally Advanced BCCs are often:

  • Large in size
  • Invasive
  • Located in difficult-to-treat locations
  • Recurrent and multifocal (exhibiting horizontal spreading) in nature

 

BCCs are likely to be difficult to treat in certain populations as well, such as:

  • People with genetic syndromes
  • The frail elderly
  • Patients with a lot of other health problems
  • Patients with low functional status (aren’t able to care for themselves)

Advanced disease can also be used to describe BCCs that metastasize (spread). This is only a small proportion—an estimated less than 0.55% (or one in 200) BCCs metastasize. For additional discussion, see below.

Science Sidebar

Staging BCC: It's Mostly About Risk

The staging for BCC is less formal than that for other cancer types. In oncology, the most widely used (and recognized) staging system is the American Joint Committee on Cancer (AJCC) system. You may have heard about cancers being staged Stage I, II, III, or IV based on this system, which considers the following factors:

  • Size of the tumor (T) and if it has grown deeper into nearby structures or tissues, such as a bone
  • Presence/degree of spread (metastasis) to nearby lymph nodes (N)
  • Presence of spread (metastasized) to distant parts of the body (M)

Because BCC rarely spreads to other sites, the above classification is not that helpful. BCC is classified into 3 groups based on prognosis (the likely outcome or course of a disease; the chance of recovery or recurrence). Two of these categories are low-risk and high-risk. In this case, the risk is based on the likelihood of the BCC coming back in the same spot (recurring) or continuing to grow and cause additional tissue damage. The third classification is advanced BCC, which is BCC that is difficult to treat or that has spread.

Regional BCC:

Regional disease (N classification) is characterized by cancer that has spread to nearby lymph nodes. As shown in the graphics, lymph nodes are small, seed-shaped structures that contain clusters of immune cells. Their function is to filter the lymphatic fluid, which helps to clear waste material from the tissues and deliver white blood cells to fight infections. Lymph nodes are found throughout the body, notably in the neck, armpit, and groin. Cancer cells often spread from the primary tumor to the nearest lymph node before traveling to other parts of the body.

How is regional disease diagnosed?

If the lymph node feels swollen or if lymph nodes are identified by imaging, then the doctor will take a sample from the lymph node for testing by

  • fine needle aspiration, wherein a hollow thin needle is attached to a syringe to take out fluid/small amounts of tissue to examine
  • core needle biopsy, which uses a larger needle with a larger hollow center (bore). This involves getting a small section of tissue, which will give you more information
Cancer involving the lymph nodes. The diagram shows the primary tumor as well as the affected lymph nodes.
Skin cancer on the scalp that has spread through the lymphatics to a lymph node on the head.
Yellow sunburst shows the site of the primary tumor on the neck and spread to the lung, liver, and bone.

Distant Metastatic BCC

The M (metastasis, distant) classification addresses what other site(s) the cancer has spread to in the body—beyond the closest lymph nodes in a process known as distant metastasis.

How is metastatic BCC diagnosed? Typically, the spread of BCC is determined by imaging studies such as computed tomography (CT) or positron emission tomography/computed tomography (PET-CT). Metastasis is a relatively rare occurrence.

Key terms:

Computed tomography (CT) is a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body. The pictures are taken from different angles and are used to create three-dimensional (3-D) views of tissues and organs. A dye may be injected into a vein or swallowed to help the tissues and organs show up more clearly. A CT scan may be used to help diagnose disease, plan treatment, or find out how well treatment is working. Also called CAT scan, computed tomography scan, computerized axial tomography scan, and computerized tomography.

PET-CT is a procedure that combines the pictures from a positron emission tomography (PET) scan and a computed tomography (CT) scan. The PET and CT scans are done at the same time with the same machine. The combined scans give more detailed pictures of areas inside the body than either scan gives by itself. A PET-CT scan may be used to help diagnose disease such as cancer, plan treatment, or find out how well treatment is working. Also called positron emission tomography-computed tomography scan.

Discussing Your Pathology Report

Here are some questions you can ask your healthcare provider about your pathology report.

Talking With Your Doctor About Your Biopsy Results
Which subtype of BCC do I have?
Can I please have a copy of the pathology report?
What is the next step?
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