Basal cell carcinoma: treatment options and prognosis, a scientific approach to a common malignancy

European consensus-based interdisciplinary guideline for diagnosis and treatment of basal cell carcinoma-update 2023

Basal cell carcinoma (BCC) is the most common malignant tumour in white populations. Multidisciplinary experts from European Association of Dermato-Oncology (EADO), European Dermatology Forum, European Society for Radiotherapy and Oncology (ESTRO), Union Européenne des Médecins Spécialistes, and the European Academy of Dermatology and Venereology developed updated recommendations on diagnosis and treatment of BCC. BCCs were categorised into 'easy-to-treat' (common) and 'difficult-to-treat' according to the new EADO clinical classification. Diagnosis is based on clinico-dermatoscopic features, although histopathological confirmation is mandatory in equivocal lesions. The first-line treatment of BCC is complete surgery. Micrographically controlled surgery shall be offered in high-risk and recurrent BCC, and BCC located on critical anatomical sites. Topical therapies and destructive approaches can be considered in patients with low-risk superficial BCC. Photodynamic therapy is an effective treatment for superficial and low-risk nodular BCCs. Management of 'difficult-to-treat' BCCs should be discussed by a multidisciplinary tumour board. Hedgehog inhibitors (HHIs), vismodegib or sonidegib, should be offered to patients with locally advanced and metastatic BCC. Immunotherapy with anti-PD1 antibodies (cemiplimab) is a second-line treatment in patients with a progression of disease, contraindication, or intolerance to HHI therapy. Radiotherapy represents a valid alternative in patients who are not candidates for or decline surgery, especially elderly patients. Electrochemotherapy may be offered when surgery or radiotherapy is contraindicated. In Gorlin patients, regular skin examinations are required to diagnose and treat BCCs at an early stage. Long-term follow-up is recommended in patients with high-risk BCC, multiple BCCs, and Gorlin syndrome.

Cryotherapy as an Effective therapeutic Option in Patients with Nodular Basal Cell Carcinoma - Case Report

Basal cell carcinoma (BCC) is a malignant tumor originating from epidermal cells. A case of BCC was reported in a 67-year-old female, with the initial complaint of skin-colored papules, which later turned into a nodule with erosion and crusts on the right shoulder. The diagnosis is established from findings consistent with nodular BCC on physical examination, and from dermoscopic appearance revealing ulceration, blue-gray ovoid nests, deeply pigmented border, and arborizing vessels. Histopathological examination showed tumor cells forming palisading structures with myxoid stroma, polymorphic, hyperchromatic and mitotic nuclei, as well as fibrocollagen connective tissue cells with lymphocyte infiltrates. Cryotherapy is a therapeutic option for BCC in old patients and has a cure rate of around 95%. Observation on the 25th day revealed clinical improvement with reduced nodular lesion size; thus, further cryotherapy was needed to enhance the therapeutic outcomes.

Intradermal Delivery of an Immunomodulator for Basal Cell Carcinoma; Expanding the Mechanistic Insight into Solid Microneedle-Enhanced Delivery of Hydrophobic Molecules

Basal cell carcinoma (BCC) is the most common cutaneous malignancy in humans. One of the most efficacious drugs used in the management of BCC is the immunomodulator, imiquimod. However, imiquimod has physiochemical properties that limit its permeation to reach deeper, nodular tumor lesions. The use of microneedles may overcome such limitations and promote intradermal drug delivery. The current work evaluates the effectiveness of using an oscillating microneedle device Dermapen either as a pre- or post-treatment with 5% w/w imiquimod cream application to deliver the drug into the dermis. The effectiveness of microneedles to enhance the permeation of imiquimod was evaluated ex vivo using a Franz cell setup. After a 24-h permeation experiment, sequential tape strips and vertical cross-sections of the porcine skin were collected and analyzed using time-of-flight secondary ion mass spectrometry (ToF-SIMS). In addition, respective Franz cell components were analyzed using high-performance liquid chromatography (HPLC). Analysis of porcine skin cross-sections demonstrated limited dermal permeation of 5% w/w imiquimod cream. Similarly, limited dermal permeation was also seen when 5% w/w imiquimod cream was applied to the skin that was pretreated with the Dermapen, this is known as poke-and-patch. In contrast, when the formulation was applied first to the skin prior to Dermapen application, this is known as patch-and-poke, we observed a significant increase in intradermal permeation of imiquimod. Such enhancement occurs immediately upon microneedle application, generating an intradermal depot that persists for up to 24 h. Intradermal colocalization of isostearic acid, an excipient in the cream, with imiquimod within microneedle channels was also demonstrated. However, such enhancement in intradermal delivery of imiquimod was not observed when the patch-and-poke strategy was used with a non-oscillating microneedle applicator, the Dermastamp. The current work highlights that using the patch-and-poke approach with an oscillating microneedle pen may be a viable approach to improve the current treatment in BCC patients who would prefer a less invasive intervention relative to surgery.

High-risk basal cell carcinoma excision in primary care: a retrospective observational study of compliance with NICE guidance

OBJECTIVES

To assess compliance with 2010 National Institute for Health and Care Excellence (NICE) guidance on cancer services relating to the management of basal cell carcinomas (BCC) in the community, where except in specific circumstances it is recommended that only low-risk BCCs should be excised routinely.

DESIGN AND SETTING

A retrospective observational study of the histopathology reports of BCC excisions received from primary care in two district general hospitals in the South of England. One hundred consecutive BCC excisions were analysed from each hospital.

OUTCOME MEASURES

The numbers of high-risk BCCs excised in primary care according to histological subtype, anatomical site and age and if these excisions were compliant with NICE 2010 guidance. Completeness of excision and mention of BCC on histology request were secondary outcomes.

RESULTS

Histologically high-risk subtypes were present in 32% (64/200) of BCCs excised in the community. Only 17/64 were excised by general practitioners (GPs) who were accredited to do so. Non-compliance regarding anatomical site occurred in 16% of samples; only one was non-compliant regarding patient age. There was a high overall rate of complete excision (94.5%) with variation in presence of the term BCC on histology request forms.

CONCLUSIONS

NICE 2010 guidance relating to BCC excision in primary care was not followed in a considerable number of cases. Compliance with NICE 2010 guidance depends on the ability to recognise high-risk BCCs clinically and manage appropriately. It also shows that despite close supervision by secondary care, there are still failures of compliance.GP training in identification of subtypes of BCC might be improved, as well as an increase in numbers of GPs accredited to carry out high-risk BCC excisions. Difficulty in diagnosing high-risk histological subtypes of BCC preoperatively should be considered in any future revision of NICE guidance.

Orthovoltage X-rays for Postoperative Treatment of Resected Basal Cell Carcinoma in the Head and Neck Area

Background:

Surgery is the golden standard for treating basal cell carcinomas. In case of positive tumor margins or recurrent disease, postoperative adjuvant or salvaging therapy is suggested to achieve good local control.

Objective:

To retrospectively report on local control and toxicity of postoperative radiotherapy by means of orthovoltage X-rays for residual or recurrent basal cell carcinoma after surgery in the head and neck area.

Methods:

Sixty-six surgically resected residual or recurrent basal cell carcinomas of the head and neck region were irradiated postoperatively by means of orthovoltage X-rays at the Netherlands Cancer Institute between January 2000 and February 2015.

Results:

After a median follow-up duration of 30.5 months, only 5 recurrences were reported. The 5-year local control rates at 1, 3, and 5 years were 100%, 87%, and 87%, respectively. The 5-year local control rate was 92% for immediate postoperative radiotherapy of incompletely resected basal cell carcinomas, 90% for recurrences after 1 previously performed excision, and 71% for multiple recurrences, namely, a history of more than 1 excision ( P = .437). Acute toxicity healed spontaneously within 3 months. Late toxicities were mild.

Conclusion:

Radiotherapy by means of orthovoltage X-ray is an excellent alternative for re-excision in case of incompletely resected or recurrent basal cell carcinomas that are at risk of serious functional and cosmetic impairments after re-excision, with a 5-year local control rate of 87% and a low toxicity profile.

Light-emitting diodes in photodynamic therapy in non-melanoma skin cancers--own observations and literature review

Photodynamic therapy (PDT) employs light activation of tissue-localized photosensitizer in an oxygen-dependent process which initiates oxidative stress, inflammation, and cell death. There are many indications for PDT, although the main ones are still non-melanoma skin cancers. The light sources used include coherent and non-coherent ones, but we would like to focus on the use of light-emitting diodes (LED) in PDT. We present four patients with skin lesions successfully treated with LED-based photodynamic therapy. The main advantage of that source is narrow emission spectrum that can correspond well with maximum absorption photosensitizers. Also, using LED source seems to be cheaper and simpler, and the field of irradiation is larger. The data showed good clinical and cosmetic outcome of LED-based PDT in actinic keratosis, basal cell carcinoma, and Bowen's disease. Since these diseases often appear on sun-exposed skin, aesthetic results are very important. The effect of LED treatment is as good or in some data even better than those in older types of PDT.

Orthovoltage for basal cell carcinoma of the head and neck: Excellent local control and low toxicity profile

OBJECTIVES/HYPOTHESIS

Evaluation of treatment results of orthovoltage X-rays for a selection of previously untreated favorable basal cell carcinomas (BCC) in the head and neck area concerning local control, cosmetic and functional outcome, and toxicity profile.

METHODS

A consecutive series of patients with primarily treated BCCs who were irradiated by means of orthovoltage X-rays in the Netherlands Cancer Institute in Amsterdam between January 2000 and February 2015 were retrospectively evaluated.

RESULTS

Two hundred fifty-three BCCs in 232 patients were primarily treated with orthovoltage X-rays. The local control rates at 1, 3, and 5 years for this selection of basal cell carcinomas were 98.9%, 97.5%, and 96.3%, respectively. Tumor size was the only significant predictor for local control because BCCs < 20 mm had a significantly higher 5-year local control rate than lesions ≥ 20 mm (96.8% vs. 89.4%, P = 0.041). Acute toxicity healed spontaneously without medical intervention, and late toxicity rates were low. Functional impairments were negligible, and the cosmetic outcome was excellent.

CONCLUSION

Orthovoltage therapy for well-selected favorable BCCs in the head and neck area resulted in excellent local control rates, a low toxicity profile, and apparently satisfactory functional and cosmetic outcomes. Orthovoltage irradiation is a good alternative for surgery for BCCs with favorable histologic prognosis at locations that are at risk for postoperative functional or cosmetic changes, such as the nose or canthus.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1796-1802, 2016.

The importance of superficial basal cell carcinoma in a retrospective study of 139 patients who underwent Mohs micrographic surgery in a Brazilian university hospital

OBJECTIVE

Mohs micrographic surgery is a specialized surgical procedure used to treat skin cancer. The purpose of this study was to better understand the profile of the patients who underwent the procedure and to determine how histology might be related to complications and the number of stages required for complete removal.

METHODS

The records of patients who underwent Mohs micrographic surgery from October 2008 to November 2013 at the Dermatology Division of the Hospital of the Campinas University were assessed. The variables included were gender, age, anatomical location, histology, number of stages required and complications.

RESULTS

Contingency tables were used to compare the number of stages with the histological diagnosis. The analysis showed that patients with superficial basal cell carcinoma were 9.03 times more likely to require more than one stage. A comparison between complications and histological diagnosis showed that patients with superficial basal cell carcinoma were 6.5 times more likely to experience complications.

CONCLUSION

Although superficial basal cell carcinoma is typically thought to represent a less-aggressive variant of these tumors, its propensity for demonstrating "skip areas" and clinically indistinct borders make it a challenge to treat. Its particular nature may result in the higher number of surgery stages required, which may, as a consequence, result in more complications, including recurrence. Recurrence likely occurs due to the inadequate excision of the tumors despite their clear margins. Further research on this subtype of basal cell carcinoma is needed to optimize treatments and decrease morbidity.

Mohs micrographic surgery for periocular skin tumours in Ireland

OBJECTIVE

To describe the shared care and outcomes of patients with periocular skin tumours who underwent Mohs micrographic surgery (MMS) performed by dermatologists, followed by oculoplastic reconstruction undertaken by ophthalmologists at two teaching and one private hospital in Ireland.

RESEARCH DESIGN AND METHODS

This was a retrospective chart review at the Royal Victoria Eye and Ear Hospital, St James Hospital and the Hermitage Clinic.

RESULTS

One hundred and twenty seven patients had periocular Mohs surgery between November 2006 and January 2013 mainly indicated for basal cell carcinoma. The mean follow-up time was 2 years and to date there have been no local recurrences.

CONCLUSIONS

MMS is available in Ireland and should be considered for patients with facial tumours in the ocular region.

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.

Basal cell carcinoma: an evidence-based treatment update

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin cancer. Surgical excision remains the standard of treatment, but several alternative treatment modalities exist.

OBJECTIVES

This review aims to provide a current analysis of evidence for the treatment of BCC; specifically, which treatments have the lowest recurrence rates and the best cosmetic outcomes.

METHODS

We searched PubMed (January 1946 to August 2013), Ovid MEDLINE (2003-August 2013), the Cochrane Central Register of Controlled Trials (January 1993 to August 2013), and the Cochrane Database of Systematic Reviews (The Cochrane Library Issue 9, 2013) databases for randomized controlled trials, systematic reviews, or comparative studies for the treatment of BCC.

RESULTS

We found 615 potential articles. Two independent reviewers selected 40 studies: 29 randomized controlled trials (RCTs), seven systematic reviews, and four nonrandomized prospective trials. Treatment modalities reviewed include surgical therapy, radiotherapy and cryotherapy, photodynamic therapy (PDT), topical imiquimod, topical 5-fluorouracil (5-FU), topical solasodine glycoalkaloids, topical ingenol mebutate, intralesional 5-FU, intralesional interferon (IFN), and oral hedgehog pathway inhibitors.

CONCLUSIONS

The available data suggest that surgical methods remain the gold standard in BCC treatment, with Mohs micrographic surgery typically utilized for high-risk lesions. Suitable alternate treatment options for appropriately selected primary low-risk lesions may include PDT, cryotherapy, topical imiquimod, and 5-FU. Radiotherapy is a suitable alternate for surgical methods for treatment in older patient populations. Electrodesiccation and curettage (ED&C) is a commonly used primary treatment option for low-risk lesions; however, there were no RCTs examining ED&C that met our inclusion criteria. New hedgehog pathway inhibitors are promising for the management of advanced BCC; however, side effects are a concern for some patients, and much remains to be learned regarding optimal treatment length, risk of recurrence, and potential development of resistance. There is insufficient evidence at present to make recommendations on topical solasodine glycoalkaloids, topical ingenol mebutate, and intralesional 5-FU and IFN-α. Overall continued research on the efficacy of treatment modalities is needed. In particular, studies should include histologic ascertainment of clearance, long-term follow-up, stratification based on tumor subtype, and comparison with surgical outcomes.

Aminolevulinic Acid-photodynamic therapy of Basal cell carcinoma and factors affecting the response to treatment: a clinical trial

Background:

Basal cell carcinoma (BCC) is the most common type of skin cancer in humans. Photodynamic therapy (PDT) is a non-invasive therapeutic modality that may be considered as a valuable treatment option for BCC. This study was designed with the aim of evaluating the efficacy of PDT in treatment of BCC and factors that may affect the response rate.

Materials and Methods:

This clinical trial was conducted on 12 patients (28 BCC lesions) who were treated with aminulevulinic acid (ALA)-PDT, monthly, up to 6 sessions and the clinical response, cosmetic results, and possible side effects were evaluated.

Results:

The study was performed on 28 BCC lesions from 12 patients. Complete response was achieved in 9 (32.1%) lesions. Complete response rate was higher in younger patients (P < 0.01) and those with smaller lesions (P < 0.001). Superficial type also had significant higher response rate (P < 0.05). Patients with history of radiotherapy for the treatment of tinea capitis in childhood showed less response (P < 0.05). Cosmetic results were excellent or good in 77.5% cases. After 6 months of follow-up, none of the resolved lesions recurred.

Conclusion:

PDT would be a good therapeutic option in treatment of BCC with acceptable efficacy and low side effects. Younger patients, superficial BCCs, and smaller lesions show better response to ALA-PDT. History of radiotherapy may be associated with a lower response rate.

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.

Skin cancers of the hand and upper extremity

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

Eighteen years of experience in Mohs micrographic surgery and conventional excision for nonmelanoma skin cancer treated by a single facial plastic surgeon and pathologist

OBJECTIVES/HYPOTHESIS

To determine and compare the efficacy of Mohs micrographic surgery (MMS)- and conventional excision (CE)-confirmed resection of nonmelanoma skin cancers (NMSCs).

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective cohort study of NMSCs treated in a tertiary referral center by a single facial plastic surgeon and a group of five histopathologists over an 18-year period. The treatment modality was either MMS or CE. The primary outcome measure was recurrence of disease. The secondary outcome measure was the size of resulting surgical excision defect.

RESULTS

Between 1990 and 2008, 795 patients were treated with MMS and 709 with CE. The median follow-up period for MMS was 24 months and for CE 16 months. Disease recurred in 6/795 and 7/709 patients, respectively (P = .78). Analysis of the resection defects with general linear models adjusted for localization and primary or recurrent disease showed significantly smaller defects after MMS (P = .008).

CONCLUSIONS

This study demonstrates that: 1) MMS and CE are safe in terms of recurrence rates in NMSCs; 2) MMS can be performed adequately by an experienced facial plastic surgeon in close collaboration with a group of pathologists; and 3) the advantage of MMS is that resection defects can be minimized in important aesthetic and functional areas, such as the nose and eyelid, possibly facilitating the reconstruction.

Risk and outcome analysis of 1832 consecutively excised basal cell carcinomas in a tertiary referral plastic surgery unit

BACKGROUND

Basal cell carcinomas are the most prevalent of all skin cancers worldwide and form the majority of the surgical workload for most modern cutaneous malignancy centres. Primary surgical removal of basal cell carcinomas remains the gold standard of treatment but, despite almost two centuries of surgical experience, rates of incomplete surgical excision of up to 50% are still reported. The aim of this study was to assess, quantify and perform comparative analysis of the outcomes and predictive factors of consecutive primarily-excised basal cell carcinomas in a tertiary centre over a six-year period.

METHODS

Retrospective audit was conducted on all patients who underwent surgical excision of basal cell carcinomas from January 2000 to December 2005. Assessment parameters included patient biographics, tumour management differences and detailed histopathological analysis of tumour margins and subtypes.

RESULTS

One thousand eight hundred and thirty two basal cell carcinomas were excised from 1329 patients over the designated time period. Two hundred and fifty one (14%) lesions were incompletely excised with 135 (7.4%) involving the peripheral margin only, 48 (2.6%) the deep margin only and 41 (2.2%) involving both. Nasal location was the most common predictor of incomplete excision.

CONCLUSIONS

Overall basal cell carcinomas excision rates compared favourably with international reported standards but attention to a variety of surgical and histological risk factors may improve this further.

Mohs micrographic surgery for the management of nonmelanoma skin cancers

Many treatment modalities have been described to address the growing epidemic of nonmelanoma skin cancer (NMSC). Mohs micrographic surgery (MMS) is a surgical technique that allows complete and precise microscopic margin analysis by using horizontal frozen sections. The purpose of MMS is twofold: to ensure definitive excision and to minimize loss of normal surrounding tissue. MMS offers the advantages of superior cure rates and, because tissue removal is minimized, excellent cosmetic outcomes. Therefore, MMS has become the treatment of choice for many high-risk tumors. Because this technique is labor intensive, MMS is not indicated in certain situations. Understanding the indications, advantages, and disadvantages of MMS remains paramount for facial plastic surgeons managing NMSC.

Guidelines for practical use of MAL-PDT in non-melanoma skin cancer

Methyl aminolaevulinate photodynamic therapy is increasingly practiced in the treatment of actinic keratoses, Bowen's disease and basal cell carcinomas. This method is particularly suitable for treating multiple lesions, field cancerization and lesions in areas where a good cosmetic outcome is of importance. Good treatment routines will contribute to a favourable result. The Norwegian photodynamic therapy (PDT) group consists of medical specialists with long and extensive PDT experience. With support in the literature, this group presents guidelines for the practical use of topical PDT in non-melanoma skin cancer.

Patient satisfaction after treatment of nonmelanoma skin cancer

BACKGROUND

Patient satisfaction is an important aspect of patient-centered care but has not been systematically studied after treatment of nonmelanoma skin cancer (NMSC), the most prevalent cancer.

OBJECTIVE

To compare patient satisfaction after treatment for NMSC and to determine factors associated with better satisfaction.

METHODS

We prospectively measured patient, tumor, and care characteristics in 834 consecutive patients at two centers before and after destruction, excision, and Mohs surgery. We evaluated factors associated with short-term and long-term satisfaction.

RESULTS

In all treatment groups, patients were more satisfied with the interpersonal manners of the staff, communication, and financial aspects of their care than with the technical quality, time with the clinician, and accessibility of their care (p<.05). Short-term satisfaction did not differ across treatment groups. In multivariable regression models adjusting for patient, tumor, and care characteristics, higher long-term satisfaction was independently associated with younger age, better pretreatment mental health and skin-related quality of life, and treatment with Mohs surgery (p<.05).

CONCLUSIONS

Long-term patient satisfaction after treatment of NMSC is related to pretreatment patient characteristics (mental health, skin-related quality of life) and treatment type (Mohs) but not tumor characteristics. These results can guide informed decision-making for treatment of NMSC.

Introduction to skin cancer nursing

The incidence of skin cancer continues to increase annually and it is the most common cancer in the UK with over 100,000 cases each year. The treatment of skin cancer can involve many different disciplines including dermatology, plastic surgery, oncology, radiotherapy, ENT and maxillofacial and involves both adult and paediatric services in primary and secondary care. This article considers the many duties of a skin cancer clinical nurse specialist, and the increasing pressure such nurses are under. The skin cancer nurse specialist must liaise and work with the many different departments, and will be involved in the care of the patient with skin cancer from diagnosis throughout the pathway to discharge or death.

Histologic safety margin in basal cell carcinoma of the eyelid: correlation with recurrence rate

OBJECTIVE

To examine the correlation between the minimum histologic safety margin (HSM) and recurrence rate of periorbital basal cell carcinomas (BCC).

DESIGN

Cohort study.

PARTICIPANTS

One hundred one patients with 101 BCCs treated surgically between 1997 and 1999 at the eye hospital in Freiburg were enrolled in this study. Mean follow-up was 7 years (range, 104 days to 9.7 years).

METHODS

The tumors' minimum HSM was measured retrospectively in photographs of hematoxylin and eosin-stained paraffin slides using the digital picture analysis system AnalySIS of Soft Imaging System Inc, and/or calculated according to the tumor-free section number. Statistical analysis was performed using the Kaplan-Meier method and the log-rank test.

MAIN OUTCOME MEASURES

Histologic margins of solid and fibrous BCC and recurrence rate.

RESULTS

Seven of the 101 patients experienced tumor recurrence (6.93%) after a mean follow-up of 34.7 months (range, 3-83) according to Kaplan-Meier analysis. The patients were assigned to 1 of 3 groups: (I) those without HSM (n = 11), 3 recurrences (27.27%); (II) those with HSM <0.2 mm (n = 18), 3 recurrences (16.67%); and (III) those with HSM >0.2 mm (n = 72), 1 recurrence (1.39%). The difference in recurrences between those groups with HSM and HSM = 0, as well as between the HSM <0.2 mm-group and HSM >0.2 mm-group were statistically significant (P = 0.01; P = 0.03).

CONCLUSIONS

Extremely small HSMs are likely to prevent recurrences. At critical and visually easily accessible tumor sites (e.g., adjacent to the lacrimal puncta) a re-resection in solid BCCs with tumor-positive margins may not be mandatory, provided the surgical site is clinically inspected regularly. This conclusion does not apply to fibrous BCC.

Phase 1 evaluation of intralesionally injected TLR9-agonist PF-3512676 in patients with basal cell carcinoma or metastatic melanoma

Synthetic oligodeoxynucleotides (ODNs), such as PF-3512676, that contain unmethylated cytosine-guanine motifs (CpG ODN) have been identified as highly potent immune activators by in vitro examinations and in murine models. CpG ODNs induce innate and adaptive immune responses by triggering Toll-like receptor 9 expressed by human B cells and plasmacytoid dendritic cells. A phase 1 study was initiated to investigate safety, tolerability, serum cytokine levels, cellular immune responses, and clinical activity of intralesional treatment with PF-3512676 in patients with basal cell carcinoma (BCC) or cutaneous or subcutaneous melanoma metastases. Intrapatient escalating doses of PF-3512676 (up to 10 mg) were injected intralesionally every 14 days in 5 patients with BCC and in cutaneous or subcutaneous metastases of 5 patients with melanoma. PF-3512676 was well tolerated. Local swelling and erythema occurred at the injection site in 9/10 patients. There was only 1 incidence of a grade III hematologic adverse event (lymphocytopenia). Local tumor regressions were observed in patients with BCC (1 complete regression, 4 partial regressions) and metastatic melanoma (1 complete regression). After treatment with PF-3512676, interleukin-6 was increased in all patients, interferon-gamma induced protein-10 in 8/10 patients, interleukin-12p40 in 7/10 patients, and tumor necrosis factor-alpha levels in 6/10 patients. All patients had biopsies; moderate to abundant cellular infiltrates of lymphocytes were found posttreatment in most lesions of both histologic types. Intralesional treatment of skin tumors with PF-3512676 was safe and well tolerated. Despite the relatively low dosage, clinical activity was demonstrated both in patients with BCC and with cutaneous or subcutaneous metastatic melanoma lesions.

Guidelines for the management of basal cell carcinoma

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

Photodynamic therapy with 5-aminolaevulinic acid, dimethylsulfoxide and curettage in basal cell carcinoma: a 6-year clinical and histological follow-up

BACKGROUND

Long-term follow-up data are needed to evaluate treatment effect after photodynamic therapy (PDT).

OBJECTIVE

To investigate long-term clinical, histological and cosmetic follow-up results in basal cell carcinoma (BCC) after PDT, including treatment response related to patients and lesion characteristics.

MATERIALS AND METHODS

A longitudinal study of 44 patients with 60 histologically verified BCC tumours, treated with one or two sessions of dimethylsulfoxide (DMSO)-supported 5-aminolaevulinic acid--PDT following curettage, was performed. Lesions in complete remission after 3 months were followed with clinical inspection, histological investigation and evaluation of cosmetic outcome at regular intervals; long-term efficacy assessed as verified recurrence within 72 months after PDT.

RESULTS

Complete remission at 3 months was achieved in 55 lesions from 39 patients. Two patients with one lesion each died. At 72 months, 43 of 53 lesions remained disease-free (81%); 68% remained after one treatment session, and 91% remained after two treatment sessions. Recurrence of tumour occurred at 6, 12, 24 and 36 months in 2, 4, 2 and 2 lesions, respectively; clinical investigation identified 97% of them. Male sex and H-mid-face zone were significantly associated with recurrence. The cosmetic outcome at 72 months was rated as good or excellent by patients and investigators in more than 90% of evaluated cases.

CONCLUSION

DMSO-PDT following curettage is an effective treatment for BCC, with favourable long-term clinical, histopathological and cosmetic results. Clinical examination of treated lesions appears to be sufficient for long term follow up.

Basal cell carcinoma treated with Mohs surgery in Australia II. Outcome at 5-year follow-up

BACKGROUND

Long-term follow-up is essential to evaluate the role of Mohs micrographic surgery (MMS) in the treatment for cutaneous basal cell carcinoma (BCC).

OBJECTIVE

Our purpose was to report the 5-year follow-up outcome of patients treated with MMS for BCC.

METHOD

This prospective, multicenter case series included all patients in Australia treated with MMS for BCC, who were monitored by the Skin and Cancer Foundation between 1993 and 2002. Parameters recorded were patient demographics, duration of tumor, site, preoperative tumor size, recurrences before MMS, histologic classification of malignancy, postoperative defect size, and 5-year recurrence after MMS.

RESULTS

Three thousand three hundred seventy (3370) patients (1594 female and 1776 male patients) completed a 5-year follow-up period. Fifty-six percent of the tumors were primary and 44% were previously recurrent. Most of them (98.4%) were located on the head and neck, and the most common histologic subtypes were nodulocystic (29.3%) and infiltrating (28.3%). Recurrence at 5 years was diagnosed in 1.4% of primary and in 4% of recurrent tumors. Previous tumor recurrence (P < .001), longer tumor duration before MMS (P = .015), infiltrating histology (P = .13), and more levels for tumor (P < .001) were the main predictors for tumor recurrence after MMS.

LIMITATION

Data were missing for some outcome measures.

CONCLUSION

The low 5-year recurrence rate of BCC with MMS emphasizes the importance of margin-controlled excision.

One-fifth of basal cell carcinomas have a morphoeic or partly morphoeic histology: Implications for treatment

A retrospective analysis of the histopathology reports for all first or single basal cell carcinomas (1567) surgically treated over a 13-year period, was undertaken. Basal cell carcinomas classified by standard skin pathology nomenclature were divided into three groups: purely morphoeic basal cell carcinomas, partly morphoeic basal cell carcinomas and non-morphoeic basal cell carcinomas. A morphoeic or partly morphoeic histology was reported in 21.8% of basal cell carcinomas, particularly on the head and neck and in those over the age of 64 years. This percentage may increase further as patients live longer, and has important implications for treatment selection.

Towards a more specific therapy: targeting nonmelanoma skin cancer cells

Epithelial cancers of the skin, e.g. basal cell carcinoma and squamous cell carcinoma, are the most common tumours in humans with increasing incidence. Hence the development of new therapeutic strategies is of utmost interest. For many years the most often used conventional therapies for these diseases were surgical procedures such as curettage and electrodesiccation, excision or, with so far the best outcome in terms of remission rates, micrographic surgery. Other ablative treatment modalities are cryotherapy, radiation therapy or the use of lasers (Er:YAG, CO(2)). All those above-mentioned treatments have in common that they are quite unspecific and do not target the tumour itself or its environment, thus leading to unwanted effects in the surrounding tissue such as scar formation or other cosmetically disfiguring events. Therefore, the development of novel, more pathogenesis-based therapies such as the use of retinoids, cyclooxygenase inhibitors, topical immunomodulators, inhibitors of the sonic-hedgehog signalling pathway or photodynamic therapy are challenging new approaches.

Non-melanoma skin cancer in patients with atopic dermatitis treated with topical tacrolimus

OBJECTIVE

To determine whether atopic dermatitis (AD) patients treated with tacrolimus ointment experienced an increased risk of non-melanoma skin cancer (NMSC).

METHODS

Data were collected from 9813 adult and paediatric patients with AD who applied 0.03% or 0.1% tacrolimus ointment twice daily and were examined every 3 months during the tacrolimus ointment development programme.

RESULTS

Thirteen adult patients were diagnosed with NMSC during the follow-up period. All patients with NMSC were white adults and 12 were over 40 years of age. Based on 1718 patient-years of tacrolimus ointment exposure in patients 40 years of age, the calculated incidence of NMSC did not suggest an increased risk of first NMSC over that of a similarly aged US cohort.

CONCLUSION

This study does not indicate an increased risk for the development of NMSC in patients with AD treated with tacrolimus ointment for a mean duration of 208 days with a maximum observation period of 1479 days.

Photodynamic therapy and imiquimod immunotherapy for basal cell carcinomas

Photodynamic therapy (PDT) and topical imiquimod immunotherapy (TII) are two recently introduced treatment modalities for certain types of basal cell carcinomas (BCC). We present a review of the relevant literature and report our own findings regarding the efficacy and tolerance of PDT and TII in the treatment of BCCs. According to published studies, the cure rates range from 75-95% for PDT and 42-100% for TII, depending on treatment modalities and BCC type. In our observations, 13 patients with nodular or superficial BCCs were treated by PDT using two courses of 3-hour topical application of methyl aminolevulinate, followed by 8 minutes illumination (lambda = 634 nm, e = 37J/cm2). Biopsies were taken before and one month after PDT. Side effects including pain and crusting were assessed. Eight patients with superficial BCC were treated by TII using 3 monthly courses each consisting of 3 weekly applications for 3 weeks followed by one week out of treatment. Biopsies were taken before and after 3 months of TII. Adverse reactions including erythema, oozing, ulceration, and crusting were recorded. Clinico-histological cure was obtained in 12/13 PDT cases as assessed after 1 month, and in 6/8 TII cases after 3 months. Minimal pain during illumination and crust formation were observed in 7/13 and 3/13 PDT cases, respectively. Variable erythema, oozing, ulceration, and crusting were observed in all TII-treated lesions. It is concluded that PDT represents an active and well tolerated alternative treatment for both nodular and superficial BCCs. TII also shows activity, although the tolerance may be poor and cure needs a longer time to be obtained. The final cosmetic appearance was fine following both PDT and TII procedures. Both PDT and TII may leave intact neoplastic aggregates inside the skin. They cannot be clinically perceived, leading to unexpected recurrences. It is stressed that the currently available efficacy information about PDT and TII deals with short term follow-up periods. A 5-year follow-up must be awaited before drawing firm conclusions.

Basosquamous carcinoma: treatment with Mohs micrographic surgery

BACKGROUND

Basosquamous carcinoma (BSC) is a rare tumor defined as a basal cell carcinoma (BCC) differentiating into squamous cell carcinoma (SCC). It is reported to have a high rate of recurrence with standard wide local excision. The aim of the current study was to report a large series of patients with BSC treated with Mohs micrographic surgery (MMS).

METHODS

The prospective, multicenter case series included all patients in Australia treated with MMS for BSC, who were monitored by the Skin and Cancer Foundation Australia between 1993 and 2002.

RESULTS

Most of the 178 tumors (95.6%) were located in the head and neck area. Recurrent tumors occurred in 47.8% of patients. The tumors were diagnosed initially as BCC in 87.4% and as SCC in 12.0% of patients. Perineural invasion was recorded in 7.9% of patients with data available. Most of these (69.0%) were previously recurrent tumors. Of 98 patients who completed a 5-year follow-up period after MMS, 4 (4.1%) had disease recurrence.

CONCLUSIONS

The low 5-year disease recurrence rate of BSC with MMS emphasized the importance of margin-controlled excision using MMS.

The management of non-melanoma skin cancer

Non-melanoma skin cancer is an increasingly common problem with a diversity of aetiologies as well as treatments. This article describes the clinical sub-groups and discusses potential management strategies as determined by best clinical practice and patients' individual needs.

Infiltrating basal cell carcinoma of the neck 34 years after irradiation of an haemangioma in early childhood. A case-report

A case of a 34-year-old Caucasian male is presented with a basal cell carcinoma deeply infiltrating the structures of the neck, including skeletal muscles and reaching the parotid gland. Radical surgical removal under meticulous histological control was performed. 18 months postoperatively, the patient is still free of recurrence. Thirty years ago the patient had undergone radiotherapy for an infantile haemangioma of the skin of the neck. The effects of this treatment when given in childhood in the aetiology of a basal cell carcinoma are discussed.

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.

Skin cancer screening campaign in the German speaking Community of Belgium

The incidence of primary malignant melanoma (MM) and skin carcinomas, including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is progressively raising. As long as their diagnosis and therapeutic managements are initiated early, their prognosis remains favorable. This underlines the importance of early recognition of skin cancers. Furthermore, it has been demonstrated that skin cancer screening programs are efficacious in increasing the population awareness of the early signs of skin cancer and of the dangers of UV - exposure. A skin cancer screening campaign was organised by dermatologists of the German-speaking Community of Belgium in cooperation with the Department of Family, Health, and Social Affairs of the Regional Ministry of the German-speaking Community of Belgium. In order to increase the screening selectivity, two risk populations were targeted; patients presenting 30 or more moles, and patients over 50 years of age presenting recent skin changes of the head and neck area. A media campaign using radio, television and daily press was started to increase the population awareness of the dangers of UV exposure and of the early signs of skin cancer. During 2 screening days, three-hour sessions were organised in 2 health centers located in Eupen and St Vith. A total of 148 patients were examined. A total of 124/148 patients met the selection criteria predefined during the media announcement. The simultaneous presence of 4 dermatologists during the screening sessions allowed a second opinion for warning lesions. Four BBCs as well as 23 patients pesenting dysplastic nevi were clinically diagnosed. During the 2 months following the screening campaign 5 MMs were identified by the same dermatologists in their routine practice. In conclusion, this skin cancer screening campaign led to the diagnosis of 4 carcinomas. The campaign furthermore increased the patient awareness, permitting the diagnosis of 5 MMs during the 2 following months. This figure represents about 30% of all MMs diagnosed yearly in this region of Belgium.

Topical photodynamic therapy in clinical dermatology

The growing incidence of cutaneous malignancies each year necessitates the development of new and more effective methods for both the diagnosis and the treatment of cancerous lesions, while assuring better cosmetic results and improving patient satisfaction. With that in mind, the use of topical photodynamic therapy (PDT) has been explored in the treatment as well as the diagnosis of various cutaneous malignancies. Using the intrinsic cellular haem biosynthetic pathway and principles of photoillumination, topical PDT carries the goal of selectively targeting abnormal cells, while preserving the normal surrounding structures. This paper will discuss the various applications and data on the use of topical PDT in dermatology.

Topical methyl aminolevulinate

Methyl aminolevulinate (MAL), an ester of aminolevulinic acid, has been used effectively as a topical photosensitizing agent in the photodynamic therapy (PDT) of epidermal lesions such as actinic keratosis (AK) and basal cell carcinoma (BCC). The optimal regimen for MAL-PDT (as used in all clinical trials) is MAL 160 mg/g applied for 3 hours before illumination with red light (570-670 nm) at a total light dose of 75 J/cm(2), as determined in dose-finding trials. In randomized, multicenter, phase III clinical trials, treatment with MAL-PDT resulted in a complete response (i.e. complete disappearance) in up to 91% of AK lesions and up to 97% of BCC lesions. With regard to lesion response rates, MAL-PDT was superior to placebo-PDT (in AK or BCC), and at least as effective as cryotherapy (in AK or BCC) or excision surgery (in BCC). Cosmetic outcome with MAL-PDT was excellent to good in the vast majority of patients, and was judged by investigators to be better than with cryotherapy (in AK or BCC) or surgery (in BCC). black triangle Over 75% of BCC lesions treated with MAL-PDT, including difficult-to-treat BCC, were still in remission 12-24 months after the last treatment. MAL-PDT was generally well tolerated in clinical trials. The most frequently reported adverse events were local phototoxicity reactions, most of which were of mild to moderate intensity, resolved rapidly and were rarely treatment limiting.