Prospective follow-up after curettage-cryosurgery for scalp and face skin cancers

Years of dermatology experience and geographic region are associated with outlier performance of excision or destruction for nonmelanoma skin cancer

INTRODUCTION

Treatments for nonmelanoma skin cancer (NMSC) include excision (surgical removal) and destruction (cryotherapy or curettage with or without electrodesiccation) in addition to other methods. Although cure rates are similar between excision and destruction for low-risk NMSCs, excision is substantially more expensive. Performing destruction when appropriate can reduce costs while providing comparable cure rate and cosmesis.

OBJECTIVE

To identify characteristics associated with exclusive (outlier) performance of excision or destruction for NMSC.

METHODS

The study consisted of malignant excision and destruction procedures submitted by dermatologists to Medicare in 2019. Proportions of services for each method were analyzed with respect to geographic region, years of dermatology experience, median income of the practice zip code, and rural-urban commuting area code.

RESULTS

Fewer years of experience predicted a higher proportion of excisions (R²=.7, p<.001) and higher odds of outlier excision performance. Outlier performance of excision was associated with practicing in the South, Midwest, and West, whereas outlier performance of destruction was associated with practicing in the Northeast and Midwest.

CONCLUSIONS

Dermatologists with less experience or in certain geographic regions performed more malignant excision relative to destruction. As the older population of dermatologists retires, the cost of care for NMSC may increase.

Nonsurgical treatment options for basal cell carcinoma

ABSTRACT

Basal cell carcinoma (BCC) is the most common form of nonmelanoma skin cancer. Surgery, including Mohs micrographic surgery, is considered the gold standard for the management of BCC, yet some patients may be unable to undergo surgery. This article describes effective nonsurgical options for treating superficial BCCs as well as some nodular and infiltrative BCCs.

Correlation of basal cell carcinoma subtype with histologically confirmed subclinical extension during Mohs micrographic surgery: A prospective multicenter study

BACKGROUND

Traditionally "aggressive" histologic subtypes (HSs) of basal cell carcinoma (BCC) are more likely to quantitatively exhibit subclinical extension (SCE), requiring more stages during Mohs micrographic surgery (MMS) and, therefore, larger margins upon excision. However, the tendency for SCE has never been compared between HSs of BCC in a prospective manner.

OBJECTIVE

To prospectively correlate the HS of BCC with the likelihood of SCE as defined by the number of MMS stages required to clear the tumor.

METHODS

In a prospective, multicenter study involving 17 Mohs surgeons in 16 different practices across the United States, data regarding 1686 cases of BCC undergoing MMS were collected. Patient demographics, tumor characteristics, number of MMS stages required for tumor clearance, and specific BCC subtypes noted on both index biopsy and the final MMS stage were recorded.

RESULTS

Analysis of the average number of MMS stages for each HS required to clear tumor revealed 2 distinct degrees of SCE (P < .0001): high (higher than average) risk of SCE (1.9 stages, 1.0 SD) and low (lower than average) risk of SCE (1.6 stages, 0.9 SD). Subtypes of BCC within the high category were morpheaform (2.1), infiltrative (1.9), metatypical (1.9), mixed (1.8), and superficial (1.8). The low category included BCC subtypes of basosquamous (1.6), micronodular (1.6), nodular (1.6), and unspecified (1.5). Three hundred twenty-four cases (22.0%) manifested HS drift or a change in subtype from index biopsy to the final MMS stage. Superficial BCC was the only subtype that showed an increase in prevalence from index biopsy to the final MMS stage (from 16.0% to 25.8%; P < .0002).

LIMITATIONS

HSs from index biopsy may not be representative of all HSs present, resulting in sampling bias.

CONCLUSION

SCE of superficial BCC was as likely as SCE of BCC subtypes that are considered "aggressive" and are deemed "appropriate" for MMS by the appropriate use criteria. Our study also found that when HS drift occurs, the most likely subtype to extend subclinically is superficial BCC.

Curettage versus cryosurgery for superficial basal cell carcinoma: a prospective, randomised and controlled trial

Background

Basal cell carcinoma (BCC) is the most common cancer in the world and has a rising incidence. Current guidelines for low‐risk BCC including superficial BCC (sBCC) recommend several treatment options including destructive treatment methods, such as cryosurgery with or without prior curettage or curettage and electrodesiccation. Curettage only (i.e. without subsequent cryosurgery or electrodesiccation) is a simple and quick destructive treatment method used for many benign skin lesions but has not been sufficiently evaluated for the treatment of sBCCs.

Objectives

The objective was to compare the effectiveness of curettage vs. cryosurgery for sBCCs in terms of overall clinical clearance rates after 1 year as well as wound healing times.

Methods

A single‐centre non‐inferiority clinical trial was conducted. Non‐facial sBCCs with a diameter of 5–20 mm were randomised to either cryosurgery using one freeze–thaw cycle or curettage. At follow‐up visits, treatment areas were evaluated regarding the presence of residual tumour after 3–6 months and recurrence after 1 year. Further, wound healing times were assessed.

Results

In total, 228 sBCCs in 97 patients were included in the analysis. At 3–6 months, no residual tumours were seen in any of the treated areas. After 1 year, the clinical clearance rates for curettage and cryosurgery were 95.7% and 100%, respectively (P = 0.060). However, the non‐inferiority analysis was inconclusive. Wound healing times were shorter for curettage (4 weeks) compared to cryosurgery (5 weeks; P < 0.0001). Overall, patient satisfaction at 1 year was high.

Conclusions

Both treatment methods showed high clinical clearance rates after 1 year, whilst curettage reduced the wound healing time.

Non-surgical treatments for basal cell skin cancer

Basal cell carcinoma is the most common nonmelanoma skin cancer. It originates from undifferentiated cells in the basal cell layer of the epidermis or from the outer root sheath of the hair follicle. The most important factor in development of basalioma is ultraviolet radiation. Surgery is considered the gold standard of treatment for basal cell cancer. However, nonsurgical options are available for individuals who are unsuitable for surgery. The purpose of this review is to summarize the efficacy and indications of alternative, nonsurgical treatments that can be used in the management of basal cell cancer Effective nonsurgical treatments include destructive methods (eg, curettage and electrodessication, cryosurgery, laser), photodynamic therapy, topical medications, hedgehog pathway inhibitors. Nonsurgical therapeutic alternatives are safe and effective for the treatment of BCC. Factors such as tumor location, size, and histopathological subtype should be taken into consideration when selecting optimal treatment, cosmetic results and patient preference should be considered too. To search for the necessary literature, the PubMed, MedLine, Web of Science and RSCI databases were used.

Beyond Mohs surgery and excisions: A focused review of treatment options for subtypes of basal cell carcinoma

Basal cell carcinoma (BCC) is the most common nonmelanoma skin cancer. It originates from undifferentiated cells in the basal cell layer of the epidermis or from the outer root sheath of the hair follicle. The most important factor in development of BCC is ultraviolet radiation. Surgery is considered the gold standard of treatment for BCC. However, nonsurgical options are available for individuals who are unsuitable for surgery. The purpose of this review is to summarize the efficacy and indications of alternative, nonsurgical treatments that can be used in the management of BCC. An extensive literature review was performed for the nonsurgical options for the treatment of BCC. Resources searched included PubMed and Google Scholars, limited to the years 1995 to 2020. Key words searched included BCC, destructive methods, photodynamic therapy (PDT), radiotherapy, topical medication, laser, hedgehog pathway inhibitors (HPIs). The most relevant results such as systematic reviews, randomized controlled trials, or comparative studies were selected to provide a summary for the most common nonsurgical methods used for treating BCC. Effective nonsurgical treatments for BCC include destructive methods (eg, curettage alone, cryosurgery, or electrodessication), PDT, topical medications, radiotherapy, laser, and HPIs. Nonsurgical therapeutic alternatives are safe and effective for the treatment of BCC. Factors such as tumor location, size, and histopathological subtype should be taken into consideration when selecting optimal treatment. In addition to clinical factors, cosmetic results and patient preference should be considered.

Nonsurgical Options for the Treatment of Basal Cell Carcinoma

Objectives

The aim of this review article is to summarize the effectiveness, potential adverse events, and indications of the main nonsurgical treatment alternatives for basal cell carcinoma.

Methods

An extensive literature review was carried out. The most relevant articles were discussed and selected by the authors in order to provide a brief but evidence-based overview of the most common nonsurgical methods used for treating basal cell carcinoma.

Results

Although surgery and Mohs micrographic surgery are often considered the optimal treatment options for basal cell carcinoma, these tumors can also be treated successfully with destructive techniques (eg, curettage alone, cryosurgery, or electrodesiccation), photodynamic therapy, topical drugs (eg, 5-fluorouracil, imiquimod, or ingenol mebutate), radiotherapy, or hedgehog pathway inhibitors. When choosing between these alternatives, physicians must take into consideration the tumor's size, location, and histopathological subtype. Special care should be taken when treating recurrent tumors. Furthermore, physician experience is of great importance when using destructive techniques. Finally, patient preference, potential adverse events, and cosmetic outcome should also be considered.

Conclusions

Dermatologists and physicians treating basal cell carcinoma should have knowledge of and experience with the large arsenal of therapeutic alternatives available for the successful, safe, and individualized management of patients with basal cell carcinoma.

A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease

Background

Skin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).

Objective

To set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.

Design

Mixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.

Setting

Secondary care, primary care and the general population.

Participants

Patients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.

Interventions

Our three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).

Results

Systematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.

Conclusions

Findings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.

Trial registration

Current Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.

Cryosurgery and curettage-cryosurgery for basal cell carcinomas of the mid-face

BACKGROUND

Surgical treatment of basal cell carcinoma (BCC) can be technically difficult in mid-face area. Cryosurgery is proposed for low-risk BCC. Cryosurgery has been poorly investigated in mid-face BCC, which is considered as having a high risk of recurrence.

OBJECTIVE

To assess the results of cryosurgery and curettage-cryosurgery in patients with mid-face BCC.

METHODS

A retrospective study was performed between 2005 and 2012 in a reference centre for cryosurgery. Inclusion criteria were: (i) diagnosis of BCC confirmed histologically; (ii) location in the mid-face area; (iii) treatment with cryosurgery performed between August 2005 and December 2010; and (iv) minimal follow-up of 18 months after cryosurgery. Follow-up data were recorded until April 2012. Curettage was performed before cryosurgery in 55 cases of nodular BCC (38%). Patients were followed after cryosurgery either by a dermatologist (n = 48) or by their general practitioner (n = 90). Twelve patients were lost to follow-up.

RESULTS

One hundred and thirty-eight patients of mean age 76.5 ± 11.1 years, with a total of 144 BCCs were included. Mean follow-up was 40.7 ± 15.6 months. Wound healing occurred after a median delay of 4 weeks (range 1-12 weeks). No severe complications were recorded. Seven recurrences (4.9%) were observed after a median time of 24 months (range 4-36 months). The 5-year Kaplan-Meier recurrence-free rate was 94%. Thirteen patients with previously treated BCC or morpheiform BCC were treated with cryosurgery as palliative indication, although their subtypes of BCC were theoretical contraindications to cryosurgery. When excluding this subgroup, the 5-year Kaplan-Meier recurrence-free rate of the rest of the population was 96.5%.

CONCLUSION

Cryosurgery and curettage-cryosurgery can be considered as an alternative and simple method for treatment of BCC of the mid-face area.

Comparison of tissue-engineered and artificial dermis grafts after removal of basal cell carcinoma on face--a pilot study

BACKGROUND

Planning reconstruction for facial defects should include the safest and least-invasive methods, with a goal of achieving optimal functional and cosmetic outcomes.

OBJECTIVE

To compare tissue-engineered dermis grafts with artificial dermis grafts after removal of basal cell carcinoma (BCC) on the face.

MATERIALS AND METHODS

A tissue-engineered dermis composed of autologous cultured dermal fibroblasts seeded on a hyaluronic acid sheet was applied to 16 patients. Grafting of hyaluronic acid sheets that did not contain fibroblasts (artificial dermis group) was performed in 13 patients. Healing time, scar condition, and patient satisfaction were compared.

RESULTS

The wounds of the tissue-engineered dermis group reepithelialized after 31.4 ± 5.3 days and those of the artificial dermis group after 34.2 ± 4.9 days. The tissue-engineered dermis graft was superior in scar quality. In particular, statistically significant differences were detected in the height and contracture of scars, although there were no significant differences in terms of scar texture or color match. Patient satisfaction in the tissue-engineered dermis graft group (8.3 ± 1.0) was also statistically superior to that in the artificial dermis group (6.9 ± 1.4).

CONCLUSION

The tissue-engineered dermis graft is superior to the artificial dermis graft for covering defects after removal of BCC on the face.

Facial dermis grafts after removal of basal cell carcinomas

Selecting a proper reconstruction method is the key to success in skin cancer management, especially for lesions involving the face. Using a skin graft is usually straightforward when covering a skin defect; however, major concerns in skin grafting include a poor color match in the recipient-site and donor-site morbidity. To overcome these limitations, the authors have developed a dermis graft, which utilizes a de-epithelialized split-thickness skin graft method. The purpose of this retrospective study was to report reliability of dermis grafts after removal of basal cell carcinomas (BCCs) on the face by presenting our clinical experience with them. This study included 38 patients who were treated for facial defects created by resection of BCCs. The locations of the defects were as follows: nose (n = 17), orbital area (n = 14), cheek (n = 4), temple area (n = 2), and forehead (n = 1). The defects ranged in size from 3.3 to 6.5 cm. Functional and cosmetic outcomes, postoperative complications, and patient satisfaction were assessed. The patients were followed up for 12 to 36 months. The entire dermis graft re-epithelialized after grafting within 17 to 27 days. Most of the patients had satisfactory results in both functional and cosmetic matters with high-quality skin characteristics. There were no significant complications and no recurrences were observed during the follow-up period. Patient satisfaction with the dermis graft was also excellent. The dermis graft may be used reliably for covering defects after removal of BCCs on the face.

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.

Prospective trial of curettage and cryosurgery in the management of non-facial, superficial, and minimally invasive basal and squamous cell carcinoma

BACKGROUND

As a variation of the curettage and destruction technique, cryosurgery can be used in place of electrodesiccation for the destructive component when managing superficial basal and squamous cell carcinomas. There are few studies, though, demonstrating the long-term cure rate associated with similar methods. This study seeks to determine the long-term cure rate associated with curettage and cryosurgery in the treatment of small, non-facial, superficial basal and squamous cell carcinomas.

MATERIALS AND METHODS

Sixty-nine patients with 100 non-facial tumors, ≤ 2 cm in diameter, consisting of superficial basal cell carcinoma, superficial nodular basal cell carcinoma with papillary dermal invasion, squamous cell carcinoma in situ, and squamous cell carcinoma with papillary dermal invasion were prospectively treated with curettage and cryotherapy, and subsequently evaluated at 1- and 5-year intervals.

RESULTS

No tumor recurred after one year of follow-up, and one recurrence occurred within the 5-year interval, for a 99% recurrence-free endpoint. Six patients died of unrelated causes after one year, and before five years, and were thus lost to follow-up.

CONCLUSIONS

Curettage and cryosurgery is a simple, highly effective, and reliable treatment method for select, low-risk non-melanoma skin cancers.

Treatment of facial Basal cell carcinoma: a review

Basal cell carcinomas (BCCs) are locally destructive malignancies of the skin. They are the most common type of cancer in the western world. The lifetime incidence may be up to 39%. UV exposure is the most common risk factor. The majority of these tumours occur on the head and neck. Despite BCCs being relatively indolent the high incidence means that their treatment now contributes a significant and increasing workload for the health service. A good understanding of the options available is important. Management decisions may be influenced by various factors including the patient's age and comorbidities and the lesion subtype and location. Due to the importance of a good cosmetic and curative outcome for facial BCCs treatment decisions may differ significantly to those that would be made for BCCs arising elsewhere. There is little good randomized controlled data available comparing treatment modalities. Although traditionally standard excision has been the treatment of choice various other options are available including: Mohs micrographic surgery, curettage and cautery, cryosurgery, radiotherapy, topical imiquimod, photodynamic therapy and topical 5-fluorouracil. We discuss and review the literature and evidence base for the treatment options that are currently available for facial BCCs.