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Definitions

Tumour

All lumps on the body are called tumours. A tumour is a Latin word meaning swelling. In medical terms it is commonly used to mean a neoplastic growth.

Malignant

A malignant tumour is a neoplasm. The word malignant is derived from the Latin word malignus which means evil disposed and is the opposite of benign.

Benign

A benign tumour behaves well and does not pose a serious danger to the patient and can usually be easily removed from the surrounding normal tissue. An example is a benigh skin mole or naevus. The word benign is derived from the Latin word benigenus meaning "a good good kind" (bene = well, genus = born of, kind).

Neoplasm

This is from the Greek words neo, meaning "new" and plasma, meaning, "formation". A neoplasm is an abnormal growth of cells arising from malfunctions in the regulatory mechanisms that oversee the cells' growth and development.

Cancer

The Latin word cancer means crab. Hippocrates the ancient Greek physician recognized the difference between benign and malignant tumours. The invasion seen in malignant tumours reminded him of crab claws.

Carcinoma

The word carcinoma means a malignant tumour that starts in epithelial tissue. The skin has an epidermis which is epithelial tissue. The Greek word karkinos means crab, and survives in the English language as carcinoma - different spelling but same sound whne spoken aloud.

Gorlin's Syndrome or Basal Cell Nevus Syndrome

This condition is autosomal dominantly inherited. The major feature is development of premature (at a young age) or multiple basal cell carcinomas particularly on the sun-exposed areas of the head and neck. These patients also get odontogenic keratocysts of the jaw, dyskeratotic pitting of the palms and soles, intracranial calcification (especially of the falx cerebri) and various craniofacial abnormalities. The latter include macrocephaly, frontoparietal bossing, a high arched palate, and a broad nasal bridge. There is a predisposition to tumours, particularly ovarian fibromas and medulloblastomas.

In view of the number of basal cell carcinomas these patients pose a clinical challenge. Although surgery is the mainstay of treatment, some of these patients develop advanced disease with extensive local invasion and loss of eyelid and ocular function after many years.

Excision

The lesion is cut out and the skin stitched up

Biopsy

The word biopsy is derived from the Greek words bio meaning life and opsis meaning vision. It literally means seeing the live tissue. It is the process of surgically removing tissue from living patients for diagnostic histopathologic examination. Biopsy can be done by the oculoplastic surgeon under local anaesthesia in an office setting or minor operating theatre as a day case procedure.

Incisional biopsy

An incisional biopsy is when a small fragment of tissue is taken surgically for histopathological analysis. It does not aim to remove the entire tumour, only to get enough tissue with which to make a diagnosis and then plan further treatment.

Excisional biopsy

An excisional biopsy is when the entire tumour is removed surgically for hisptopathological analysis. The aim is to ensure that no tumour is left behind, so usually includes a planned frill or margin excision of tissue which is clear of tumour. It is therefore larger than an incisonal biopsy and is both diagnostic and treatment.

Pathologist

Pathology is a word derived from the Greek pathos, meaning suffering and logos meaning discourse or study. It is the science or study of disease. A pathologist studies the cause or nature of the diseases and identifies the changes diseases create in our body. In a hospital practically all the diagnostic tests performed with material removed from the body are evaluated or performed by pathologist.

Histopathologist

This physician is a specialist pathologist who examines tissue samples microscopically in order to make diagnosis and ensure tumour excision is complete.

Shave, curettage and cautery

Many tiny basal cell carcinomas can be successfully removed by surgically removing just the top layers of the skin and the wound usually heals rapidly without needing stitches. But, curettage and cautery is not recommended for the management of basal cell carcinomas at high risk sites, for instance the central face, peri-ocular area and eyelids, nor for recurrent, large, morphoeic tumours.

Freezing (cryotherapy)

Dermatologists sometimes use liquid nitrogen as a special surgical technique to remove small basal cell carcinomas. N.B. Both cryosurgery and curettage and cautery can result in wounds that take longer to heal than excision wounds. There is a risk of recurrence as there is not tissue evidence that the entire tumour has been removed. In cryosurgery no tissue is available for histological examination

Dermatological surgeon

A skin physician who has trained especially as a specialist in skin tumour surgery. They remove tumour tissue for diagnosis and for treatment. They can repair many tissue defects created by removing the tumour.

Flap

A flap is the movement of adjacent skin and subcutaneous tissue from one location to another with a direct blood supply. eg skin graft

Graft

A graft is movement of tissue, usually from a distant site, without an intact blood supply

Radiotharapy

Radiotherapy can be used for some BCCs usually on the forehead or temporal regions in elderly elderly patients where surgical excision biopsy option is not taken. It is important to biopsy the tissue first to confirm the diagnosis. Sometimes basal cell carcinomas on the lower eyelid are treated with radiotherapy.

Photodynamic therapy

Topical photodynamic treatment is used only for very thin superficial basal cell carcinomas. It heals well and is good cosmetically. Photodynamic therapy technique uses -aminolaevulinic acid made up as a 20% emulsion and applied topically to the tumour. Tumour tissue absorbs this porphyrin metabolite and becomes photosensitive with its conversion to protoporphyrin IX which is then photodestructed when exposed to light in the wavelength range 620-670 nm. The disadvantage is that clearance rate for superficial basal cell carcinoma is less than 90% (not even as good as cryotherapy) and very low, just over 50% for nodular basal cell carcinoma. This difference may be related to tumour thickness affecting uptake of photosensitiser and penetration of the light source.

It is not currently recommended for basal cell carcinomas of the central face, peri-ocular area and eyelids. It is potentially useful in patients with Gorlin’s syndrome and frequent small basal cell carcinomas.

Fluorouracil

Fluorouracil is the active ingredient in EFUDEX®, and is used to treat superficial basal cell carcinoma (less 2mm thick) and actinic keratoses. It is an antimetabolite which interferes with a cell's ability to reproduce. Unhealthy cells absorb the fluorouracil in EFUDEX® faster than healthy, normal cells, and then die.