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Basal Cell Carcinoma | Nasal Tumours | Nose | Otorhinolaryngology (Ear Nose Throat / E.N.T) | 4th Year (Fourth Year) | MBBS | Detailed Free Notes

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1. EXAM-READY DEFINITION

  • Basal cell carcinoma (BCC) of the nose is a malignant epithelial tumour arising from basal cells of the epidermis or hair follicle units, characterized by slow growth, local tissue destruction, and extremely rare metastasis.

  • It is the most common malignant tumour of the external nose and the most common skin cancer worldwide.

One-Line University Answer

Basal cell carcinoma is a slow-growing malignant tumour of basal epidermal cells with local invasiveness and rare metastasis.

2. WHY BASAL CELL CARCINOMA IS IMPORTANT IN ENT

  • Nose is the commonest site due to sun exposure

  • Frequently asked in:

    • Short notes

    • Viva

    • OSCE spotters

  • ENT relevance due to:

    • External nose involvement

    • Cosmetic deformity

    • Local destruction of cartilage and bone

  • Often confused with squamous cell carcinoma in exams

3. EPIDEMIOLOGY (VERY HIGH-YIELD)

3.1 INCIDENCE

  • Most common skin malignancy worldwide

  • Accounts for 70–80% of non-melanoma skin cancers

3.2 AGE

  • Common after 40 years

  • Peak incidence: 6th–7th decade

3.3 SEX

  • Slight male predominance

  • Increasing incidence in females due to sun exposure

3.4 GEOGRAPHICAL DISTRIBUTION

  • Higher incidence in:

    • Tropical and subtropical regions

    • Fair-skinned populations

3.5 COMMON SITES ON NOSE (VERY IMPORTANT)

Nasal Subsite Frequency
Nasal ala Most common
Tip of nose Very common
Dorsum Common
Nasolabial fold Common
Columella Rare

Exam Line

The nasal ala is the most common site of basal cell carcinoma of the nose.

4. ETIOLOGY & RISK FACTORS (CORE EXAM CONTENT)

4.1 ULTRAVIOLET (UV) RADIATION — MOST IMPORTANT

  • Chronic sun exposure

  • UV-B causes:

    • DNA damage

    • p53 tumour suppressor gene mutation

4.2 SKIN TYPE

  • Fair skin

  • Light eyes

  • Blonde or red hair

4.3 AGEING

  • Reduced DNA repair mechanisms

4.4 GENETIC FACTORS

  • Basal cell nevus syndrome (Gorlin syndrome)

  • PTCH gene mutation

4.5 OTHER RISK FACTORS

  • Ionizing radiation

  • Chronic arsenic exposure

  • Previous scars or burns

  • Immunosuppression

Exam Line

Chronic sun exposure is the most important etiological factor for basal cell carcinoma.

5. APPLIED ANATOMY OF NOSE (ENT-SPECIFIC, HIGH-YIELD)

5.1 ANATOMICAL FEATURES PREDISPOSING TO BCC

  • Nose is:

    • Prominent

    • Maximally sun-exposed

  • Thin skin over cartilage and bone

  • Poor lymphatic drainage relevance (metastasis rare)

5.2 IMPORTANT STRUCTURES AT RISK

  • Alar cartilage

  • Septal cartilage

  • Nasal bones

  • Upper lateral cartilage

  • Nasolabial fold

Clinical Importance

  • Deep invasion causes:

    • Nasal collapse

    • Cosmetic deformity

    • Functional nasal obstruction

6. PATHOGENESIS (VERY HIGH-YIELD, STEP-WISE)

6.1 INITIATION

  • UV radiation → DNA damage in basal cells

  • Failure of DNA repair

6.2 PROMOTION

  • Mutation in:

    • p53 tumour suppressor gene

    • Hedgehog signaling pathway (PTCH gene)

6.3 TUMOUR BEHAVIOUR

  • Slow-growing

  • Locally invasive

  • Destructive growth pattern

  • Rare lymphatic or hematogenous spread

Exam Line

Basal cell carcinoma spreads by local infiltration rather than metastasis.

7. MORPHOLOGICAL TYPES (VERY HIGH-YIELD)

7.1 CLINICAL MORPHOLOGICAL VARIANTS

A. NODULAR BCC (MOST COMMON)

  • Pearly, translucent nodule

  • Raised rolled edges

  • Central ulceration

  • Surface telangiectasia

Classic Description

“Rodent ulcer”

B. ULCERATIVE BCC

  • Central ulcer with raised margins

  • Slowly enlarges

  • Bleeds easily

C. PIGMENTED BCC

  • Brown or black pigmentation

  • Mimics melanoma

D. MORPHEAFORM (SCLEROSING) BCC

  • Scar-like lesion

  • Ill-defined margins

  • Aggressive local invasion

  • High recurrence rate

7.2 GROSS APPEARANCE (EXAM FAVORITE)

  • Pearly borders

  • Rolled margins

  • Central ulcer

  • Crusting

  • Telangiectasia

8. HISTOPATHOLOGY (EXAM ESSENTIAL)

8.1 MICROSCOPIC FEATURES

  • Nests of basaloid cells

  • Peripheral palisading of nuclei

  • Hyperchromatic nuclei

  • Scant cytoplasm

  • Retraction artifact (clefting)

8.2 STROMAL FEATURES

  • Myxoid stroma

  • Mucin deposition

Exam Line

Peripheral palisading of basaloid cells is characteristic of basal cell carcinoma.

9. GROWTH & SPREAD PATTERN

9.1 LOCAL SPREAD

  • Invades:

    • Cartilage

    • Bone

  • Causes:

    • Nasal deformity

    • Septal perforation (late)

9.2 LYMPH NODE METASTASIS

  • Extremely rare

  • <1%

9.3 DISTANT METASTASIS

  • Exceptionally rare

  • Occurs only in neglected advanced cases

10. EARLY CLINICAL PRESENTATION (INTRODUCTION)

(Detailed clinical features, diagnosis, management, OSCE, MCQs in Part 2 & Part 3)

  • Small painless nasal lesion

  • Slowly enlarging

  • Occasional bleeding

  • Non-healing ulcer

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Year / Professional) Otorhinolaryngology (ENT) Free Material

11. CLINICAL FEATURES (VERY HIGH-YIELD, EXAM CORE)

11.1 GENERAL CHARACTERISTICS

  • Slow-growing lesion

  • Painless in early stages

  • Locally destructive

  • Rarely metastasizes

  • Commonly ignored by patients due to indolent nature

11.2 LOCAL CLINICAL FEATURES OF NASAL BCC

A. EARLY STAGE

  • Small papule or nodule on nose

  • Pearly or translucent appearance

  • Smooth surface

  • Telangiectatic vessels on surface

  • Occasional bleeding on minor trauma

B. INTERMEDIATE STAGE

  • Gradual enlargement

  • Raised rolled margins

  • Central depression or ulcer

  • Crusting

  • Non-healing lesion

Classic Description

“Rodent ulcer of the nose”

C. ADVANCED STAGE

  • Deep ulceration

  • Destruction of:

    • Alar cartilage

    • Nasal septum

    • Nasal bones

  • Nasal deformity

  • Nasal obstruction

  • Secondary infection

  • Foul discharge

11.3 SYMPTOMS REPORTED BY PATIENT

  • Painless nasal lesion

  • Recurrent bleeding

  • Cosmetic disfigurement

  • Nasal blockage (late)

  • Occasionally pain (advanced disease)

11.4 REGIONAL LYMPH NODES

  • Usually not involved

  • Palpable nodes suggest:

    • Secondary infection

    • Alternative diagnosis (e.g., SCC)

Exam Line

Absence of lymph node involvement favors basal cell carcinoma over squamous cell carcinoma.

12. DIFFERENTIAL DIAGNOSIS (VERY IMPORTANT TABLE — EXAM FAVORITE)

Condition Differentiating Feature
Squamous cell carcinoma Rapid growth, pain, nodal spread
Actinic keratosis Premalignant, scaly lesion
Malignant melanoma Pigmented, irregular borders
Lupus vulgaris Apple-jelly nodules
Keratoacanthoma Rapid growth, central keratin plug
Chronic ulcer No rolled edges

Exam Line

Rolled pearly margins favor basal cell carcinoma.

13. INVESTIGATIONS (STEP-WISE, EXAM ORIENTED)

13.1 CLINICAL DIAGNOSIS

  • Often suspected clinically due to classical appearance

  • Must be confirmed histologically

13.2 BIOPSY (CONFIRMATORY)

A. PUNCH BIOPSY

  • Most commonly used

  • Provides tissue diagnosis

B. EXCISION BIOPSY

  • For small lesions

  • Diagnostic and therapeutic

13.3 HISTOPATHOLOGICAL CONFIRMATION

  • Basaloid cells

  • Peripheral palisading

  • Retraction artifact

13.4 IMAGING (SELECTED CASES)

  • CT scan nose and PNS:

    • Suspected bone invasion

    • Large neglected lesions

  • MRI:

    • Soft tissue extension

    • Perineural spread (rare)

14. STAGING OF BASAL CELL CARCINOMA

14.1 TNM STAGING (SIMPLIFIED FOR EXAMS)

  • T1: ≤2 cm, no high-risk features

  • T2: >2 cm or high-risk features

  • T3: Bone invasion

  • T4: Skull base or deep structure involvement

N stage

  • Usually N0

M stage

  • Usually M0

15. PRINCIPLES OF MANAGEMENT (CORE EXAM SECTION)

GOALS

  • Complete tumour removal

  • Preservation of function

  • Cosmetic reconstruction

  • Prevention of recurrence

16. SURGICAL MANAGEMENT (TREATMENT OF CHOICE)

16.1 WIDE LOCAL EXCISION

  • Standard treatment

  • Adequate margin:

    • 3–5 mm for low-risk lesions

  • Margin clearance essential

16.2 MOHS MICROGRAPHIC SURGERY

  • Indications:

    • Recurrent BCC

    • Morpheaform BCC

    • Lesions on nasal ala, tip

  • Advantages:

    • Tissue-sparing

    • Lowest recurrence rate

Exam Line

Mohs surgery offers maximum cure with minimal tissue loss.

17. NON-SURGICAL TREATMENT (SELECTED CASES)

17.1 RADIOTHERAPY

  • Elderly patients

  • Medically unfit for surgery

  • Inoperable lesions

17.2 TOPICAL THERAPY

  • Imiquimod

  • 5-Fluorouracil

  • Only for superficial BCC

17.3 CRYOTHERAPY

  • Small superficial lesions

  • Limited role

18. RECONSTRUCTION AFTER EXCISION (ENT RELEVANCE)

OPTIONS

  • Primary closure

  • Local flaps:

    • Nasolabial flap

    • Forehead flap

  • Skin grafting

Principle

  • Oncological clearance before reconstruction

19. FOLLOW-UP & RECURRENCE

  • Regular follow-up essential

  • Recurrence risk:

    • Higher in morpheaform BCC

    • Inadequate margins

  • Lifelong skin surveillance advised

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Year / Professional) Otorhinolaryngology (ENT) Free Material

20. COMPLICATIONS OF BASAL CELL CARCINOMA OF THE NOSE (EXAM-CRITICAL)

Although basal cell carcinoma is slow growing and rarely metastasizes, neglected or inadequately treated lesions can lead to significant local complications.

20.1 LOCAL DESTRUCTIVE COMPLICATIONS (MOST IMPORTANT)

  • Progressive destruction of:

    • Nasal ala

    • Tip of nose

    • Columella

    • Septal cartilage

    • Nasal bones

  • Collapse of external nose

  • Cosmetic disfigurement

  • Functional nasal obstruction

Exam Line

Basal cell carcinoma is locally destructive despite its low metastatic potential.

20.2 CARTILAGE AND BONE INVASION

  • In advanced lesions:

    • Alar cartilage erosion

    • Septal perforation

    • Nasal bone destruction

  • Leads to:

    • Saddle nose deformity

    • External nasal collapse

20.3 SECONDARY INFECTION

  • Ulcerated lesions may get infected

  • Foul-smelling discharge

  • Pain and inflammation

20.4 PERINEURAL SPREAD (RARE BUT IMPORTANT)

  • Seen especially in:

    • Morpheaform BCC

  • Leads to:

    • Pain

    • Numbness

    • Recurrence after treatment

20.5 METASTASIS (EXTREMELY RARE)

  • Incidence <1%

  • If present, suggests:

    • Very large neglected tumour

    • Aggressive histological subtype

21. PROGNOSIS (VERY HIGH-YIELD)

21.1 OVERALL PROGNOSIS

  • Excellent prognosis with early diagnosis

  • Cure rate >95% with adequate excision

  • Survival rate very high

21.2 FACTORS AFFECTING PROGNOSIS

Favorable Unfavorable
Early detection Delayed presentation
Small lesion Large lesion
Nodular BCC Morpheaform BCC
Adequate margins Incomplete excision

21.3 RECURRENCE

  • Recurrence rate:

    • Low after Mohs surgery

    • Higher after incomplete excision

  • Common sites of recurrence:

    • Nasal ala

    • Nasolabial fold

22. OSCE / PRACTICAL STATIONS (COMPLETE SET)

22.1 SPOTTER STATION

Finding

  • Pearly ulcer with rolled margins on nasal ala

Diagnosis

  • Basal cell carcinoma of nose

22.2 IMAGING / HISTOLOGY STATION

Slide

  • Basaloid cells with peripheral palisading

Diagnosis

  • Basal cell carcinoma

22.3 COUNSELLING STATION

  • Explain:

    • Slow-growing nature

    • Low chance of spread

    • Need for surgical excision

    • Possible reconstruction

22.4 PROCEDURE STATION

  • Describe:

    • Wide local excision

    • Mohs micrographic surgery

    • Reconstruction options

23. LONG & SHORT CASES (UNIVERSITY STYLE)

23.1 LONG CASE

History

  • Elderly male

  • Non-healing ulcer on nose

  • Occasional bleeding

  • Slowly increasing size

Examination

  • Pearly rolled margins

  • Central ulceration

  • No lymphadenopathy

Diagnosis

  • Basal cell carcinoma of nose

Management

  • Biopsy confirmation

  • Wide local excision

  • Reconstruction as required

  • Follow-up

23.2 SHORT NOTES

  • Rodent ulcer

  • Mohs micrographic surgery

  • Morpheaform basal cell carcinoma

  • Risk factors for BCC

24. MCQs (EXAM-ORIENTED)

1. Most common malignant tumour of the external nose is:
A. Squamous cell carcinoma
B. Basal cell carcinoma
C. Malignant melanoma
D. Adenocarcinoma
Correct Answer: B

2. Characteristic histological feature of basal cell carcinoma:
A. Keratin pearls
B. Reed–Sternberg cells
C. Peripheral palisading
D. Signet ring cells
Correct Answer: C

3. Treatment of choice for basal cell carcinoma of nasal ala:
A. Radiotherapy
B. Chemotherapy
C. Wide local excision
D. Antibiotics
Correct Answer: C

25. VIVA QUESTIONS (HIGH-FREQUENCY)

  • Define basal cell carcinoma

  • Why is metastasis rare in BCC?

  • Common site of BCC on nose

  • Difference between BCC and SCC

  • Indications for Mohs surgery

26. EXAMINER TRAPS (VERY IMPORTANT)

  • Assuming BCC metastasizes early (wrong)

  • Missing morpheaform variant

  • Inadequate excision margins

  • Reconstructing before oncologic clearance

  • Confusing pigmented BCC with melanoma

27. PREVENTION (EXAM-RELEVANT)

  • Avoid excessive sun exposure

  • Use sunscreens

  • Protective clothing

  • Early treatment of premalignant lesions

  • Regular dermatological check-ups

28. CLINICAL PEARLS (EXAM GOLD)

  • BCC is the commonest skin cancer

  • Nose is the most common site

  • Rolled pearly margins are diagnostic

  • Metastasis is rare but local destruction is severe

  • Mohs surgery gives best cosmetic and oncological results

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Year / Professional) Otorhinolaryngology (ENT) Free Material

Hunain Zia

Hunain Zia has previously achieved considerable success in the high-school educational stream, gaining a massive 154 Total A Grades and 7 Major Distinctions, a process in which he broke/ set 11 different world records, including the most A grades ever achieved, most subjects ever appeared in, most distinctions, gaining distinctions across two separate boards (Pearson Edexcel and CAIE) within the same year/ ever, and even 19 hours of constant examination. All records stand intact today. Hunain pursued his Honors Accounting Degree from the prestigious Bentley University, and then completed an LLB (in Honors) from University of London. Currently, he manages multiple social and commercial projects, has founded digital streams and works tirelessly in the education sector.

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