Recurrence rates of primary nonmelanoma skin cancers treated by surgical excision compared to electrodesiccation-curettage in a private dermatological practice

Non-Surgical Treatments for Keratinocyte Carcinomas

Skin cancer is the most common malignancy worldwide, comprising approximately 30% of all human tumors. In recent decades, the incidence of keratinocyte carcinomas, which include basal cell carcinoma and cutaneous squamous cell carcinoma, has been steadily increasing globally (Rogers et al. in JAMA Dermatol 151(10):1081-1086. https://doi.org/10.1001/jamadermatol.2015.1187 , 2015; Nehal and Bichakjian in N Engl J Med 379(4):363-374. https://doi.org/10.1056/nejmra1708701 , 2018). Most tumors are cured with surgical excision; however, some tumors are best treated with non-surgical approaches. Superficial tumors can often be cured with non-surgical methods whereas more advanced stage tumors may not be amenable to surgery. Additionally, surgical treatment may not be available for all populations depending on geographic location and accessibility to care. This article reviews commonly utilized nonsurgical options such as cryotherapy, photodynamic therapy, topical treatments, and radiation as well as systemic treatments including immunotherapies and chemotherapies.

Treatment of Non-melanoma Skin Cancers in the Absence of Mohs Micrographic Surgery

Non-melanoma skin cancers are the most common malignancies globally. Although non-melanoma skin cancers exhibit low metastatic potential, they can be locally destructive, necessitating complex excisions and reconstructions. Mohs micrographic surgery is the gold-standard treatment for high-risk non-melanoma skin cancers in patients who are appropriate surgical candidates. Despite its efficacy, Mohs micrographic surgery is not readily available in most geographic regions, necessitating that plastic surgeons be well-versed in alternative treatment modalities for non-melanoma skin cancer. Herein, we will discuss the management of non-melanoma skin cancers in settings where Mohs micrographic surgery is not readily available.

An Update on the Role of Dietary Phytochemicals in Human Skin Cancer: New Insights into Molecular Mechanisms

Human skin is continuously subjected to environmental stresses, as well as extrinsic and intrinsic noxious agents. Although skin adopts various molecular mechanisms to maintain homeostasis, excessive and repeated stresses can overwhelm these systems, leading to serious cutaneous damage, including both melanoma and non-melanoma skin cancers. Phytochemicals present in the diet possess the desirable effects of protecting the skin from damaging free radicals as well as other benefits. Dietary phytochemicals appear to be effective in preventing skin cancer and are inexpensive, widely available, and well tolerated. Multiple in vitro and in vivo studies have demonstrated the significant anti-inflammatory, antioxidant, and anti-angiogenic characteristics of dietary phytochemicals against skin malignancy. Moreover, dietary phytochemicals affect multiple important cellular processes including cell cycle, angiogenesis, and metastasis to control skin cancer progression. Herein, we discuss the advantages of key dietary phytochemicals in whole fruits and vegetables, their bioavailability, and underlying molecular mechanisms for preventing skin cancer. Current challenges and future prospects for research are also reviewed. To date, most of the chemoprevention investigations have been conducted preclinically, and additional clinical trials are required to conform and validate the preclinical results in humans.

Whole Fruit Phytochemicals Combating Skin Damage and Carcinogenesis

Skin is arguably the largest organ of the body and is continuously subjected to intrinsic, extrinsic, and environmental stresses. Therefore, skin developed elaborate mechanisms to maintain homeostasis, including antioxidant, antiinflammatory, and DNA damage repair capabilities. However, repeated and excessive stresses can overwhelm these systems, causing serious cutaneous damages, including skin carcinogenesis. Phytonutrients present in the diet possess a myriad of health-promoting effects by protecting skin from damaging free radicals as well as by other mechanisms. Although many chemoprotective phytonutrients have been shown to be efficacious individually, a combination of multiple agents could have synergistic response in curtailing or preventing cutaneous damages. Here, we discuss the benefits of natural amalgamation of phytonutrients in select fruits against skin damage including carcinogenesis. However, a majority of these studies have been done in preclinical models. Therefore, clinical studies are needed to determine the human relevance of the available preclinical data, especially in the human population who are at higher risk for skin cancers (e.g., organ transplant patients). In addition, detailed well-structured preclinical animal studies in the models of high-risk skin carcinogenesis could also be useful toward informing the design for human 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.

Recent advances in field cancerization and management of multiple cutaneous squamous cell carcinomas

Cutaneous squamous cell carcinoma (SCC) is among the most common cancers in humans, and many patients with SCC will develop multiple tumors within their lifetime. The field cancerization concept, originally proposed over 60 years ago, hypothesized that multiple primary cancers may arise simultaneously and coexist with subclinical precursor lesions within a defined field. Genetic sequencing of SCC and precursor lesions has identified what may be the earliest clonal proliferations in SCC development and confirmed that field cancerization in the skin is mediated by ultraviolet radiation. For patients with multiple SCCs and severe actinic damage, treatment of precursor lesions within a cancerized field can decrease the risk of subsequent cancer development. Sunblock is an effective intervention for field cancerization, even in patients with established disease. There is now direct evidence that field therapy with topical 5-fluorouracil is effective in reducing the incidence of subsequent SCC, and there is indirect evidence suggesting that topical imiquimod, topical ingenol mebutate, and photodynamic therapy are similarly effective. There is limited direct evidence to show that systemic acitretin or nicotinamide can decrease incident SCC in patients with field cancerization. In this review, an approach to the management of patients with multiple SCCs and field cancerization is presented along with the rationale to support field-directed therapy.

Neoplastic Multifocal Skin Lesions: Biology, Etiology, and Targeted Therapies for Nonmelanoma Skin Cancers

Neoplastic skin lesions are multifocal, diffuse skin infiltrations of particular relevance in the differential diagnosis of ulcerative, nodular, or crusting skin lesions. Nonmelanoma skin cancers (NMSCs), namely, basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and also actinic keratosis (AK), are the most common malignant tumors in humans. BCCs do not proliferate rapidly and most of the times do not metastasize, while SCCs are more infiltrative, metastatic, and destructive. AKs are precursor lesions of cutaneous SCCs. The classical therapy of NMSCs makes use of photodynamic therapy associated with chemotherapeutics. With improved understanding of the pathological mechanisms of tumor initiation, progression, and differentiation, a case is made towards the use of targeted chemotherapy with the intent to reduce the cytotoxicity of classical treatments. The present review aims to describe the current state of the art on the knowledge of NMSC, including its risks factors, oncogenes, and skin carcinogenesis, discussing the classical therapy against new therapeutic options.

Interventions for non-metastatic squamous cell carcinoma of the skin: systematic review and pooled analysis of observational studies

OBJECTIVES

To assess the effects of treatments for non-metastatic invasive squamous cell carcinoma (SCC) of the skin using evidence from observational studies, given the paucity of evidence from randomised controlled trials.

DESIGN

Systematic review of observational studies.

DATA SOURCES

Medline, Embase, to December 2012.

REVIEW METHODS

Observational studies of interventions for primary, non-metastatic, invasive, SCC of the skin that reported recurrence during follow-up, quality of life, initial response to treatment, adverse events, cosmetic appearance, or death from disease. Studies were excluded if data for primary cutaneous SCC was not separable from other data. Data were extracted independently by two reviewers. Meta-analysis was performed where appropriate using a random effects model to estimate the pooled proportion of an event with 95% confidence intervals.

RESULTS

118 publications were included, covering seven treatment modalities. Pooled estimates of recurrence of SCCs were lowest after cryotherapy (0.8% (95% confidence interval 0.1% to 2%)) and curettage and electrodesiccation (1.7% (0.5% to 3.4%)), but most treated SCCs were small, low risk lesions. After Mohs micrographic surgery, the pooled estimate of local recurrence during variable follow-up periods from 10 studies was 3.0% (2.2% to 3.9%), which was non-significantly lower than the pooled average local recurrence of 5.4% (2.5% to 9.1%) after standard surgical excision (12 studies), and 6.4% (3.0% to 11.0%) after external radiotherapy (7 studies). After an apparently successful initial response of SCCs to photodynamic therapy, pooled average recurrence of 26.4% (12.3% to 43.7%; 8 studies) was significantly higher than other treatments. Evidence was limited for laser treatment (1 study) and for topical and systemic treatments (mostly single case reports or small non-comparative series with limited follow-up).

CONCLUSIONS

Many observational studies have looked at different treatment modalities for SCC, but the evidence base for the effectiveness of these interventions is poor. Comparison of outcomes after different treatments should be interpreted cautiously owing to biases inherent in the types of study included, and lack of direct comparisons to enable the estimation of relative treatment effect. Further evidence is needed to develop a prognostic model and stratify individuals at high risk of developing SCC, to improve the evidence base for this common cancer and to optimise clinical management.

PROTOCOL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) registration number CRD42011001450.

A challenging case of multiply recurrent nasal basal cell carcinoma

BACKGROUND

Basal cell carcinoma (BCC) is the most common human malignancy worldwide and represents a significant cost to health care systems. Most cases occur on the head and neck, and many are successfully treated with relatively simple measures. However, if high-risk or complicated cases are not treated effectively, they may result in considerable disfigurement or morbidity. We report on a patient with a complex nasal basal cell carcinoma (BCC) that failed multiple treatments by electrodesiccation and curettage (EDC). Management strategies for primary and recurrent BCC, including EDC, standard excision, Mohs micrographic surgery (MMS), and radiation therapy, are discussed. This case required extensive resection, and we review the literature for predictive factors of significant subclinical spread.

OBJECTIVE

To present a complex case that illustrates the management options of high-risk, recurrent BCC of the head and neck.

MATERIALS AND METHODS

Case report and review of the literature.

RESULTS

MMS offers the lowest recurrence rate in the treatment of recurrent BCC in surgical candidates. A validated risk scale may predict subclinical spread in patients with BCC of the head and neck.

CONCLUSIONS

BCC can progress to locally advanced disease, necessitating definitive treatment. EDC performed by an experienced dermatologist may offer cure rates comparable to those of surgery in lower-risk BCC. However, in higher-risk tumors, such as recurrent or larger lesions, methods that ensure clear margins should be considered first line, especially in sensitive locations. The routine use of a validated risk scale can better prepare patients and dermatologists for potentially extensive resections. In cases with risk of extensive involvement, strategies to clearly communicate options and progress at all stages of the process should be available.

Nonsurgical treatment of nonmelanoma skin cancer

The ever-increasing incidence of primary cutaneous malignancies has heralded the need for multiple treatment options. Surgical modalities remain the mainstay of treatment of nonmelanoma skin cancer. However, it is important for the dermatologic surgeon to have an understanding of all treatment options to assist the patient in making the most informed decision possible, ultimately leading to the most favorable outcome. This article explores the available nonsurgical treatment options, their indications, and their efficacy.

Cutaneous malignancies: melanoma and nonmelanoma types

This article reviews melanoma and nonmelanoma cutaneous malignancies.

Cutaneous squamous cell carcinoma of the head and neck

Cutaneous squamous cell carcinoma of the head and neck is an epidemic that reaches all parts of the world. Making the diagnosis relies on the acumen of the clinician and pathologist. Various pathologic subtypes exist and differ in histology and prognosis. High-risk tumors need aggressive treatment and vigilant surveillance to monitor for recurrence. Large tumors, deep tissue invasion, perineural involvement, recurrence, location in high-risk areas, and immunosuppression are implicated in worsening prognosis. Surgery is the mainstay of treatment with adjuvant radiation therapy as needed for aggressive tumors; however, other modalities are potentially useful for low-risk lesions. The use of Mohs surgery has become increasingly useful and has shown high success rates. Involvement of parotid and neck lymph nodes significantly affects outcomes and the physician should be comfortable with management of this complex disease. This paper examines the diagnosis, pathology, clinical course, and treatment options for cutaneous squamous cell carcinoma of the head and neck.

Non-surgical treatments of primary, non-melanoma eyelid malignancies: a review

The diagnosis and management of periocular cutaneous malignancies are essential components of an ophthalmologist's practice. Skin cancers comprise nearly one-third of newly diagnosed malignancies. Furthermore, the incidence of skin cancer appears to be increasing. Multiple treatment modalities exist for periocular cutaneous malignancy. Surgical extirpation, often with the combined expertise of a Mohs micrographic surgeon, is typically the first line therapy and is often curative in the periocular region, depending on a variety of factors, including tumour histology, specific location, depth of invasion and surgical technique. However, there are instances where a less invasive, non-surgical treatment option is warranted, including patients who are poor surgical risks or those with diffuse disease. The purpose of this article is to review the literature and describe the non-surgical treatment options, indications and efficacies for non-melanoma primary eyelid malignancies.

Surgical excision versus curettage plus cryosurgery in the treatment of basal cell carcinoma

BACKGROUND

Both cryosurgery, with and without prior curettage, and surgical excision (SE) are common therapeutic strategies for basal cell carcinoma (BCC).

OBJECTIVE

The objective was to compare the efficacy between curettage plus cryosurgery (C&C) and SE in nonaggressive BCC of the head and neck.

MATERIALS AND METHODS

A randomized controlled trial was carried out, in which tumors were assigned to either C&C (n=51) or SE (n=49). C&C was performed with a double freeze-thaw cycle after prior curettage of the tumor. SE was performed with a margin of 3 mm and with delayed histologic examination.

RESULTS

Recurrences occurred 9 times after C&C (17.6%) and 4 times after SE (8.2%). The overall 5-year recurrence probability was 19.6% for C&C and 8.4% for SE (p=.10). A hazard ratio of 2.57 (95% CI, 0.79-8.34) indicated a putative, but not statistically significant, advantage of SE.

CONCLUSION

These data reflect the outcome of the first randomized controlled trial with long-term follow-up in the treatment of BCC, comparing C&C with SE. Although not statistically significantly different, the observed differences could still be of clinical relevance. Owing to the trend toward lower recurrence rates, better cosmetic results, and reduced wound healing time, we believe that SE should be preferred to C&C in the treatment of primary, nonaggressive BCC of the head and neck.

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.

Treatment of basal cell carcinoma with curettage alone

BACKGROUND

Although curettage and electrodesiccation (C&E) is widely used to treat basal cell carcinoma, whether electrodesiccation improves outcome is unknown.

OBJECTIVE

We sought to compare cure rates of curettage alone with those of C&E.

METHODS

We conducted a retrospective records review of patients treated with curettage alone at 5-year follow-up or longer that extracted data about tumor location, size, histologic subtype, biopsy specimen margin involvement, and recurrence, as well as data about the medical history of patients treated in a dermatology clinic in a tertiary-care academic medical institution.

RESULTS

Biopsy-proven tumors (302) amenable to treatment with C&E and treated by a single investigator with curettage alone had a 5-year cure rate of 96.03%, with minimal complications (hypopigmentation, scarring). Tumors involving more than 50% of the deep edge of the shave biopsy specimen had an increased risk of recurrence.

LIMITATIONS

This is a retrospective study based on historic controls.

CONCLUSION

For nonaggressive basal cell carcinoma, curettage alone has a cure rate similar to the published rates for C&E.

Current modalities and new advances in the treatment of basal cell carcinoma

Basal cell carcinoma (BCC) is one of the most common cancers. Surgical extirpation is currently the standard of care for BCC, which is associated with several advantages and disadvantages. Procedures such as surgical excision used to treat superficial BCC (sBCC) and nodular BCC (nBCC) may have high 5-year recurrence rates if tumors are not completely excised. Curettage with electrodesiccation is a common method for treating primary BCC. However, multiple cycles are recommended and the procedure can have unsatisfactory cosmetic results (e.g. scarring and hypopigmentation). Mohs micrographic surgery has a low rate of disease recurrence but is a specialized procedure usually limited to specific indications (e.g. high-risk tumors). Cryosurgery and photodynamic therapy require multiple cycles and are associated with variable cosmetic outcomes and recurrence rates. As with any procedure, potential risks and patient quality-of-life issues need to be considered. In addition, substantial patient and healthcare provider inconvenience limit the practical utility of some modalities. Pharmacologic interventions provide another treatment option as adjunctive or monotherapy. Investigations of imiquimod, a novel immune response modifier, have indicated that this topical, noninvasive agent is safe and well tolerated and may be efficacious in the treatment of BCC. This review will highlight the role of standard treatment modalities and introduce new advances in the treatment of BCC.

Mohs' micrographic surgery for treatment of basal cell carcinoma of the face--results of a retrospective study and review of the literature

BACKGROUND

The incidence of skin cancer and especially basal cell carcinoma (BCC) has increased in the last decade and is still increasing. Many treatment modalities can be used to treat BCC; surgical excision is the most frequently used. Mohs' micrographic surgery (MMS) is an advanced excision technique which is often used to treat BCC in the U.S.A. In Europe it is practised less frequently.

OBJECTIVE

The aim of this article was to evaluate the efficiency of MMS for the treatment of facial BCC.

METHODS

In a retrospective study recurrence rates after the treatment of facial BCC by MMS were estimated by reviewing the records of all patients with BCCs (620 patients with 720 BCCs) treated by MMS in our department from April 1992 until December 1999.

RESULTS

The 5-year recurrence rates estimated from this study were 3.2% for primary BCC and 6.7% for recurrent BCC. Prognostic factors for recurrence are: an aggressive histopathological subtype, more than four Mohs' stages, a large defect size and a recurrent BCC.

CONCLUSION

Based on the fact that MMS provides the lowest recurrence rates, it is the treatment of first choice for primary facial BCCs with an aggressive histopathological subtype and for recurrent BCCs in the face.