Treating BCC: Surgical excision trumps curettage plus cryosurgery

April 1, 2008

For the first time, a randomized, controlled trial gives a slight edge to surgical excision for basal cell carcinomas when comparing the procedure to curettage plus cryosurgery.

Key Points

Breda, the Netherlands - Results of a recent study comparing two common therapeutic procedures to treat primary, nonaggressive basal cell carcinoma (BCC) of the head and neck confers a slight advantage to surgical excision (SE) over curettage plus cryosurgery (C&C).

"While our findings were not statistically or significantly different, we found surgical excision to be preferable to curettage-cryosurgery because of the high risk for recurrence with C&C and the superior cosmetic results of SE," lead author Danielle I.M. Kuijpers, M.D., Ph.D., a dermatologist at Amphia Hospital, tells Dermatology Times.

Although the two procedures have long been applied, until now, no evidence was available that had been based on a randomized, controlled trial with long-term follow-up of patients following SE or C&C. This research was undertaken to do that, Dr. Kuijpers says.

The study included 88 patients (50 men, 38 women) with 100 BCCs. The mean age of the patients at the time of treatment - June 1996 to March 1999 - was 67 years. The carcinomas were located mostly on the forehead or temple, the nose or paranasal zone and on the cheeks/chin region. The mean size of the tumors was 5.4 mm.

Ninety-six of the tumors had a histologic nodular subtype and four were superficial.

Dr. Kuijpers offers a precaution for dermatologists: "Always keep in mind that with conventional histopathological examination - the so-called bread loaf technique - only a fraction of the surgical edges are examined, not 100 percent.

"As one-third of all BCC consists of more than one subtype, there always is a risk of missing tumor cells with this conventional exam."

Treatment

In the study group, forty-nine of the BCCs were treated by SE and 51 by cryosurgery. In the excision group, 46 BCCs were completely treated in the first procedure, and three BCCs were excised incompletely. C&C was performed using a double freeze-thaw cycle after prior curettage of the tumor. The SE was performed using a margin of 3 mm with a delay in histologic examination.

Among the tumors treated by cryosurgery, none had clinically residual tumor during the first month, and consequently, these tumors were considered to be treated completely.

Follow-up

The average time of follow-up was 4.29 years. Eighty-five tumors (85 percent) were followed for five years. Thirteen patients with 15 tumors were lost due to death by unrelated cause. The difference in death rates between the two groups was: In the excision group, two tumors (4 percent) were lost to follow-up compared with 13 tumors (25 percent) in the cryosurgery group.

"The difference between the two treatment groups seems to be a coincidence because of the high number of unrelated deaths," Dr. Kuijpers says.

Recurrence

Overall, 13 BCCs recurred - nine after C&C and four after SE. After excluding all patients who were not followed throughout the five-year period, the recurrence rates would be 23.7 percent after C&C (9/38) and 8.5 percent following SE (4/47). The total five-year recurrence probability is 19.6 percent for C&C and 8.4 percent for SE.

In addition, an increased age (age >70 years) and being female seemed to be associated with a somewhat lower risk of recurrence (HR, 0.82; and HR, 0.65, respectively.)

Although previous literature has proven that recurrent BCCs are more difficult to treat, it's actually Mohs surgery that offers the highest accuracy in histopathological examination and the lowest recurrence rates, according to Dr. Kuijpers.