Risk factors for developing advanced BCC

An assortment of clinical and pathologic features drives the risk of BCC recurrence.

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) identify various features of BCC that correlate with greater likelihood of disease recurrence in patients who initially present with early-stage, localized disease.1

Clinical and pathologic high-risk features for BCC recurrence1

Clinical features  
Location/size  Trunk, extremities ≥ 2cm
Cheeks, forehead, scalp, neck, and pretibia any size
"Mask areas"*, genitalia, hands, and feet
Borders  Poorly defined 
Primary vs recurrent disease  Recurrent 
Site of prior radiotherapy
Pathologic features  
Subtype Aggressive growth pattern
Perineural involvement +


Mask areas of face includes central face, eyelids, eyebrows, periorbital, nose, lips [cutaneous and vermilion], chin, mandible, preauricular and postauricular, skin /sulci, temple, and ear.


This area constitutes high risk based on location, independent of size. Narrow excision margins due to anatomic and functional constraints are associated with increased recurrence rates with standard histologic processing. Complete margin assessment such as with Mohs micrographic surgery is recommended for optimal tumor clearance and maximal tissue conservation. For tumors <6 mm in size, without other high-risk features, other treatment modalities may be considered if at least 4-mm clinically tumor-free margins can be obtained without significant anatomic or functional distortions.

Having (mixed) infiltrative, micronodular, morpheaform, basosquamous, sclerosing, or carcinosarcomatous differentiation features in any portion of the tumor. In some cases basosquamous tumors may be prognostically similar to SCC; clinicopathologic correlation is recommended in these cases.

References: 1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell Skin Cancer V.2.2021. © National Comprehensive Cancer Network, Inc. 2021. All rights reserved. Accessed August 12, 2021. To view the most recent and complete version of the guidelines, go online to NCCN.org. 2. Data on file. Regeneron Pharmaceuticals, Inc.

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