Management of 2cm Basal Cell Carcinoma on the Cheek

Introduction to High-Risk Lesions

The National Comprehensive Cancer Network (NCCN) guidelines state that any BCC in the H-zone (central face, including cheeks) constitutes high risk independent of size 1
Low-risk primary BCC is defined as well-defined lesions <2cm, making this 2cm lesion at the upper boundary or potentially beyond low-risk classification 2

The American Academy of Dermatology recommends Mohs micrographic surgery (MMS) for high-risk BCCs, as it achieves superior cure rates with 5-year recurrence rates of 1% for primary BCC 1, 3
MMS provides complete margin control through en face horizontal sectioning, allowing examination of 100% of peripheral and deep margins, critical for facial locations where subclinical extension is unpredictable 3
MMS maximizes tissue preservation, essential on the cheek where cosmetic and functional outcomes matter 3, 4

For high-risk tumors where MMS is unavailable, standard excision with wider margins (5-10mm) is suggested, though even these may be insufficient without complete margin control 4, 5
Standard excision must include complete histologic margin assessment with verification of negative margins before closure 1, 3

The American Academy of Dermatology guidelines explicitly state that 4mm margins are for low-risk primary BCC only, and this lesion does not meet low-risk criteria due to its facial location and 2cm size 1, 2
Positive margins carry a 26.8% recurrence risk, versus 5.9% with negative margins 1, 3
Facial BCCs have higher recurrence rates, with 12.2% recurrence at 10 years, and 56% of recurrences identified beyond 5 years 1

Do not treat facial BCCs as low-risk, as location automatically elevates risk regardless of clinical appearance 1, 2
Do not use curettage and electrodesiccation for facial lesions, as they show 47% residual tumor rates and 19-27% recurrence 2, 4
Do not assume well-defined borders mean limited subclinical extension, as BCCs characteristically show asymmetrical subclinical extension beyond visible margins 1, 3