BCC tx decisions complex

Treatment of basal cell cancers depends upon histology of the tumor - whether it's superficial, nodular or infiltrative. A second factor is tumor location, says Marc Brown, M.D., professor of dermatology and oncology, University of Rochester, N.Y.

Cutaneous oncologists consider the mask area of the face a high-risk area, for example. Whether the patient possesses a primary or recurring cancer also drives treatment decisions, as does tumor size. One must also consider factors such as patients' cosmetic concerns and whether patients desire clear margins or will be satisfied with a simpler procedure.

PDT: New treatment option Researchers have begun studying the possibility of using photodynamic therapy (PDT) against BCC. It uses red or blue light energy to selectively destroy target tissue that has been rendered susceptible to injury through the application of topical 5 amino levulinic acid (ALA). One trial comparing PDT with topical methyl aminolevulinate to surgery in nodular BCC found the former method to be effective, with slightly better cosmesis but a trend toward higher recurrence rates (Rhodes et al. Arch Dermatol. 2004 Jan;140(1):17-23).

Mohs surgery "Mohs micrographic surgery offers the highest cure rate - 98 to 99 percent on primary BCCs. The disadvantage is that it takes longer and is a little more expensive than some of the other procedures," Dr. Brown says.

Other advantages of Mohs surgery include tissue and structure sparing, as well as the opportunity for immediate reconstruction of defects. However, the Mohs method typically requires extra fellowship training on the part of the surgeon. As such, it's often best reserved for cases considered high-risk, namely those that display an aggressive histologic growth pattern, measure 6 mm or larger, involve recurrent tumors, or impact areas such as the nose, lips, eyelids or ears (pre- and postauricular).

Curettage Curettage is the most commonly used surgical technique, largely because it's relatively quick, effective and low-risk, though it offers no margin control. One retrospective analysis of 2,314 BCCs treated between 1955 and 1986 with curettage and electrodesiccation found an overall five-year recurrence rate of 13 percent. As one might expect, tumors measuring 0 mm to 5 mm posted the lowest recurrence rate - 8.5 percent; rates for larger tumors ranged from 15 percent to 26 percent (Silverman et al. J Dermatol Surg Oncol. 1991;17:720-726).

Curettage also can be used before Mohs surgery to debulk tumors and delineate margins. A recent study involving 599 patients found curettage added a mean 2.35-mm margin around clinically apparent tumors, and that, without curettage, an extra Mohs stage would have been required in 90 percent of patients (Ratner and Bagiella. Dermatol Surg. 2003 Sep;29(9):899-903).

Cryosurgery "Cryosurgery is used primarily for precancerous lesions," Dr. Brown adds. "But there is some good data out there that shows it's effective for basal cell cancers. If you use cryosurgery for BCCs, it's important to use a cryoprobe to make sure you're getting an adequate depth and temperature (-25 to -50 degrees C) of freeze. It's probably one of the least commonly used methods. The major disadvantage is slow healing - up to six weeks. And there's usually some significant hypopigmentation of the skin after treatment. So patients are not always completely happy with the white scar they can be left with after a cryosurgical procedure."