Effectiveness of curettage and electrodesiccation in the removal of basal cell carcinoma

Nanotechnology-empowered strategies in treatment of skin cancer

In current scenario skin cancer is a serious condition that has a significant impact on world health. Skin cancer is divided into two categories: melanoma skin cancer (MSC) and non-melanoma skin cancer (NMSC). Because of its significant psychosocial effects and need for significant investment in new technology and therapies, skin cancer is an illness of global health relevance. From the patient's perspective chemotherapy considered to be the most acceptable form of treatment. However, significant negatives of chemotherapy such as severe toxicities and drug resistance pose serious challenges to the treatment. The field of nanomedicine holds significant promise for enhancing the specificity of targeting neoplastic cells through the facilitation of targeted drug delivery to tumour cells. The integration of multiple therapeutic modalities to selectively address cancer-promoting or cell-maintaining pathways constitutes a fundamental aspect of cancer treatment. The use of mono-therapy remains prevalent in the treatment of various types of cancer, it is widely acknowledged in the academic community that this conventional approach is generally considered to be less efficacious compared to the combination treatment strategy. The employment of combination therapy in cancer treatment has become increasingly widespread due to its ability to produce synergistic anticancer effects, mitigate toxicity associated with drugs, and inhibit multi-drug resistance by means of diverse mechanisms. Nanotechnology based combination therapy represents a promising avenue for the development of efficacious therapies for skin cancer within the context of this endeavour. The objective of this article is to provide a description of distinct challenges for efficient delivery of drugs via skin. This article also provides a summary of the various nanotechnology based combinatorial therapy available for skin cancer with their recent advances. This review also focuses on current status of clinical trials of such therapies.

Advancements in nanoparticle-based treatment approaches for skin cancer therapy

Skin cancer has emerged as the fifth most commonly reported cancer in the world, causing a burden on global health and the economy. The enormously rising environmental changes, industrialization, and genetic modification have further exacerbated skin cancer statistics. Current treatment modalities such as surgery, radiotherapy, conventional chemotherapy, targeted therapy, and immunotherapy are facing several issues related to cost, toxicity, and bioavailability thereby leading to declined anti-skin cancer therapeutic efficacy and poor patient compliance. In the context of overcoming this limitation, several nanotechnological advancements have been witnessed so far. Among various nanomaterials, nanoparticles have endowed exorbitant advantages by acting as both therapeutic agents and drug carriers for the remarkable treatment of skin cancer. The small size and large surface area to volume ratio of nanoparticles escalate the skin tumor uptake through their leaky vasculature resulting in enhanced therapeutic efficacy. In this context, the present review provides up to date information about different types and pathology of skin cancer, followed by their current treatment modalities and associated drawbacks. Furthermore, it meticulously discusses the role of numerous inorganic, polymer, and lipid-based nanoparticles in skin cancer therapy with subsequent descriptions of their patents and clinical trials.

Controlling depth of electrosurgery after curettage of skin tumors-an in vitro study

BACKGROUND

Depth of tissue injury in electrosurgery depends on generator power, electrode size, speed of electrode movement on tissue, and current delivery method. We sought to evaluate the depth of tissue injury associated with different methods of electrocoagulation in an effort to make electrocoagulation more reproducible.

METHODS

A knife-shaped electrode was used to apply an electrosurgical current to the surface of a piece of bovine liver. Different electrosurgical methods were performed. Cross sections of the liver were then studied for tissue effect.

RESULTS

Fulguration provided only superficial coagulation. Contact electrocoagulation and electrodesiccation using the flat side of the electrode provided significantly deeper levels of coagulation and were associated with less smoke than fulguration. Desiccation provided the deepest tissue effect.

CONCLUSIONS

Electrofulguration can be used for superficial tissue destruction. For deeper coagulation, a relatively larger electrode can be used in contact mode. Slower movement of the electrode on tissue in contact mode is associated with desiccation and the deepest level of tissue destruction.

Review and Update on Evidence-Based Surgical Treatment Recommendations for Nonmelanoma Skin Cancer

Nonmelanoma skin cancer (NMSC) is the most commonly diagnosed malignancy in the United States. Surgery is considered the gold standard treatment. Techniques include curettage and electrodesiccation, surgical excision, and Mohs micrographic surgery. While each is effective, there are relative advantages and disadvantages with respect to cost, time, quality of life, and role in patients with limited life expectancy. Preventing local tumor recurrence is the primary objective; however, recurrence rates are based on retrospective data, and high-quality comparator studies assessing effectiveness are scarce. Prospective and randomized controlled trials are imperative to create comprehensive, evidence-based recommendations for the surgical management of NMSC.

Skin cancers of the hand and upper extremity

Skin cancers represent the most common primary malignancies of the hand. They typically present as painless lesions on areas of high sun exposure, such as the dorsum of the hand and upper extremity. The most common malignancy is squamous cell carcinoma, followed by basal cell carcinoma and melanoma. The key to successful treatment is early and accurate diagnosis and treatment. Unlike open biopsies, which are indicated for deep soft tissue and bone lesions, biopsies for skin cancer can be performed under local anesthesia in the office setting in the form of shave or punch biopsies. A number of nonsurgical treatment options are available for treatment. However, when surgical excision is indicated, appropriate margin resections are dictated by the grade and stage of the malignancy.

Guidelines for the management of basal cell carcinoma

This article represents a planned regular updating of the previous British Association of Dermatologists guidelines for the management of basal cell carcinoma. These guidelines present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

Clinical and histological findings in re-excision of incompletely excised cutaneous squamous cell carcinoma

BACKGROUND

Current guidelines mandate treatment of primary cutaneous squamous cell carcinoma (SCC) through to completion, including the demonstration of a margin of normal tissue, with surgical excision as the treatment of choice. Histologically incomplete excisions of all cutaneous SCC are preferably treated by surgical re-excision. The yield of performing further resection of scar tissue in patients with incompletely excised SCCs has not been previously evaluated.

METHODS

A retrospective audit was conducted of 676 consecutive patients with surgically managed SCCs treated in our unit during 2005-2006.

RESULTS

One hundred and nineteen (17.6%) tumours were incompletely excised, of which 84 underwent further excision. Routine histological examination revealed residual SCC in 24 (28.6%) of these specimens. Logistic regression analysis revealed tumour diameter and Breslow thickness to contribute independently to residual SCC (P<0.001). A lengthier delay between initial excision and re-excision predicted less residual tumour (P<0.005). Although the positive re-excision group tended towards a higher mean age (79+/-9 vs 74+/-12), with more head and neck lesions (79 vs 66%), logistic regression revealed no independent influence of age, gender, histological grade or anatomical site of the original lesion.

CONCLUSION

In our series, 28.6% of incompletely excised primary cutaneous SCCs showed residual tumour in re-excision specimens. Factors associated with residual tumour were similar to characteristics of high risk SCCs; larger lesions in particular are more likely to result in residual SCC at re-excision and may benefit from greater excision margins at the time of original resection. It is possible that regression of remaining tumour cells may contribute to our time-dependent findings and this warrants further research.

Recurrence rates of primary basal cell carcinoma in facial risk areas treated with curettage and electrodesiccation

BACKGROUND

The incidence of basal cell carcinoma (BCC) is increasing. Curettage and electrodesiccation (CE) are not recommended for BCC treatment at medium- and high-risk facial sites. Surgical excision has been proposed as the treatment of choice.

OBJECTIVE

We sought to evaluate the cumulative recurrence rate (RR) of primary BCC in facial areas of medium and high risk after CE.

METHODS

This nonrandomized, clinical trial enrolled 257 patients with primary BCC located in medium- and high-risk facial areas, and treated with 4 or 5 cycles of CE by a single operator from a section specializing in BCC CE in a tertiary teaching hospital in Oviedo, Spain. Exclusion criteria for study entry included: recurrent BCC, fibrosing BCC, ill-defined BCC, and BCC larger than 10 mm in diameter (high-risk facial sites) or larger than 15 mm in diameter (medium-risk sites); BCC smaller than 4 mm; and nonbiopsy-proven BCC. BCCs included in the study were from the nose, and paranasal and nasal-labial fold (n = 105); eyelids and canthi (n = 48); perioral areas (n = 12); ears (n = 11); forehead and temples (n = 48); periauricular areas (n = 14); and malar areas and cheeks (n = 19). The primary outcome was recurrence of carcinoma, which was clinically evaluated by at least two observers in consensus. Data were analyzed using both a life table method and Kaplan-Meier analysis. The statistical analysis included best- and worst-case scenarios (which means that all cases lost to follow-up were considered as recurrences).

RESULTS

The 5-year cumulative non-RR in the best-case scenario was 98.80% (SE 0.70, 95% confidence interval 97.40%-100%); thus, a 5-year cumulative RR of 1.20% was found after CE in our medium- and high-risk BCCs of the face (best case). The 5-year cumulative non-RR in the worst-case scenario was 79.40% (95% confidence interval 78.90%-79.90%); thus, a 5-year cumulative RR of 20.60%.

LIMITATIONS

Retrospective design with a relatively small number of patients lost to follow-up is a study limitation.

CONCLUSION

High 5-year cure rates can be obtained after CE of primary, nonfibrosing BCCs of medium- and high-risk areas of the face performed in a specialized section.

Economic impact of preoperative curettage before Mohs micrographic surgery for basal cell carcinoma

BACKGROUND

The role of curettage before Mohs micrographic surgery for basal cell carcinoma (BCC) remains controversial. Preoperative curettage may allow the surgeon to better delineate the subclinical extensions of high-risk BCCs, thereby enabling a more precise first-stage excision around tumor-containing tissue.

OBJECTIVE

To assess the economic impact of preoperative curettage for high-risk BCCs treated with Mohs micrographic surgery on patients, providers, and insurers.

METHODS

Given the enormous variability in practice styles, it was estimated that the time required to complete a second stage of Mohs surgery was 25, 50, or 75% of that required to complete the first stage. New York City Medicare and Standard reimbursement rates were used to approximate the cost of an additional stage of Mohs surgery for high-risk BCCs.

RESULTS

Assuming that preoperative curettage increases operative efficiency by reducing the number of required Mohs stages from 2 to 1, the time saved can be quantified. Thus, if the Mohs surgeon estimates that the time required to remove a second stage is 75% of that of the first stage, the time savings with preoperative curettage equals 75% of the duration of a one-stage Mohs surgery. Similarly, when a second stage requires 50 or 25% of the time needed to complete the first stage, the time saved equals 50 or 25% of the duration of a one-stage Mohs surgery. Reducing the number of stages from 2 to 1 saves insurers and privately paying patients approximately $250 and $500, respectively.

CONCLUSIONS

Whether preoperative curettage can offer a more precise first-stage excision without compromising tissue conservation remains a subject of debate. Preoperative curettage may reduce the number of Mohs surgical stages required for tumor clearance, potentially shortening patient encounters and allowing surgeons to treat additional patients, while decreasing costs for patients and insurers.

An open-label, pilot study examining the efficacy of curettage followed by imiquimod 5% cream for the treatment of primary nodular basal cell carcinoma

SUMMARY The short-term efficacy of imiquimod 5% cream for the treatment of primary superficial basal cell carcinoma has been established. This study investigated its efficacy following curettage (without electrodesiccation) for the treatment of primary nodular basal cell carcinoma on the trunk and limbs. Seventeen patients with a total of 34 lesions were enrolled. Curettage was used to de-bulk the lesion and confirm suitable histology. Lesions displaying more aggressive subtypes (such as micronodular or morpheoic components) were excluded. Lesions were treated daily for 6 to 10 weeks with imiquimod 5% cream. Three months post treatment all lesions were excised, and 32 of 34 treated lesions (94%) were histologically clear of basal cell carcinoma. Fourteen of 17 patients rated the cosmetic outcome of treatment as excellent or good. Curettage followed by imiquimod 5% cream is effective for the treatment of primary nodular basal cell carcinoma on the trunk and limbs, and most patients are pleased with the cosmetic outcome.

The role of Mohs' micrographic surgery in the management of skin cancer and a perspective on the management of the surgical defect

In the past 30 years, MMS has become recognized as the treatment of choice for certain uncommon cutaneous neoplasms and for certain variants of BCC, squamous cell carcinoma, and melanoma. It offers an extremely high cure rate and maximally preserves healthy tissue, which often allows for preservation of function as well as an optimal cosmetic outcome. Because it is performed in an office setting under local anesthesia, MMS is a very cost-effective procedure and often extends operability to patients who are poor candidates for general anesthesia. In the past 30 years, MMS has evolved in a number of ways. The fixed tissue technique is uncommonly employed today. This makes the procedure less painful and faster and allows for immediate reconstruction. In addition, because statistics have demonstrated the reliability of MMS, it has become less necessary to delay definitive reconstruction or use temporizing measures. With experience and training, more Mohs' surgeons have become adept at repairing the surgical defects they create; nevertheless, at times, it is necessary for the Mohs' surgeon to call on his or her colleagues to reconstruct the Mohs' defect or to assist in ridding patients of their cancer. At times, a multidisciplinary approach may provide the best care for patients. It also encourages collegiality and this has led to increasing respect for MMS by other surgical disciplines in the past 30 years.

Effects of biopsy-induced wound healing on residual basal cell and squamous cell carcinomas: rate of tumor regression in excisional specimens

BACKGROUND

Wound healing following a partial biopsy of basal cell (BCC) and squamous cell carcinomas (SCC) may induce tumor regression.

METHODS

Nonmelanoma skin cancer (NMSC) biopsy and re-excision specimens from 1994 to 2001 were reviewed for histologic evidence of scar vs. presence of residual tumor in excision specimens. Regressed and non-regressed tumors were analyzed to assess the influence of anatomic location, biopsy technique (punch vs. shave), histologic subtype of BCC or SCC, time interval between biopsy and excision, and patient age.

RESULTS

Nine hundred and ten excisions were performed for transected BCC or SCC, 217 (24%) of which showed scar with no residual tumor. Logistic regression analysis revealed significant differences in the regressed vs. non-regressed subsets. SCCs were more likely to regress than BCCs (40% vs. 20%, respectively, p < 0.00001). Independent of the NMSC type, tumors regressed more often following shave rather than punch biopsy (34% vs. 15%, respectively, p < 0.00001), as did tumors on the trunk and extremities compared with head and neck cases (31% vs. 21%, respectively, p < 0.01).

CONCLUSIONS

In our series, 24% of NMSCs transected on the initial biopsy showed no residual tumor in the excision specimens, implying that some event in the interval between biopsy and excision may lead to the eradication of residual tumor. The exact mechanism is unclear, but wound healing likely plays an important role.

The current status of curettage and electrodesiccation

Curettage and electrodesiccation (CE) is a technique widely used in the destruction of benign and selected malignant cutaneous neoplasms. CE is used mainly by dermatologists and family practice physicians, whereas plastic surgeons and other surgeons excise most benign and malignant lesions. The use of CE for the treatment of skin cancer has been widely extolled and also fervently criticized. Some practitioners treat most non-melanoma skin cancers (NMSC) with CE, and others have called for abandoning the technique in the treatment of such lesions. A thorough review of the literature reveals that CE has both virtues and flaws. In taking a rational approach to the treatment of benign and malignant cutaneous lesions it is essential to learn the basis for CE, the likely cure rates for given lesions, the proper technique, and the expected level of cosmesis. As the surgical treatment of skin cancer has become firmly entrenched in the field of dermatology, it is valuable to examine this technique in depth and to come to some thoughtful conclusions about its use for patients with skin cancer and assorted benign skin lesions. Last year a remarkably complete and exhaustive favorable review of curettage, electrosurgery, and skin cancer was published by Sheridan and Dawber. This article is a must read for anyone performing curettage; however, the author is writing with a slightly different perspective, that of a dermatologic surgeon. Although the author believes that CE has value and he uses this technique frequently, he disagrees with some of the truisms expressed in the literature about CE and attempts to define carefully what he believes are the strengths and limitations of this technique.

Ultrapulse CO2 used for the successful treatment of basal cell carcinomas found in patients with basal cell nevus syndrome

BACKGROUND

Basal cell nevus syndrome (BCNS) is an inherited condition marked by multiple basal cell carcinomas (BCCs) associated with several other abnormalities. Various treatment modalities have been used to eradicate these tumors. However, recurrences and scarring limit their use.

OBJECTIVE

To evaluate the treatment of multiple BCCs associated with BCNS.

METHODS

We describe three cases of BCNS in which multiple BCCs were effectively treated with ultrapulse CO2 laser. Postoperative Mohs micrographic surgical sections (thin sections looking for residual tumor) verified complete histologic clearance of the tumors.

RESULTS

All three patients were effectively treated with ultrapulse CO2 laser. Minimal scarring was noted at follow-up.

CONCLUSION

Ultrapulse CO2 laser can be used to effectively treat small BCCs in low-risk areas associated with BCNS with minimal posttreatment scarring.

Techniques in the removal of skin lesions

The skin is one of the most easily accessible organs of the human body. Various skin lesions may be removed safely and easily in the office. This article describes various available methods, with suggestions regarding which method to use under selected circumstances.

Cutaneous malignancies and their management

Skin cancer is the most common malignancy occurring in humans, and the incidence of basal cell carcinoma, squamous cell carcinoma, and melanoma continues to rise. Advances in the diagnosis and treatment of skin cancer have led to more successful management of these tumors. A number of options for the treatment of skin cancer are available to the patient and physician, allowing for high cure rates and excellent functional and cosmetic outcomes.

Curettage, electrosurgery and skin cancer

The scientific literature is replete with reports extolling the virtues of curettage and electrosurgery in the treatment of skin disease. Published cure rates for selected skin cancers consistently equal those for other treatment modalities, including scalpel excision. Despite this, curettage is often overlooked as a first line treatment for skin cancer. We review the evidence-based literature for patient selection criteria and curettage and electrosurgery techniques.

Does wound healing contribute to the eradication of basal cell carcinoma following curettage and electrodessication?

BACKGROUND

Histologic studies indicate that C&D fails to mechanically remove all the tumor in a percentage of cases that far exceeds the 5-year recurrence rate. This raises the question that if C&D does not mechanically remove the tumor in a significant number of patients, why don't we observe tumor recurrence in most of these patients? Our previous study indicates that inflammation occurring over 1 month following C&D does not clear residual tumor. It may be some other process, requiring more time, that clears the residual tumor. Perhaps the proliferative or maturation phase of wound healing or, alternatively, a slow-acting process such as a low-grade immune response set in motion earlier, clears the residual tumor.

OBJECTIVE

To test the hypothesis that wound healing and maturation following C&D clear residual tumor that has not mechanically removed by the procedure.

METHODS

The frequency of residual BCC detected histologically immediately following C&D was compared with the frequency 3 months after the C&D, an amount of time in which the maturation phase of wound healing is well under way.

RESULTS

Twenty-two of 29 primary BCC less than 1 cm in size were tumor-free immediately following the procedure (clearance rate 75.9%). Twelve primary BCC <1 cm were treated by C&D, allowed to heal for 3 months, and then excised and checked histologically. Ten of the twelve BCC were free of tumor, for a clearance rate of 83.3%, which is not a statistically significant difference (p = 0.7187).

CONCLUSION

By 3 months, the proliferative phase of wound healing is complete, and our study indicates that this phase has no effect on clearing the tumor. The maturation phase is well under way three months following C&D, and no statistically significant effect was observed.

Mohs' micrographic surgery for basal cell carcinoma

Mohs' surgery for basal cell carcinoma (BCC) is widely recommended by dermatologists as first line surgical therapy for recurrent or ill-defined skin tumours. The technique assumes that BCC spread by contiguous growth and that all tumour cells have to be removed. Advocates claim that Mohs' surgery provides a better chance of cure, and because less uninvolved tissue is excised the smaller defect can be readily closed resulting in a superior cosmetic result. This review examines the evidence for these claims.

Does inflammation contribute to the eradication of basal cell carcinoma following curettage and electrodesiccation?

BACKGROUND

Curettage and electrodesiccation (C&D) is probably the technique most frequently utilized by dermatologists to treat basal cell carcinomas (BCC). From histologic studies, it appears C&D does not completely mechanically remove all nests of BCC in a substantial number of cases. Nevertheless, the reported 5-year reoccurrence rate following C&D is significantly less than this histologically observed residual tumor frequency immediately following C&D. Among the multiple possibilities that exist to explain why these residual nests do not appear as recurrent tumor more frequently is the theory that inflammation developing after C&D clears residual tumor.

OBJECTIVE

To test the hypothesis that inflammation developing after C&D clears residual tumor not mechanically removed by the procedure.

METHODS

The frequency of residual BCC detected histologically immediately following C&D was compared with the frequency 1 month after the C&D, an amount of time in which an effect (if any) of inflammation could occur.

RESULTS

Twenty-two of 29 primary BCC < 1 cm treated by C&D were tumor free immediately following the procedure (clearance rate, 75.9%). Eleven of 14 primary BCC < 1 cm treated by C&D then allowed to granulate 1 month before excision and histologic analysis were tumor free, for a clearance rate of 78.6%. Examination of larger tumors immediately following C&D revealed size is a significant variable for clearance rates. Eleven primary BCC > 1 cm but < 2 cm were examined histologically immediately following C&D; only three were tumor free for a clearance rate of 27.3%. Only one of five tumors > 2 cm thus treated was tumor free, for a clearance rate of 20%. Nine recurrent BCC of various sizes were treated by C&D and immediately examined histologically. Two were tumor free for a clearance rate of 22.2%. Two recurrent BCC were allowed to heal 1 month following C&D; one of these was tumor free when excised.

CONCLUSION

For primary BCC < 1 cm, no evidence was found that inflammation occurring over 1 month following C&D clears residual tumor. It was also noted that C&D fails to completely remove tumor in a large majority of primary BCC > 1 cm, and in recurrent BCC.

Prognostic value of Ki67 antigen expression in basal cell carcinomas

Recurrence of basal cell carcinoma (BCC) following treatment is a common event and long-term follow-up of all patients presenting with a primary BCC has been recommended. Proliferation indices have been recognized as important prognostic factors in several tumour types in a variety of cancer systems, being significantly elevated in more aggressive lesions. We have examined 51 BCCs (17 non-recurrent tumours [group 1], 17 original tumours which later recurred [group 2-O], and the corresponding 17 recurrent specimens [group 2-R]) for Ki67 antigen expression, a proliferation-associated antigen using immunohistochemistry with the monoclonal antibody MIB1. There was a significant increase in the percentage positive for MIB1 in the Group 2-O as compared with the group 1 BCCs (P < 0.05). p53 protein expression, as assessed by immunohistochemistry with the monoclonal antibody DO7, was similar in each group. These results show that Ki67 antigen expression differs between BCCs which later recur and BCCs that do not recur.

Treatment of basal cell carcinoma by dermatologists in the United Kingdom. British Association of Dermatologists Audit Subcommittee and the British Society for Dermatological Surgery

Details of presentation and treatment were obtained prospectively by questionnaire for 1366 patients with basal cell carcinoma, first attending under the care of 166 consultant dermatologists in the U.K., during a 2-week period. One thousand five hundred and ninety-seven tumours were reported in these patients (median age 71 years). Most were situated on the head and neck, and their median size was 9 mm. Excision was the most common treatment used in 58% of tumours, curettage and cautery was used in 24%, cryotherapy in 8%, and radiotherapy in 8%. On average, one in four tumours were referred to other specialists for treatment (range 0-70%). Very few patients (2%) were referred to a combined dermatology/radiotherapy/plastic surgery clinic, calling into question its value and availability. There was considerable variation in practices between dermatologists, demonstrating a clear need for individual, local audit of the management of this common dermatological problem. The data collected in this study form a suitable measure with which local performance may be compared.

Mohs surgery of basal cell carcinoma--a critical review

Mohs surgery for basal cell carcinoma (BCC) of the skin attempts to ensure complete tumour removal by histological examination of the entire excision margin and further excision of involved sites. Advocates recommend its use in recurrent or incompletely excised tumours, poorly defined, histologically aggressive or large primary tumours and BCCs situated at high risk or cosmetically important sites. The claimed advantages over other surgical therapies are that it provides a better chance of cure and since less normal tissue is removed the simpler surgical repair ensures a superior cosmetic result. This review examines the published evidence that supports the enthusiasm for the use of Mohs surgery in the treatment of BCC, contrasting cure rates and cosmetic outcome with results achieved by attempted single complete excision and examines the 2 principles upon which Mohs surgery is based, namely that BCCs spread by contiguous growth and that all tumour cells have to be destroyed to achieve a cure.

Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma

We reviewed all studies (since 1945) reporting recurrence rates for treatment of recurrent (previously treated) basal cell carcinomas (BCC) using surgical excision, radiotherapy, cryotherapy, curettage and electrodesiccation, and Mohs micrographic surgery. The 5-year recurrence rate for Mohs micrographic surgery is 5.6%. The recurrence rate for non-Mohs modalities of 19.9% is nearly four times higher. Individual recurrence rates for the non-Mohs modalities are 17.4% for surgical excision, 40.0% for curettage and electrodesiccation, and 9.8% for radiation therapy. There are no studies reporting 5-year data for cryotherapy. However, the recurrence rate is 13.0% for cryotherapy when the follow-up period is less than five years. The data support the following conclusions: (1) Mohs surgery is the treatment of choice for recurrent BCC; (2) if the patient is not a surgical candidate and the lesion is small, radiation therapy is an alternative that offers a better chance for cure than the other non-Mohs modalities; and (3) curettage and electrodesiccation should not be used to treat recurrent basal cell carcinoma.

Management of basal cell carcinoma. Which option is best?

Basal cell carcinoma, the most common type of skin cancer, can be treated successfully by a variety of methods. The most commonly employed techniques are curettage with electrodesiccation, scalpel excision, Mohs' chemosurgery, cryosurgery, and radiation therapy, all of which have advantages and disadvantages. The primary care physician needs to be aware of available forms of therapy, problems with recurrent lesions, and the importance of adequate follow-up.

Multifocal recurrent basal cell carcinoma following primary tumor treatment by electrodesiccation and curettage

Eight recurrent basal cell carcinomas and their adjacent scars, which were previously treated with electrodesiccation and curettage, were completely excised by Mohs micrographic surgery and then studied by serial vertical sections. Through the study of an average of 291 serial sections of each recurrent tumor, it was found that four of eight recurrent basal cell carcinomas contained multiple foci of unconnected tumor. It is concluded that iatrogenic multifocality of recurrent basal cell carcinoma previously treated with electrodesiccation and curettage is common. Complete excision of the recurrent basal cell carcinoma and its adjacent scar is supported in view of the high risk of multiple unconnected tumor foci.

Carbon dioxide laser vaporization and curettage in the treatment of large or multiple superficial basal cell carcinomas

Many of the standard forms of therapy for large or multiple superficial basal cell carcinomas are limited by significant postoperative pain, excessive scarring, and prolonged wound healing time. Combining traditional curettage with carbon dioxide laser vaporization creates a procedure that allows excellent visualization, due to the bloodless surgical field produced by the laser, minimal nonspecific thermal damage, rapid healing, and diminished postoperative pain. In addition, the speed and ease with which this procedure can be performed allow successful treatment of many lesions in a single outpatient session. We wish to report our results using this technique for the treatment of 52 patients with 370 superficial basal cell carcinomas.

The technic of curettage surgery

Curettage is the most common surgical procedure carried out by dermatologists, yet the mechanics of curettage surgery are seldom described in standard textbooks or emphasized in the literature. The procedure for curettage is discussed and the mechanics of two technics, the pencil technic and the potato peeler technic, are described. The advantages of the potato peeler technic include better immobility of the lesion being curetted, more effective control of bleeding, and greater stability and increased flexibility and movement of the hand holding the curet.

Histologic evolution of recurrent basal cell carcinoma and treatment implications

The pathologic specimens from forty-seven patients with fifty-one recurrent basal cell carcinomas referred for Mohs' surgery were studied. Specimens from the original tumor and from each subsequent recurrence were reviewed. Of the original tumors, 65% demonstrated an aggressive* histologic picture characterized by poor palisading and an infiltrating and/or micronodular pattern. In twelve cases the recurrent tumor developed a more aggressive histologic picture, but in seven cases the histologic picture became more benign. Electrodesiccation and curettage was the initial treatment for forty-one basal cell carcinomas. Ten tumors had been excised previously, with routine pathologic examination indicating tumor-free margins in six of these lesions. It can be concluded that many recurrent basal cell carcinomas are aggressive from the beginning, and this often can be predicted from the histologic picture. Lesions with an aggressive pathologic picture should not be managed by blind technics such as electrodesiccation and curettage and may defy routine pathologic examination of conventional excision specimens. Mohs' surgery appears to be the treatment of choice for such lesions.

Treatment of basal cell epithelioma by curettage and electrodesiccation

A total of 233 biopsy-proved basal cell epitheliomas (BCEs) treated by curettage and electrodesiccation (C&D) in our office in 1976 and 1977 were followed a minimum of 5 years. There were seven recurrences, a cure rate of 97.0%. Our results, both for recurrence rates and cosmetic appearance, varied according to the size and location of the cancers. The cosmetic results were generally excellent especially in the smaller cancers. Smaller BCEs'less than 2 cm diameter, excluding the nose and nasolabial area, had our highest cure rate, 99.4% (171/172). Our treatment method is described in detail. Although not a complicated procedure, C&D does require skill, thoroughness and selection of patients to achieve high cure rates and is still an excellent treatment choice for many BCEs.