BASAL CELL CARCINOMA

Medical Care: In nearly all cases, the recommended treatment modality for Basal Cell Carcinoma is surgery. While newer, nonsurgical therapeutic modalities are future possibilities, currently available medical modalities are considered to be experimental, with cure rates less than that of surgical modalities.

5-fluorouracil applied twice daily for 2-12 weeks of treatment can be effective in treating superficial Basal Cell Carcinoma, with a reported cure rate as high as 93%. The use of 5-fluorouracil for other types of Basal Cell Carcinoma is generally not recommended because it may not penetrate deeply enough into the dermis to eradicate all tumor cells. Irritation and crusting is common and expected, although significant irritation and discomfort are not uncommon.

In a small study by Greenway et al, 1.5 million IU interferon alfa-2b injected intralesionally 3 times per week for 3 weeks resulted in clearing 3 cases of primary nonrecurrent Basal Cell Carcinoma and 5 cases of primary superficial Basal Cell Carcinoma. Because larger studies are needed, most practitioners consider this an experimental therapeutic modality. Acetaminophen can be administered to patients who experience the flulike symptoms associated with this therapy.

Imiquimod cream has been used recently for the treatment of Basal Cell Carcinoma. Small studies have shown cure rates of up to 88% for superficial Basal Cell Carcinoma and nodular BCC. Studies for other histologic types of BCC are currently underway. Imiquimod is only FDA approved for the treatment of superficial Basal Cell Carcinoma. Treatment is usually initiated 3 times per week and advanced as tolerated to once daily and even twice daily if tolerated to maintain mild-to-moderate skin irritation.

Surgical Care: The goal of therapy for patients with BCC is removal of the tumor with the best possible cosmetic result. By far, surgical modalities are the most studied, most effective, and most used treatments for Basal Cell Carcinoma. The effectiveness of surgical modalities depends heavily on the surgeon's skills; considerable differences in cure rates have been observed among surgeons. Modalities used include electrodesiccation and curettage, excisional surgery, Mohs micrographically controlled surgery, and cryosurgery. Ionizing radiation, although a nonsurgical modality, should be considered in select patients and is discussed below.

Selection of the modality depends on whether the tumor is primary or recurrent, as well as on its location, size, and histologic type. The American Academy of Dermatology has published guidelines regarding the treatment of Basal Cell Carcinoma.

*Electrodesiccation and curettage: After adequate anesthesia is administered to the patient, the tumor is scraped using a curette, and then the base and lateral margins are electrodesiccated. This is repeated twice.

Advantages: Electrodesiccation and curettage is a short procedure (5 min) and is effective in treating primary nodular and superficial Basal Cell Carcinoma. Cure rates are as high as 95%.

Disadvantages: The procedure is operator-dependent and often leaves a white atrophic scar. It is less effective on the nose, and the tumor often tracks down pilosebaceous units. This procedure is less effective in treating infiltrating Basal Cell Carcinoma, micronodular Basal Cell Carcinoma, morpheaform (sclerosing) Basal Cell Carcinoma, and recurrent Basal Cell Carcinoma than Mohs micrographic surgery, which is believed to be the treatment of choice in most instances.

*Curettage (without desiccation): After adequate anesthesia is administered to the patient, the tumor is scraped using a curette. This is often repeated twice more.

Advantages: This is a short procedure (5 min) and is effective in treating primary nodular and superficial Basal Cell Carcinoma. Cure rates may be as high as 95%, although it has been studied less than electrodesiccation and curettage. This procedure is believed by some to have a better cosmetic outcome than electrodesiccation and curettage.

Disadvantages: This procedure is not widely accepted and not commonly performed. The procedure is operator-dependent and often leaves a white atrophic scar. It is less effective on the nose, and the tumor often tracks down pilosebaceous units. This procedure is less effective in treating infiltrating Basal Cell Carcinoma, micronodular BCC, morpheaform (sclerosing) Basal Cell Carcinoma, and recurrent Basal Cell Carcinoma than Mohs micrographic surgery, which is believed to be the treatment of choice in most instances.

*Curettage with erbium: YAG laser ablation: After adequate anesthesia is administered to the patient, the tumor is scraped using a curette. The newly formed ulcer is then ablated along with a narrow (1 mm) margin of adjacent epidermis. This is often repeated 2 more times.

Advantages: This is a short procedure (5 min) and is effective in treating primary nodular and superficial Basal Cell Carcinoma. Cure rates may be as high as 95%, although it has been studied less than electrodesiccation and curettage. This procedure is believed by some to have a better cosmetic outcome than electrodesiccation and curettage.

Disadvantages: This procedure is less commonly performed than electrodesiccation and curettage. The procedure is operator-dependent and may leave a white atrophic scar. It is less effective on the nose, and the tumor often tracks down pilosebaceous units. This procedure is less effective in treating infiltrating Basal Cell Carcinoma, micronodular Basal Cell Carcinoma, morpheaform (sclerosing) Basal Cell Carcinoma, and recurrent Basal Cell Carcinoma than Mohs micrographic surgery, which is believed to be the treatment of choice in most instances.

*Surgical excision: After adequate anesthesia is administered to the patient, a No. 15-blade or 10-blade scalpel is used to incise down to the subcutis. To increase the likelihood of complete tumor removal, one must remove a margin of normal-appearing skin in order to remove all clinically invisible tumor extension. The larger the amount of clinically normal-appearing skin removed, the higher the cure rate, although the more extensive removal leaves a larger surgical defect and a poorer cosmetic result in most patients. In most circumstances, a 3- to 4-mm margin of normal, clinically uninvolved skin is removed.

Advantages: Surgical excision usually produces good-to-excellent cosmetic results and cure rates as high as 95%.

Disadvantages: Surgical excision is operator-dependent, as those more experienced may be better at detecting tumor margins. Excision is less effective in treating tumors without clearly defined clinical margins (eg, infiltrating Basal Cell Carcinoma, micronodular Basal Cell Carcinoma, morpheaform [sclerosing] Basal Cell Carcinoma), and is far less effective in treating recurrent Basal Cell Carcinoma than it is in treating primary Basal Cell Carcinoma.

*Mohs micrographically controlled surgery: After adequate anesthesia is administered to the patient, the clinically apparent tumor is often removed by curettage or excision. The surgeon then removes a thin layer of tissue (called stage I), usually less than 1 mm in thickness, of surrounding epidermis and either dermis or subcutis, which then is examined under the microscope. The tumor is removed and processed to allow for localization of any tumor that might persist. This process allows the surgeon to take additional sections (stages) from the location where the tumor persists.

Advantages: Mohs micrographically controlled surgery has the highest cure rate of any treatment modality (99% for primary BCC, 90-95% for recurrent Basal Cell Carcinoma), spares as much uninvolved skin as possible, and is the treatment of choice for infiltrating Basal Cell Carcinoma, micronodular Basal Cell Carcinoma, morpheaform (sclerosing) Basal Cell Carcinoma, and recurrent Basal Cell Carcinoma.

Disadvantages: Mohs micrographic surgery is time consuming, and patients might require additional anesthesia before each stage.

*Cryosurgery: Liquid nitrogen is applied to the clinically apparent tumor. A temperature probe is inserted into the skin at a lateral margin. Treatment stops when the temperature at the lateral margins reaches -60°C.

Advantages: Cryosurgery has good cosmetic results and good cure rates when treating tumors with well-defined clinical margins (eg, nodular Basal Cell Carcinoma). The procedure is a good option for patients who are not surgical candidates.

Disadvantages: Cryosurgery is operator-dependent, as accurate clinical detection of tumor margins increases the effectiveness of treatment. Ionizing radiation: Superficial x-ray is usually administered as 10 treatments of 4 gray (Gy) (400 rad). Electrons (electron beam) can be used and has gained favor over superficial x-rays by many radiation oncologists.

Advantages: Ionizing radiation is a good treatment option for patients who are not surgical candidates, especially those patients who have facial tumors.

Disadvantages: Radiation therapy requires multiple visits. Treatment results in radiation damage and, therefore, should be reserved for older patients. Radiation therapy is less effective for nonfacial tumors. Activity: Instruct patients to avoid sun exposure and other possible predisposing factors (eg, ionizing radiation, arsenic ingestion, tanning beds).