Punch biopsy shows nodular pigmented basal cell. It looks small but sits on the upper rim/edge of a crater scar from radiation of an "aggressive" basal cell in 2004. This is the 4th basal cell on my nose, in the past 11 years; 1st was nodular on right nasal wall, 2nd was the more aggressive one in 2004, 3rd was nodular on nasal tip in 2009, and now the 4th borders on the former "aggressive" one, though it's "nodular." Should this be treated as a "recurrence?" Please advise on Mohs vs.excision.
Which Surgery for Nodular Basal Cell Lesion on Left Distal Nose (Bordering on the Tip and Just Left of the Mid-line)?
Doctor Answers 3
Mohs vs excision for BCC
Mohs is the preferred method of BCC removal for areas where the most minimal amount of skin should be removed, and the maximum amount of clear tissue preserved. On somewhere like the nose, this is the ideal place for Mohs. An excision wouldn't be able to show clear margins and a larger piece may be taken than necessary, or worse, a smaller piece taken and the margins wouldn't be clear, thus a second procedure would be needed. In your situation, Mohs is needed.
Choice for Treatment of Basal Cell Carcinoma on Nose
Mohs micrographic surgery is the treatment of choice for skin cancers on areas where tissue preservation is paramount and where other treatment options have a higher recurrence rate. This would include the nose, eyelids, lips, ears. Other options that would work but don't have as high of a cure rate include radiation therapy, surgical excision, imiquimod topical therapy, and curettage & electrodesiccation. Other reasons when Mohs might be the preferred option: poorly defined clinical margins; aggressive types of skin cancer (e.g. infiltrative or sclerosing basal cell carcinoma); recurrent skin cancers; tumors with perineural involvement; patients who are immunosuppressed. Talk to your doctor about what is the best choice for you. Good luck.
Indications for Mohs surgery
Mohs surgery is the treatment of choice for skin cancers that develop on sensitive areas of the body. This includes areas including the face, hands, feet and genital area, where preserving cosmetic appearance and function is extremely important. Certainly, your nose would qualify as one of these sensitive areas. Furthermore, the Mohs procedure's ability to spare and presevre healthy tissue while giving exceedingly high cure rates would be other benefits to you.
There are some additional indications for Mohs surgery. If your skin cancer growns in scar tissue or recurs after a previous treatment, such as radiation or another type of therapy, Mohs is typically recommended. If the skin cancer is very large or growing rapidly, Mohs is indicated. Finally, if the edges of your skin cancer cannot be well-defined, Mohs is an effective procedure. If a patient has a suppressed immune system because of medication or other medical condition, Mohs surgery is often also recommended.
Without examining you, it is difficult to tell if your basal cell carcinoma is a recurrence or a new tumor that has developed. Often, basal cell skin cancers can display both nodular and aggressive features. However, the fact that you have had other surgeries in this area and it is close, if not connected to an area that previously had radiation, I would recommend Mohs surgery in your situation.