Interventions for basal cell carcinoma of the skin: systematic review

Clinical and toxicity outcomes with 3D based-HDR surface mold brachytherapy in skin cancer

INTRODUCTION

Surface mold brachytherapy (SMBT) is an established treatment modality in skin cancer, especially in accessible areas, and has shown comparable outcomes to surgery. We have presented our results for the skin tumor treatment with SMBT treated with high-dose-rate (HDR) brachytherapy in terms of clinical outcomes and toxicity at our institute.

MATERIALS AND METHODS

In this retrospective analysis, 15 patients with skin cancer were treated with customized tube-based SMBT at our institute between January 2019 and July 2021. The patients were treated using HDR-brachytherapy using Iridium-192. The median dose was 40 Gy in 10 fractions. The dosimetric parameters were assessed, and patients were followed up as per the institutional protocol. All patients underwent individualized CT-based planning. Skin toxicity was assessed using the Dermatology Life Quality Index (DLQI).

RESULTS

With the majority of the patients being male, the median age was 59 years and the most common site affected was the face (8/15; 53.3%). Among the 15 cases, five were squamous cell carcinoma, nine were basal cell carcinoma, and a single case of sebaceous cell carcinoma. The median depth of invasion was 4 mm, and the median catheter-to-surface distance was 1 mm. The complete response rate among the 10 definitive cases was 90% and partial response in one case. The treatment was well-tolerated with no grade 3-5 toxicities. The median V95% and V90% were 94.8% and 97.1%, respectively. The mean coverage index (C.I.), dose non-uniformity ratio (DNR), and overdose volume index (ODI) were 0.97, 0.13, and 0.05, respectively. After a median follow-up of 12 months, none of the patients had recurrence. On assessment of DLQI, the scores were found to be significant in association with the tumor size and tumor site with scores favoring <2 cm and non-exposed area lesions.

CONCLUSION

SMBT is a safe and effective treatment modality for skin tumors providing excellent response and cosmetic outcomes. It is well-tolerated and a non-invasive option for elderly patients with comorbidities and lesions in inoperable areas.

Intraoral Basal Cell Carcinoma of Soft Palate: A Diagnostic Dilemma and Review of Literature

Basal cell carcinoma is the most common cancer worldwide. Most of basal cell carcinoma can be detected in the early stages and are generally well controlled with local resection. Despite the high incidence of BCC, intramucosal BCC is a very rare clinical entity. We hereby present a rare case report of pigmented BCC on soft palate and review the literature of this entity.

Guidelines for the diagnosis and treatment of basal cell carcinoma: a GRADE approach for evidence evaluation and recommendations by the Italian Association of Medical Oncology

Basal cell carcinoma (BCC) is the most common form of cancer, with a high impact on the public health burden and social costs. Despite the overall prognosis for patients with BCC being excellent, if lesions are allowed to progress, or in a small subset of cases harboring an intrinsically aggressive biological behavior, it can result in local spread and significant morbidity, and conventional treatments (surgery and radiotherapy) may be challenging. When a BCC is not amenable to either surgery or radiotherapy with a reasonable curative intent, or when metastatic spread occurs, systemic treatments with Hedgehog inhibitors are available. These guidelines were developed, applying the GRADE approach, on behalf of the Italian Association of Medical Oncologists (AIOM) to assist clinicians in treating patients with BCC. They contain recommendations with regard to the diagnosis, treatment and follow-up, from primitive tumors to those locally advanced or metastatic, addressing the aspects of BCC management considered as priorities by a panel of experts selected by AIOM and other national scientific societies. The use of these guidelines in everyday clinical practice should improve patient care.

Early clinical experience with a degraded 4 MeV electron beam in radiotherapy of superficial basal cell carcinoma

The most common non-melanoma skin cancer is basal cell carcinoma (BCC). Surgery is the gold standard treatment but also non-surgical alternatives are needed. The purpose of this work was to present the early clinical experiences of degraded 4 MeV electron beam as a treatment method for superficial BCC. Twelve patients underwent two weeks radiation therapy treatment with either 5 × 7 Gy or 2 × 12 Gy. There were no significant differences in treatment outcome with different fractionations or lesion locations. The degraded beam method is a safe and valid non-surgical solution for suitable patients with superficial lesions.

Advances in Management and Therapeutics of Cutaneous Basal Cell Carcinoma

Simple Summary

Basal cell carcinoma (BCC) is the most common malignancy in humans with a range of treatment options available. Tumor and patient characteristics aid in risk-stratification, which influences treatment considerations. Here, we review the advancements in surgical, topical, field, immunotherapeutic, molecular-targeted, and experimental treatment modalities that can be employed in the correct clinical setting for the treatment of BCC.

Abstract

Basal cell carcinoma (BCC), the most common cancer in humans, is a malignant neoplasm of cells derived from the basal layer of the epidermis. Tumor characteristics such as histologic subtype, primary versus recurrent tumor, anatomic location, size, and patient attributes determine the risk level and acceptable treatment options. Surgical options offer histologic confirmation of tumor clearance. Standard excision provides post-treatment histologic assessment, while Mohs micrographic surgery (MMS) provides complete margin assessment intraoperatively. Additional treatment options may be employed in the correct clinical context. Small and low-risk BCCs, broad field cancerization, locally-advanced disease, metastatic disease, cosmetic concerns, or morbidity with surgical approaches raise consideration of other treatment modalities. We review herein a range of treatment approaches and advances in treatments for BCC, including standard excision, MMS, electrodesiccation and curettage, ablative laser treatment, radiation therapy, targeted molecular therapies, topical therapies, field therapies, immunotherapy, and experimental therapies.

Basal Cell Carcinoma: A Narrative Review on Contemporary Diagnosis and Management

Basal cell carcinoma (BCC) is the most common, accounting for 80–90% of skin cancers. It arises from the basal layer of the epidermis and its appendages. A complex interplay of environmental, phenotypic and genetic variables leads to the development of BCC. Literature has documented several clinical subtypes of BCC, the most common of which are nodular, superficial and morpheaform. Expeditious diagnosis and analysis are essential for improving the outcome of BCC. Preventive measures, particularly when implemented in childhood and adolescence, may play a critical role. Due to its low metastatic potential, treatment for BCC mostly focuses on local management. The standard treatment of basal cell carcinoma involved complete removal of the lesion by excision or Mohs surgery. In special circumstances, basal cell carcinoma can be treated with cryosurgery, electrodesiccation and curettage, topical medications and photodynamic therapy. This review aimed to evaluate the contemporary diagnosis and management of basal cell carcinoma.

Development of a Core Outcome Set for Basal Cell Carcinoma (BCC), Including Low-Risk and Advanced Tumors

BACKGROUND

There is variation in the outcomes reported in clinical studies of basal cell carcinoma (BCC). This can prevent effective meta-analyses to answer important clinical questions.

OBJECTIVE

To identify a recommended minimum set of core outcomes for BCC clinical trials.

METHODS

Patient and professional Delphi process to cull a long-list, culminating in a consensus meeting. To be provisionally accepted, outcomes needed to be deemed 'important' (score: 7-9, of maximum of 9) by 70% of each stakeholder group.

RESULTS

235 candidate outcomes identified via a systematic literature review and survey of key stakeholders were reduced to 74 that were rated by 100 health care professionals and patients in two Delphi rounds. 27 outcomes were provisionally accepted. The final core set of 5 agreed-upon outcomes after the consensus meeting was: complete response; persistent or serious adverse events; recurrence-free survival; quality of life; and patient satisfaction, including with cosmetic outcome.

LIMITATIONS

English-speaking patients and professionals rated outcomes extracted from English-language studies.

CONCLUSIONS

A core outcome set (COS) for basal cell carcinoma has been developed. Use of relevant measures may improve the utility of clinical research and the quality of therapeutic guidance available to clinicians.

Metastatic basal cell carcinoma of buccal mucosa: a report of a rare case

Background

Basal cell carcinoma (BCC) is the most common cancer worldwide. Most of BCCs can be detected in the early stages and are generally well controlled with local resection. Despite the high incidence of BCC, metastasis is rarely observed. Metastatic BCCs generally have an aggressive phenotype and are refractory to conventional treatment.

Case presentation

We describe a rare case of BCC in which a series of local relapses culminated in metastasis into the oral cavity 10 years after the first diagnosis of cutaneous BCC. We performed surgical resection and postoperative radiotherapy in this patient; 11 months after the final course of radiotherapy, the BCC remains stable, and the patient continues to be monitored regularly.

Conclusions

Because metastatic BCC is refractory to current treatment and difficult to control, his treatment history and the pathohistological features of BCC had to be considered in posttreatment planning.

Assessment of Basal Cell Carcinoma Using Dermoscopy and High Frequency Ultrasound Examination

Basal cell carcinoma (BCC) is the most common form of cutaneous neoplasia in humans, and dermoscopy may provide valuable information for histopathological classification of BCC, which allows for the choice of non-invasive topical or surgical therapy. Similarly, dermoscopy may allow for the identification of incipient forms of BCC that cannot be detected in clinical examination. The importance of early diagnosis using the dermoscopy of superficial BCC forms is proven by the fact that despite their indolent clinical appearance, they can be included in high-risk BCC forms due to the rate of postoperative recurrence. Nodular pigmentary forms of BCCs present ovoid gray-blue nests or multiple gray-blue dots/globules associated with arborized vessels, sometimes undetectable on clinical examination. The management of BCC depends on this, as pigmentary forms have been shown to have a poor response to photodynamic therapy. High frequency ultrasound examination (HFUS) aids in the diagnosis of BCC with hypoechoic tumour masses, as well as in estimating tumour size (thickness and diameter), presurgical margin delineation, and surgical planning. The examination is also useful for determining the invasion of adjacent structures and for studying local recurrences. The use of dermoscopy in combination with HFUS allows for optimisation of the management of the oncological patient.

Integrated care pathways and the hub-and-spoke model for the management of non-melanoma skin cancer: A proposal of the Italian Association of Hospital Dermatologists (ADOI)

The term non-melanoma skin cancer (NMSC) refers to skin cancer different from melanoma, and it is usually restricted to basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and their pre-cancerous lesions, e.g., actinic keratosis. These conditions represent the most frequent tumors in Caucasians and are characterized by an increasing incidence worldwide and a high socio-economic impact. The term Integrated Care Pathway (ICP) refers to "a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period". The purpose of this paper is to present a proposal from the Italian Association of Hospital Dermatologists (ADOI) for an ICP organization of care of NMSC, considering the hub-and-spoke model in the different geographical areas. This proposal is based on the most recent literature and on documents from the Italian Association of Medical Oncology (AIOM), the European consensus-based interdisciplinary guidelines from the European Association of Dermato- Oncology (EADO), and the National Comprehensive Cancer Network (NCCN). We initially discuss the NMSC outpatient clinic, the role of the multidisciplinary working groups, and the hub-and-spoke model regarding this topic. Then, we define the ICP processes specific for BCC and SCC. The ICP for NMSC is an innovative strategy to guarantee the highest possible quality of health care while the hub-andspoke model is crucial for the organization of different health care structures. Considering the importance on this topic, it is essential to create a valid ICP together with an efficient organization within the different geographical areas.

Three-dimensional histology vs. serial section histology in the treatment of primary basal cell carcinoma: a randomized, prospective, blinded study of 569 tumours

BACKGROUND

For basal cell carcinoma (BCC), only few controlled data have been published so far, which directly compare micrographically controlled surgery with conventional serial section histology. In addition to Mohs surgery, which uses cryostat sections, also three-dimensional histology (3D-histology), based on paraffin sections, is available to ensure complete control of the margins and basic sections.

OBJECTIVES

To investigate the rate of local recurrence (LR) as well as the number of required re-excisions for basal cell carcinomas with serial section histology vs. 3D-histology.

METHODS

We compared serial sections histology with 3D-histology in a prospective, randomized, controlled blinded trial and analysed 569 BCC of all subtypes up to 30 mm diameter, 287 BCC in the 3D group and 282 BCC in the serial section group. Excisions were performed with adapted primary resection margin according to location and size of the tumour. Surgeons were blinded at the time of surgery as they did not know which histological method will be used. Both methods used paraffin sections.

RESULTS

Both groups did not differ regarding patients age, tumour location, tumour diameter, tumour subtypes or primary resection margins. In the serial section group, re-excisions were required in 21%; 24 tumours (8.4%) recurred after a median of 2.2 years. In the 3D-histology group, re-excisions were required in 39%; 10 tumours recurred (3.5%) after a median of 2.8 years. The recurrence rates differed significantly between both groups. Mean follow-up was 4.5 years.

CONCLUSIONS

3D-histology is a useful technique to detect tumour outgrowths at the excision margins, but required a high rate of re-excisions. 3D-histology was associated with a significantly lower LR rate than serial section histology.

Computed tomography-based flap brachytherapy for non-melanoma skin cancers of the face

PURPOSE

Non-melanoma skin cancers of the face are at high-risk for local recurrence and metastatic spread. While surgical interventions such as Mohs microsurgery are considered the standard of care, this modality has the potential for high rates of toxicity in sensitive areas of the face. Catheter flap high-dose-rate (HDR) brachytherapy has shown promising results, with high rates of local control and acceptable cosmetic outcomes.

MATERIAL AND METHODS

Patients with non-melanoma skin cancers (NMSC) located on the face were treated with 40 Gy in 8 fractions, given twice weekly via catheter flap HDR brachytherapy. Clinical target volume (CTV) included the visible tumor plus a margin of 5 mm in all directions, with no additional planning target volume (PTV) margin.

RESULTS

Fifty patients with 53 lesions on the face were included, with a median follow-up of 15 months. All were considered high-risk based on NCCN guidelines. Median tumor size and thickness were 18 mm and 5 mm, respectively. Median PTV volume and D90 were 1.7 cc and 92%, respectively. Estimated rate of local control at twelve months was 92%. Three patients (5%) experienced acute grade 2 toxicity. Two patients (4%) continued to suffer from chronic grade 1 skin toxicity at 12 months post-radiotherapy (RT), with an additional two patients (4%) experiencing chronic grade 2 skin toxicity. Forty-nine lesions (92%) were found to have a good or excellent cosmetic outcome with complete tumor remission.

CONCLUSIONS

CT-based flap applicator brachytherapy is a valid treatment option for patients with NMSC of the face. This modality offers high rates of local control with acceptable cosmetic outcomes and low rates of toxicity.

Recommended Surgical Margins for Basal Cell Carcinoma: Is 3 mm Safe Enough?

OBJECTIVE

The primary aim of treatment of basal cell carcinoma (BCC) is the complete excision of the tumor. Reconstruction of the defect after surgical excision varies, depending on the location and size of the defect and the skin to be used in the reconstruction. In this study, investigators compared the rates of tumor positivity at the edges of BCC specimens excised with 3- or 5-mm surgical margins.

METHODS

Researchers analyzed data related to 113 patients with a preliminary diagnosis of BCC between August 2016 and June 2018. In total, 99 lesions from 91 patients not exceeding 2 cm in size excised with 3-mm (n = 53) or 5-mm (n = 46) surgical margins were included. Statistical analysis was performed using the χ test.

RESULTS

After histopathologic assessment, 3 of 53 lesions that were excised with 3-mm surgical margins had a positive surgical margin, whereas none of the 46 lesions excised with 5-mm margins indicated a positive tumor presence. However, there was no statistical difference between the groups.

CONCLUSIONS

A 3-mm surgical margin may be sufficient and safe for BCC excision.

Basal Cell Carcinoma: From Pathophysiology to Novel Therapeutic Approaches

Basal cell carcinoma (BCC) is the most common human cancer worldwide, and is a subtype of nonmelanoma skin cancer, characterized by a constantly increasing incidence due to an aging population and widespread sun exposure. Although the mortality from BCC is negligible, this tumor can be associated with significant morbidity and cost. This review presents a literature overview of BCC from pathophysiology to novel therapeutic approaches. Several histopathological BCC subtypes with different prognostic values have been described. Dermoscopy and, more recently, reflectance confocal microscopy have largely improved BCC diagnosis. Although surgery is the first-line treatment for localized BCC, other nonsurgical local treatment options are available. BCC pathogenesis depends on the interaction between environmental and genetic characteristics of the patient. Specifically, an aberrant activation of Hedgehog signaling pathway is implicated in its pathogenesis. Notably, Hedgehog signaling inhibitors, such as vismodegib and sonidegib, are successfully used as targeted treatment for advanced or metastatic BCC. Furthermore, the implementation of prevention measures has demonstrated to be useful in the patient management.

[Surgical techniques in the treatment of basal cell carcinoma-a prospective investigation]

Hintergrund

Basalzellkarzinome sind die häufigsten epithelialen Hauttumoren und eine häufige Indikation für dermatologische Eingriffe. Trotz der Etablierung medikamentöser Therapieoptionen stellt die Operation weiterhin die Therapie der Wahl dar. Hierbei stehen verschiedene Möglichkeiten zur Verfügung, die von der Kürettage bis hin zu komplexen dermatochirurgischen Eingriffen reichen. Neben dem Hauptaspekt der geringen lokalen Rezidivraten sind auch ästhetische Faktoren und die Anzahl der Eingriffe für die Wahl der Therapie wichtig.

Methoden

In dieser Studie wurden 347 Patienten mit 398 Basalzellkarzinomen (nodulärer Typ, Durchmesser bis 10 mm) prospektiv untersucht. Die Patienten wurden randomisiert in 2 Behandlungsarme eingeteilt: In einer Gruppe wurden die Tumoren kürettiert, in der anderen Gruppe exzidiert. Als Kontrolle dienten Patienten, die im gleichen Untersuchungszeitraum 3‑D-histologisch kontrolliert operiert wurden.

Ergebnisse

Die höchste lokale Rezidivrate wurde nach der Kürettage (14,0 %) beobachtet, während die Gruppe mit 3‑D-Histologie die niedrigste Rezidivrate (0,9 %; p < 0,001) aufwies. In der 3‑D-Gruppe waren mehr Re-Exzisionen erforderlich, um eine vollständige Entfernung des Tumors zu erreichen, als in der Gruppe mit histologischen Serienschnitten. Die Patienten bewerteten das ästhetische Ergebnis am besten nach der Kürettage. Die mittlere Nachbeobachtungszeit betrug 3,9 Jahre.

Schlussfolgerung

Die Wahl der chirurgischen Therapie bei kleinen nodulären Basalzellkarzinomen hängt von den individuellen Gegebenheiten ab. 3‑D-histologisch kontrollierte Exzisionen mit Wundverschluss nach vollständiger Tumorentfernung zeigten in unserer Studie die geringste Rezidivrate. Aber auch die Kürettage stellt eine mögliche chirurgische Therapieoption mit minimalem Aufwand und einer akzeptablen Rezidivrate dar, die zu guten ästhetischen Ergebnissen führen kann.

Surgical Margin of Excision in Basal Cell Carcinoma: A Systematic Review of Literature

Skin cancer is one of the most common cancers in the world and consists of melanoma and non-melanoma skin cancer (NMSC). Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the most common non-melanoma skin cancers. The ideal surgical treatment for BCC is complete removal, and it can be achieved either with safety margins or with micrographic control. The currently accepted treatment for basal cell carcinoma is an elliptical excision with a 4-mm surgical margin of clinically normal skin. However, because of cosmetic and functional constraints on the face, a 4-mm surgical margin is often not feasible. We used PubMed, PubMed Central (PMC), and Google scholar as our main databases to search for the relevant published studies and used "Basal cell carcinoma" and "narrow excision margins" as Medical Subject Headings (MeSH) keywords. Fifteen studies were finalized for the review, which included 3843 lesions. The size of the lesions ranged from 3 to 30 mm, with a mean size of 11.7 mm. Surgical margins varied from 1 to 5 mm. This review was done to evaluate if small, well-defined primary BCCs can be excised using narrow surgical margins. Based on the reviewed literature, we found that for primary well-demarcated BCCs smaller than 2 cm, in the low-risk group, a safety margin of 3 mm gives satisfactory results. In the high-risk group, and for lesions larger than 2 cm, a 4-6 mm margin is suggested for getting clear margins. Mohs micrographic surgery is advocated for more complex and recurrent lesions where the clinical margin is not apparent. However, micrographic surgery is not readily available in many places and requires more training and experience. Therefore, excision with 2 mm margins for clinically well-defined lesions with close follow-up can be followed to preserve the healthy tissue in anatomic constraint lesions and avoid the need for complex reconstructive procedures.

A dosimetric study of electron beam therapy vs. high-dose-rate mould brachytherapy in adjuvant treatment of non-melanoma skin carcinomas of the head and neck region

Purpose

Radiation for superficial tumours of the head and neck region can be given either by brachytherapy or electrons. Brachytherapy (BT), due to rapid dose fall-off and minor set-up errors, should be superior to external beam radiotherapy (EBRT) for treatment of lesions in difficult locations such as the nose and earlobe. The present study is a dosimetric comparison of computed tomography (CT)-based mould brachytherapy treatment plans with 3D conformal electron beam therapy in the treatment of non-melanoma skin cancers (NMSC).

Material and methods

From December 2017 to November 2018 10 patients with NMSC of the head and neck region (forehead, nose, cheek) who underwent adjuvant radiation with HDR brachytherapy (BT) with a surface mould individual applicator were enrolled for analysis. We evaluated dose coverage by minimal dose to 90% of planning target volume (PTV, D₉₀), volumes of PTV receiving 90-150% of prescribed dose (PD) (VPTV_90-150), conformal index for 90% and 100% of PD (COIN₉₀, COIN₁₀₀), dose homogeneity index (DHI), dose nonuniformity ratio (DNR), and exposure of organs at risk (OARs) (eyes, lens, underlying bone and skin). Prospectively, we created CT-based treatment plans for electron beam therapy. We compared conformity (COIN₉₀, COIN₁₀₀), dose coverage of PTV (D₉₀, VPTV₉₀, VPTV₁₀₀), volumes of body receiving 10-90% of PD (V₁₀-V₉₀), doses to OARs (D_0.1cc and D_2cc) of BT and electron plans.

Results

We obtained mean BT-DHI 0.81, BT-DNR 0.608, Electron-DHI 1.25. We observed no significant differences in VPTV_90,100 and D₉₀ between BT and electron beam. Mean BT-VPTV_125,150 were significantly higher than Electron-VPTV_100,125. COIN₉₀ was superior for BT plans.

Conclusions

CT-based surface mould brachytherapy results in better conformity of superficial lesions on small, irregular surfaces such as the nose and inner canthus than electrons with a slightly higher skin dose.

Electrochemotherapy and Ablative Therapies in Non-melanoma Skin Cancer

Although surgery and radiotherapy remain the most commonly used treatments for non-melanoma skin cancer, there are a variety of alternatives. Here we discuss the use of electrochemotherapy and ablative treatments and examine the evidence for their effectiveness against a number of non-melanoma skin cancers.

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.

Basal cell carcinoma: Contemporary approaches to diagnosis, treatment, and prevention

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education series provides a comprehensive and contemporary review of basal cell carcinoma. The second article in this series will present both the current standard of care and newly developed approaches to diagnosis, treatment, and prevention of this disease.

Basal cell carcinoma: Epidemiology; pathophysiology; clinical and histological subtypes; and disease associations

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education article will provide a comprehensive and contemporary review of basal cell carcinoma. The first article in this series describes our current understanding of this disease regarding epidemiology, cost, clinical and histopathologic presentations, carcinogenesis, natural history, and disease associations.

Treatments of Primary Basal Cell Carcinoma of the Skin: A Systematic Review and Network Meta-analysis

BACKGROUND

Most interventions for basal cell carcinoma (BCC) have not been compared in head-to-head randomized trials.

PURPOSE

To evaluate the comparative effectiveness and safety of treatments of primary BCC in adults.

DATA SOURCES

English-language searches of MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Embase from inception to May 2018; reference lists of guidelines and systematic reviews; and a search of ClinicalTrials.gov in August 2016.

STUDY SELECTION

Comparative studies of treatments currently used in adults with primary BCC.

DATA EXTRACTION

One investigator extracted data on recurrence, histologic clearance, clinical clearance, cosmetic outcomes, quality of life, and mortality, and a second reviewer verified extractions. Several investigators evaluated risk of bias for each study.

DATA SYNTHESIS

Forty randomized trials and 5 nonrandomized studies compared 18 interventions in 9 categories. Relative intervention effects and mean outcome frequencies were estimated using frequentist network meta-analyses. Estimated recurrence rates were similar for excision (3.8% [95% CI, 1.5% to 9.5%]), Mohs surgery (3.8% [CI, 0.7% to 18.2%]), curettage and diathermy (6.9% [CI, 0.9% to 36.6%]), and external-beam radiation (3.5% [CI, 0.7% to 16.8%]). Recurrence rates were higher for cryotherapy (22.3% [CI, 10.2% to 42.0%]), curettage and cryotherapy (19.9% [CI, 4.6% to 56.1%]), 5-fluorouracil (18.8% [CI, 10.1% to 32.5%]), imiquimod (14.1% [CI, 5.4% to 32.4%]), and photodynamic therapy using methyl-aminolevulinic acid (18.8% [CI, 10.1% to 32.5%]) or aminolevulinic acid (16.6% [CI, 7.5% to 32.8%]). The proportion of patients reporting good or better cosmetic outcomes was better for photodynamic therapy using methyl-aminolevulinic acid (93.8% [CI, 79.2% to 98.3%]) or aminolevulinic acid (95.8% [CI, 84.2% to 99.0%]) than for excision (77.8% [CI, 44.8% to 93.8%]) or cryotherapy (51.1% [CI, 15.8% to 85.4%]). Data on quality of life and mortality were too sparse for quantitative synthesis.

LIMITATION

Data are sparse, and effect estimates are imprecise and informed by indirect comparisons.

CONCLUSION

Surgical treatments and external-beam radiation have low recurrence rates for the treatment of low-risk BCC, but substantial uncertainty exists about their comparative effectiveness versus other treatments. Gaps remain regarding high-risk BCC subtypes and important outcomes, including costs.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42016043353).

The economic burden of occupational non-melanoma skin cancer due to solar radiation

Solar ultraviolet (UV) radiation is the second most prevalent carcinogenic exposure in Canada and is similarly important in other countries with large Caucasian populations. The objective of this article was to estimate the economic burden associated with newly diagnosed non-melanoma skin cancers (NMSCs) attributable to occupational solar radiation exposure. Key cost categories considered were direct costs (healthcare costs, out-of-pocket costs (OOPCs), and informal caregiver costs); indirect costs (productivity/output costs and home production costs); and intangible costs (monetary value of the loss of health-related quality of life (HRQoL)). To generate the burden estimates, we used secondary data from multiple sources applied to computational methods developed from an extensive review of the literature. An estimated 2,846 (5.3%) of the 53,696 newly diagnosed cases of basal cell carcinoma (BCC) and 1,710 (9.2%) of the 18,549 newly diagnosed cases of squamous cell carcinoma (SCC) in 2011 in Canada were attributable to occupational solar radiation exposure. The combined total for direct and indirect costs of occupational NMSC cases is $28.9 million ($15.9 million for BCC and $13.0 million for SCC), and for intangible costs is $5.7 million ($0.6 million for BCC and $5.1 million for SCC). On a per-case basis, the total costs are $5,670 for BCC and $10,555 for SCC. The higher per-case cost for SCC is largely a result of a lower survival rate, and hence higher indirect and intangible costs. Our estimates can be used to raise awareness of occupational solar UV exposure as an important causal factor in NMSCs and can highlight the importance of occupational BCC and SCC among other occupational cancers.

Imiquimod 5% cream for the treatment of large nodular basal cell carcinoma at the medial canthal area

Context (Background):

Imiquimod (IMQ) 5% cream is an immunomodulatory and antitumorigenic agent, which was used as a topical treatment regimen, who had periocular basal cell carcinoma (BCC).

Aim:

This study aims to present three cases with large BCC at the medial canthal area treated with IMQ 5% cream.

Materials and Methods:

IMQ 5% cream was used in three patients with ages 45, 49, and 73 who preferred medical treatment over surgery. Following incisional biopsy IMQ cream was used once a day, 5 times a week and the patients were followed up weekly during 12 week treatment period and monthly after the clearance of the lesion.

Results:

Erythema and erosion on the surface of the lesion, injection of conjunctiva, burning and itching sensation, epiphora and punctate keratitis were seen in all patients during the treatment period. The ophthalmic side effects could be managed by topical lubricating eye drops and the inflammatory reactions resolved within 1 month after cessation of therapy. The patients were followed up for at least 3 years without tumor recurrence and the biopsies taken from the suspected area were found to be tumor free.

Conclusion:

Surgical excision of carcinoma of the eyelid at medial canthal area can be difficult without causing damage to the lacrimal system and reconstruction of the defect may need grafts or flaps. IMQ may provide an alternative therapy to surgery in certain cases.

Non-melanoma skin cancer: new and future synthetic drug treatments

INTRODUCTION

Non-melanoma skin cancers (NMSC) mainly comprise two different entities: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC); beneath these two entities, Merkel cell carcinoma, adnexal tumors, dermatofibrosarcoma protuberans, angiosarcoma, and cutaneous lymphoma belong to NMSC. These rare skin tumors are not the topic of this review. BCC and SCC are the most common cancers diagnosed in humans. The preferred treatment is surgery, which in most cases is curative. Although a high recurrence rate is seen, these cancers rarely metastasize. Therefore, systemic treatments were not a priority for these patients. It is long known that the abnormal activation of Hedgehog and epidermal growth factor receptor pathways were involved in BCC and SCC. In the last decade, metastatic disease became an important area of research, mostly because new therapies that targeted components of these two pathways became available. Areas covered: Here we cover the available therapeutic options for patients diagnosed with BCC and SCC, focus on systemic and targeted therapies. Expert opinion: BCC and SCC are common cancers, with good prognosis. More than the metastatic disease, advanced local disease and recurrent disease pose clinicians a great challenge. Albeit there are promising results with targeted therapies, resistance development has already been described.

Highly conformal CT based surface mould brachytherapy for non-melanoma skin cancers of earlobe and nose

Purpose

Brachytherapy (BT), due to rapid dose fall off and minor set-up errors, should be superior to external beam radiotherapy (EBRT) for treatment of lesions in difficult locations like nose and earlobe. Evidences in this field are scarce. We describe computed tomography (CT) based surface mould BT for non-melanoma skin cancers (NMSC), and compare its conformity, dose coverage, and tissue sparing ability to EBRT.

Material and methods

We describe procedure of preparation of surface mould applicator and dosimetry parameters of BT plans, which were implemented in 10 individuals with NMSC of nose and earlobe. We evaluated dose coverage by minimal dose to 90% of planning target volume (PTV) (D₉₀), volumes of PTV receiving 90-150% of prescribed dose (PD) (VPTV_90-150), conformal index for 90 and 100% of PD (COIN₉₀, COIN₁₀₀), dose homogeneity index (DHI), dose nonuniformity ratio (DNR), exposure of organs. Prospectively, we created CT-based photons and electrons plans. We compared conformity (COIN₉₀, COIN₁₀₀), dose coverage of PTV (D₉₀, VPTV₉₀, VPTV₁₀₀), volumes of body receiving 10-90% of PD (V₁₀-V₉₀) of EBRT and BT plans.

Results

We obtained mean BT-DHI = 0.76, BT-DNR = 0.23, EBRT-DHI = 1.26. We observed no significant differences in VPTV₉₀ and D₉₀ between BT and EBRT. Mean BT-VPTV₁₀₀ (89.4%) was higher than EBRT-VPTV₁₀₀ (71.2%). Both COIN₉₀ (BT-COIN₉₀ = 0.46 vs. EBRT-COIN₉₀ = 0.21) and COIN₁₀₀ (BT-COIN₁₀₀ = 0.52 vs. EBRT-COIN₁₀₀ = 0.26) were superior for BT plans. We observed more exposure of normal tissues for small doses in BT plans (V₁₀, V₂₀), for high doses in EBRT plans (V₇₀, V₉₀).

Conclusions

Computed tmography-based surface mould brachytherapy for superficial lesions on irregular surfaces is a highly conformal method with good homogeneity. Brachytherapy is superior to EBRT in those locations in terms of conformity and normal tissue sparing ability in high doses.

Traditional versus streamlined management of basal cell carcinoma (BCC): A cost analysis

BACKGROUND

Facing rising incidence of basal cell carcinoma (BCC) and increasing pressure to contain health care spending, physicians need to contemplate cost-effective paradigms for managing BCC.

OBJECTIVE

We sought to perform a cost analysis comparing the traditional BCC management scheme with a simplified detect-and-treat scheme that eliminates the biopsy before initiating definitive treatment.

METHODS

A decision analytic model was developed to compare the costs of traditional BCC management with the detect-and-treat scheme, under which qualifying lesions diagnosed clinically were either treated with shave removal or referred to Mohs micrographic surgery for on-site histologic check. Values for model parameters were based on literature and our institutional data analysis. Costs were based on 2014 Medicare fee schedule.

RESULTS

The average cost per lesion with detect-and-treat scheme was $449 for non-Mohs micrographic surgery-indicated lesions (vs $566 with traditional management, $117 in savings) and $819 for Mohs micrographic surgery-indicated lesions (vs $864 with traditional management, $45 in savings). The combined weighted average savings per case was $95 (15% of total average cost). Conclusions were similar under various plausible scenarios.

LIMITATIONS

Model parameter values may vary based on individual practices.

CONCLUSIONS

A simplified management strategy eliminating routine pretreatment biopsy can reduce BCC treatment cost without compromising quality of care.

Burden of basal cell carcinoma in USA

Basal cell carcinoma (BCC) is the most common malignancy diagnosed in the USA and its incidence continues to increase. While BCC is still most prevalent in the older segments of the population, it is becoming ever more frequent in younger individuals. The costs of treatment and morbidity associated with BCCs place a heavy public health and economic burden on patients, their families and the American healthcare system and underscore the importance of efficient management and prevention efforts directed toward this malignancy. In this article, we address economic aspects of BCC using evidence from large-scale epidemiological studies. This information may help clinicians in developing better and more cost-effective methods for dealing with the most common cancer in America and in the world.

Basal cell carcinoma of the skin (part 2): diagnosis, prognosis and management

Basal cell carcinoma (BCC) is a heterogeneous malignant neoplasm with different biological and clinical behaviors, often slow growing and rarely metastatic and conveying an excellent prognosis. However, BCC is the most frequent skin cancer worldwide and can cause great morbidity, as most occur in high visible areas of the body, often relapse and may invade and destroy local tissues. This review aims to present a concise and updated overview of BCC histopathology and clinical presentation and progression. We also present a summary of currently available treatment options and some of the new promising agents.

Dermoscopy in the diagnosis and management of basal cell carcinoma

The dermoscopic findings of basal cell carcinoma (BCC) were first described more than a decade ago and the list of BCC-related criteria has been several times updated and enriched. Today, the dermatoscope is considered the key tool for the diagnosis of BCC, since it allows its early detection and enables its discrimination from other pigmented and nonpigmented skin tumors. The dermoscopic pattern of BCC results from several combinations of well-known BCC criteria, depending on several factors, including histopathologic subtype, location, gender, age and pigmentary trait. In addition, recent evidence highlighted that dermoscopy is also useful in the management of BCC, since it provides information on the tumor subtype, the presence of pigmentation or ulceration and the response to nonablative treatments.

Consensus for nonmelanoma skin cancer treatment: basal cell carcinoma, including a cost analysis of treatment methods

BACKGROUND

Basal cell carcinoma (BCC) is the most common cancer in the US population affecting approximately 2.8 million people per year. Basal cell carcinomas are usually slow-growing and rarely metastasize, but they do cause localized tissue destruction, compromised function, and cosmetic disfigurement.

OBJECTIVE

To provide clinicians with guidelines for the management of BCC based on evidence from a comprehensive literature review, and consensus among the authors.

MATERIALS AND METHODS

An extensive review of the medical literature was conducted to evaluate the optimal treatment methods for cutaneous BCC, taking into consideration cure rates, recurrence rates, aesthetic and functional outcomes, and cost-effectiveness of the procedures.

RESULTS

Surgical approaches provide the best outcomes for BCCs. Mohs micrographic surgery provides the highest cure rates while maximizing tissue preservation, maintenance of function, and cosmesis.

CONCLUSION

Mohs micrographic surgery is an efficient and cost-effective procedure and remains the treatment of choice for high-risk BCCs and for those in cosmetically sensitive locations. Nonsurgical modalities may be used for low-risk BCCs when surgery is contraindicated or impractical, but the cure rates are lower.

The dermatoscopic universe of basal cell carcinoma

Following the first descriptions of the dermatoscopic pattern of basal cell carcinoma (BCC) that go back to the very early years of dermatoscopy, the list of dermatoscopic criteria associated with BCC has been several times updated and renewed. Up to date, dermatoscopy has been shown to enhance BCC detection, by facilitating its discrimination from other skin tumors and inflammatory skin diseases. Furthermore, upcoming evidence suggests that the method is also useful for the management of the tumor, since it provides valuable information about the histopathologic subtype, the presence of clinically undetectable pigmentation, the expansion of the tumor beyond clinically visible margins and the response to non-ablative treatments. In the current article, we provide a summary of the traditional and latest knowledge on the value of dermatoscopy for the diagnosis and management of BCC.

Predictors of recurrence after radiotherapy for non-melanoma skin cancer

Predictive factors of recurrence were examined in 448 non-melanoma skin cancers (72% basal cell carcinoma, 28% squamous cell carcinoma) treated with radiotherapy. The overall recurrence rate was 15.8% at a median follow-up of 18.4 months. In multivariate analysis, significant factors for recurrence were age (p = 0.0197), tumour size 2 cm or greater (p = 0.0095), immunosuppression (p = 0.0082), and treatment modality (p = 0.0009).

Characteristics of Mixed Type Basal Cell Carcinoma in Comparison to Other BCC Subtypes

Background:

There are limited data exploring the characteristics of mixed type basal cell carcinoma (BCC).

Objectives:

To explore different characteristics of mixed type BCC.

Design:

Cross sectional study.

Materials and Methods:

825 patients with BCC enrolled in this study.

Results:

Among 825 patients, 512 (62%) were male. Three hundred and fifty five (43%) presented with nodular subtype, 267 (32.4%) with mixed subtype, 25 with superficial and the 178 remaining presented with other subtypes. Four hundred and eighty three (58.6%) of the lesions were on the face, 243 (29.5%) on scalp, 52 (6.3%) on ears, 20 (2.4%) on neck, 15 (1.8%) on trunk and 12 (1.4%) on extremities. Anatomic distribution of mixed type was as follows: 137 on face, (51.4%), 100 (37.3%) on scalp, 19 (7%) on ear, 6 (2.1%) on neck, 4 (1.5%) extremity and 1 (0.7%) on trunk, which the difference from non mixed types was statistically significant (P = 0.002). The mean diameter of the mixed types and non mixed type BCCs were significantly different (2.7 ± 2.1 cm vs. 2.2 ± 1.6 cm; P = 0.01. The prevalence of necrosis in mixed type BCC was two times higher than non mixed type BCCs (OR = 2.3, CI 95% 1.3-3.9, P = 0.001). The most frequent combined subtypes were nodular-infiltrative (P < 0.001).

Conclusion:

Mixed type BCC has differences with other BCC subtypes in anatomical distribution and tumor diameter. Indeed, mixed type BCCs are frequently composed of aggressive subtypes than nonaggressive subtypes.

A light emitting diode (LED) based spatial frequency domain imaging system for optimization of photodynamic therapy of nonmelanoma skin cancer: quantitative reflectance imaging

BACKGROUND

Photodynamic therapy (PDT) offers the potential for enhanced treatment of nonmelanoma skin cancer (NMSC) with minimal scarring. Yet, PDT has not achieved consistent long term effectiveness to gain widespread clinical acceptance for treatment of skin cancer. Therapeutic response varies between practitioners, patients and lesions. One important contributing factor is the absence of quantitative tools to perform in vivo dosimetry. To this end, we have developed a new quantitative imaging device that can be used to investigate parameters related to optimizing dosimetry.

METHODS

We present a spatial frequency domain imaging (SFDI) based device designed to: (1) determine the optical properties at the therapeutic wavelength, which can inform variations in light penetration depth and (2) measure the spatially resolved oxygen saturation of the skin cancer lesions and surrounding tissue. We have applied this system to a preliminary clinical study of nine skin cancer lesions.

RESULTS

Optical properties vary greatly both spatially [101%, 48% for absorption and reduced scattering, respectively] and across patients [102%, 57%]. Blood volume maps determined using visible wavelengths (460, 525, and 630 nm) represent tissue volumes within ∼1 mm in tissue (1.17 ± 0.3 mm). Here the average total hemoglobin concentration is approximately three times greater in the lesion than that detected in normal tissue, reflecting increased vasculature typically associated with tumors. Data acquired at near infrared wavelengths (730 and 850 nm) reports tissue blood concentrations and oxygenations from the underlying dermal microvasculature (volumes reaching 4.36 ± 1.32 mm into tissue).

CONCLUSIONS

SFDI can be used to quantitatively characterize in vivo tissue optical properties that could be useful for better informing PDT treatment parameters. Specifically, this information provides spatially resolved insight into light delivery into tissue and local tissue oxygenation, thereby providing more quantitative and controlled dosimetry specific to the lesion. Ultimately, by optimizing the execution of PDT, this instrument has the potential to positively improve treatment outcomes.

A light emitting diode (LED) based spatial frequency domain imaging system for optimization of photodynamic therapy of nonmelanoma skin cancer: quantitative reflectance imaging

BACKGROUND

Photodynamic therapy (PDT) offers the potential for enhanced treatment of nonmelanoma skin cancer (NMSC) with minimal scarring. Yet, PDT has not achieved consistent long term effectiveness to gain widespread clinical acceptance for treatment of skin cancer. Therapeutic response varies between practitioners, patients and lesions. One important contributing factor is the absence of quantitative tools to perform in vivo dosimetry. To this end, we have developed a new quantitative imaging device that can be used to investigate parameters related to optimizing dosimetry.

METHODS

We present a spatial frequency domain imaging (SFDI) based device designed to: (1) determine the optical properties at the therapeutic wavelength, which can inform variations in light penetration depth and (2) measure the spatially resolved oxygen saturation of the skin cancer lesions and surrounding tissue. We have applied this system to a preliminary clinical study of nine skin cancer lesions.

RESULTS

Optical properties vary greatly both spatially [101%, 48% for absorption and reduced scattering, respectively] and across patients [102%, 57%]. Blood volume maps determined using visible wavelengths (460, 525, and 630 nm) represent tissue volumes within ∼1 mm in tissue (1.17 ± 0.3 mm). Here the average total hemoglobin concentration is approximately three times greater in the lesion than that detected in normal tissue, reflecting increased vasculature typically associated with tumors. Data acquired at near infrared wavelengths (730 and 850 nm) reports tissue blood concentrations and oxygenations from the underlying dermal microvasculature (volumes reaching 4.36 ± 1.32 mm into tissue).

CONCLUSIONS

SFDI can be used to quantitatively characterize in vivo tissue optical properties that could be useful for better informing PDT treatment parameters. Specifically, this information provides spatially resolved insight into light delivery into tissue and local tissue oxygenation, thereby providing more quantitative and controlled dosimetry specific to the lesion. Ultimately, by optimizing the execution of PDT, this instrument has the potential to positively improve treatment outcomes.

A light emitting diode (LED) based spatial frequency domain imaging system for optimization of photodynamic therapy of nonmelanoma skin cancer: quantitative reflectance imaging

BACKGROUND

Photodynamic therapy (PDT) offers the potential for enhanced treatment of nonmelanoma skin cancer (NMSC) with minimal scarring. Yet, PDT has not achieved consistent long term effectiveness to gain widespread clinical acceptance for treatment of skin cancer. Therapeutic response varies between practitioners, patients and lesions. One important contributing factor is the absence of quantitative tools to perform in vivo dosimetry. To this end, we have developed a new quantitative imaging device that can be used to investigate parameters related to optimizing dosimetry.

METHODS

We present a spatial frequency domain imaging (SFDI) based device designed to: (1) determine the optical properties at the therapeutic wavelength, which can inform variations in light penetration depth and (2) measure the spatially resolved oxygen saturation of the skin cancer lesions and surrounding tissue. We have applied this system to a preliminary clinical study of nine skin cancer lesions.

RESULTS

Optical properties vary greatly both spatially [101%, 48% for absorption and reduced scattering, respectively] and across patients [102%, 57%]. Blood volume maps determined using visible wavelengths (460, 525, and 630 nm) represent tissue volumes within ∼1 mm in tissue (1.17 ± 0.3 mm). Here the average total hemoglobin concentration is approximately three times greater in the lesion than that detected in normal tissue, reflecting increased vasculature typically associated with tumors. Data acquired at near infrared wavelengths (730 and 850 nm) reports tissue blood concentrations and oxygenations from the underlying dermal microvasculature (volumes reaching 4.36 ± 1.32 mm into tissue).

CONCLUSIONS

SFDI can be used to quantitatively characterize in vivo tissue optical properties that could be useful for better informing PDT treatment parameters. Specifically, this information provides spatially resolved insight into light delivery into tissue and local tissue oxygenation, thereby providing more quantitative and controlled dosimetry specific to the lesion. Ultimately, by optimizing the execution of PDT, this instrument has the potential to positively improve treatment outcomes.

Recurrence rates of aggressive histologic types of basal cell carcinoma after treatment with electrodesiccation and curettage alone

BACKGROUND

Basal cell carcinoma (BCC) is the most common cancer in Caucasians. Treatment options include electrodesiccation and curettage (EDC), surgical excision, and Mohs micrographic surgery (MMS). EDC is standard for smaller BCCs in low-risk locations with nonaggressive histologic subtypes. Larger BCCs in higher-risk locations and aggressive histologic subtypes are treated using surgical excision or MMS. We found no studies reporting recurrence rates for aggressive BCC subtypes treated using EDC alone.

OBJECTIVE

To determine recurrence rates of histologically aggressive BCC treated using EDC.

METHODS AND MATERIALS

This population-based, retrospective case study reviewed 37 primary infiltrative, desmoplastic, morpheaform, or micronodular BCCs in 34 patients treated with EDC. Recurrence was defined as reappearance of BCC within the boundaries of or contiguous to the scar resulting from initial treatment.

RESULTS

Of 37 primary aggressive BCCs, 10 recurred within 3.3 years. Average primary tumor diameter was 0.69 cm. Average primary tumor diameter was 0.73 cm for those that recurred and 0.67 cm for those that did not recur. Six recurrences were in high-risk areas, three in moderate-risk areas, and one in a low-risk area.

CONCLUSION

We report a 27% recurrence rate for histologically aggressive BCCs treated using EDC alone with median 6.5 years follow-up.

Tumor recurrence 5 years after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma

For most cutaneous basal cell and squamous cell carcinomas (nonmelanoma skin cancers [NMSC]) data are insufficient to permit evidence-based choices among treatments. To compare tumor recurrence after treatments, we conducted a prospective cohort study of consecutive patients with primary NMSC treated with the most common treatments in two practices in 1999–2000. Recurrence was determined from medical records by observers blinded to treatment type. 24.3% of tumors (N=361) were treated with destruction with electrodessication / curettage, 38.3% (N=571) with excision, and 37.4% (N=556) with histologically-guided serial excision (Mohs surgery). Follow-up was available for 1174 patients with 1488 tumors (93.8%) at median 7.4 years; overall 5-year tumor recurrence rate [95% Confidence Interval] was 3.3% [2.3, 4.4]. Unadjusted recurrence rates did not differ after treatments: 4.9% [2.3, 7.4] after destruction, 3.5% [1.8, 5.2] after excision, and 2.1% [0.6, 3.5] after Mohs surgery (P=0.26), and no difference was seen after adjustment for risk factors. In tumors treated only with excision or Mohs surgery, the hazard of recurrence was not significantly different, even after adjustment for propensity for treatment with Mohs surgery. These data indicate that common treatments for NMSC were at least 95% effective, and further studies are needed to guide therapeutic choices for different clinical subgroups.

Usefulness of margin detection by digital dermoscopy in the traditional surgical excision of basal cell carcinomas of the head and neck including infiltrative/morpheaform type

Incomplete or suboptimal surgical excision of basal cell carcinoma of the head and neck is a relatively frequent occurrence. Methods of preoperative assessment of tumoral margins are therefore of paramount importance. The aim of this study was to compare the preoperative evaluation of margins with digital dermoscopy and clinical definition. One hundred and 12 patients with histologically confirmed basal cell carcinoma were selected for surgical excision. Subsequently, the margin of excision was determined by either clinical (45 patients) or dermoscopic evaluation (67 patients). After pre-surgical clinical evaluation, 22% of histological specimens of excised basal cell carcinoma showed suboptimal margins of excision. Pre-surgical dermoscopic evaluation had only 7% suboptimal excision. Preoperative digital dermoscopy is a better method to determine tumoral margins than clinical evaluation alone. Indeed, preoperative digital dermoscopy is an effective, simple, non-invasive procedure for the pre-surgical determination of margins.

Recurrence after treatment of nonmelanoma skin cancer: a prospective cohort study

OBJECTIVE

To determine long-term tumor recurrence rates after treatment of primary nonmelanoma skin cancer (NMSC). Data are currently insufficient to permit evidence-based choices among treatments for NMSC.

DESIGN

Prospective study of an inception cohort observed for a median of 6.6 years after treatment.

SETTING

Dermatology clinic at a Veterans Affairs hospital. Care was provided by dermatology resident or attending physicians.

PATIENTS

Consecutive sample of all 495 patients with 616 primary NMSCs diagnosed in 1999 and 2000 and treated with electrodessication and curettage (ED&C), excision, or Mohs surgery. Follow-up was available for 608 tumors (99%).

MAIN OUTCOME MEASURE

Tumor recurrence, determined by medical record review, with validation by clinical examination.

RESULTS

The mean age at diagnosis was 71 years; 97% were men. Overall, 127 tumors were treated with ED&C (20.9%); 309 with excision (50.8%); and 172 with Mohs surgery (28.3%). Over the course of the study, 21 tumors recurred (3.5% [95% confidence interval (CI), 2.2%-5.2%]): 2 after ED&C (1.6% [95% CI, 0.2%-5.6%]), 13 after excision (4.2% [95% CI, 2.2%-7.1%]), and 6 after Mohs surgery (3.5% [95% CI, 1.3%-7.4%]).

CONCLUSIONS

Recurrence of primary NMSC after treatment occurred in less than 5% of tumors. The recurrence rate after ED&C was lower than expected, and the recurrence rate after Mohs surgery was higher than expected. These findings may be related to the risk for recurrence in the treatment groups.

Plesiotherapy for non-melanoma skin cancer: innovating to overcome!

Background:

The non-surgical management of non-melanoma skin cancers is an area requiring clinical investigation. Radiotherapy has a role in treatment for a defined subset of patients.

Aims:

The application of radiotherapy is subject to availability of proper equipment, non-availability of which precludes appropriate radiotherapy in most centers in third world countries.

Materials and Methods:

The introduction of innovations is needed to circumvent this. Plesiotherapy is such a mode of therapy for non-melanoma skin cancer.

Methods:

The introduction of innovations is needed to circumvent this. Plesiotherapy is such a mode of therapy for non-melanoma skin cancer.

Results:

In this paper we present successful management of a cohort of non-melanoma skin cancer patients with plesiotherapy using stepping source¹⁹² Ir HDR source.

Conclusions:

Plesiothrapy is an effective mode of therapy for non-melanoma skin cancer.