July 23, 2010
Dear Mayo Clinic:
I have had Mohs surgery three times in the past 18 months to remove a basal cell carcinoma on my nose. Is there some other treatment that I should be pursuing? Is it common to have so many recurrences in such a short amount of time?
Our noses are the No. 1 spot for skin cancer. So it's not surprising that basal cell carcinoma appeared on your nose.
Basal cell carcinoma is the most common skin cancer, the most easily treated and the least likely to spread. Previously thought to be a condition that affected mostly the elderly, it's increasingly common in patients in their 20s and 30s.
Getting more than one basal cell carcinoma is common. Patients with a previous diagnosis of skin cancer are 40 percent more likely to be diagnosed with new skin cancer, compared to those who have never had skin cancer. However, three times in 18 months in one location is unusual. A basal cell carcinoma recurrence after Mohs surgery is uncommon.
Mohs surgery, a very precise surgical technique, is the preferred treatment for basal cell carcinoma, especially when it occurs on the face. The tumor is excised layer by layer, with the surgeon taking time during the procedure to look at the excised cells under a microscope. Usually only one or two layers need to be removed for each Mohs procedure.For more complex tumors, many more stages of excision may be needed. The check-and-continue process allows the surgeon to remove all of the tumor while sparing surrounding healthy tissue. Typically the surgery takes about four hours.
Mohs is very effective when done by a physician trained in this approach. The five-year cure rate is 99 percent. Given the success rate of these procedures, your situation is very rare, but possible explanations include:
Compromised immune system: Basal cell carcinoma is more likely to recur in immunosuppressed patients, such as those with AIDS or patients who have undergone organ transplants. If this is your situation, the recurrence is less surprising.
Family history: Occurrence and recurrence of basal cell carcinoma is more likely when a family member also has had this cancer.
An overlooked tumor: It's possible that the second and third cancers weren't obvious at the time of the previous surgeries. Basal cell carcinoma has several different looks. It can appear as a translucent nodule; a scaly, red patch similar to psoriasis or eczema; or less often, as a white, waxy scar.
A different skin cancer: Other skin cancers, such as melanoma, are more likely to skip cell layers and spread. A biopsy would confirm the specific cancer type.
Missed cancer cells: It could be that the surgeon didn't get all the cancer cells during the Mohs procedure, and the tumor kept growing.
Other treatment options for basal cell carcinoma include creams, radiation and laser therapy. While these options may be appropriate in some situations, they usually aren't as effective as Mohs surgery.
For peace of mind, I'd suggest that you consult with another dermatologist trained in the Mohs procedure, which, by the way, was named after Frederic Mohs, M.D. He developed the technique while he was a medical student at the University of Wisconsin in the 1930s.
Ask the doctor about his/her specific training and experience in the Mohs procedure. Learning this approach requires a yearlong fellowship in procedural dermatology that is accredited by the ACGME (Accreditation Council for Graduate Medical Education). Continue to see a doctor for regular skin checks to catch any new or recurring skin cancer as early as possible. After treatment for basal cell carcinoma, patients should be rechecked every three to six months for two years and annually thereafter.
— Randall K. Roenigk, M.D., Dermatology, Mayo Clinic, Rochester, Minn.
Hello Shawn and Dr. Roenigk,
I also have a BCC that has recurred in less than a few months. I am 33 and had a small ~5-7mm BCC removed from the side of my nose a little over 4 months ago by MMS. The margin was clear after 2 rounds and I didn't get a call back after the final pathology report, but have noticed the same type of lesion growing in the same spot for about a month, already 3-4mm. I have an appointment with my Mohs surgeon in 2 months (and trying to get in earlier).
A couple of questions for Dr. Roenigk:
1. Could the fact that I was pregnant (I gave birth in December, 2 months before the surgery) and therefore sort of immune system compromised, and am now lacking sleep (new baby) contribute to the recurrence?
2. Do we know anything about long term prognosis for metastasis in young people with recurrent BCC? I know the metastatic rates are very low, but BCC grows very slowly and usually BCC occurs in older populations, so I wonder if 30 years from now I may have BCC metastases show up. I found a news article a while back from a researcher who thinks the rates of metastasis for BCC may be higher than previously thought because of this.
3. What questions should I ask my Mohs surgeon (other than the above)?
Any information would be helpful. Although I understand that rBCC is still considered a very manageable disease, as a new mom, and as any patient with a recurring cancer, the recurrence has been a great source of anxiety for me.
As a side note, I'm a research scientist with a PhD in biomedical engineering and I've worked on technologies to image surgical margins for more complete removal of malignant cells (microscopy, optical coherence tomography, near-infrared imaging, spectroscopy).