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Background
The treatment of basal cell carcinomas, the most common malignancy of adults, has undergo radical expansion and advancement in a few short years. The outline below will direct you to the latest therapies.
OUTLINE
Prognosis Treatment Commonly Used Terms Internet Links
PROGNOSIS CHARACTERIZATION PROGNOSIS In general, the type and adequacy of the initial treatment will determine the local recurrence rate and potential complications
J Am Acad Dermatol 2001;44:224-30
Multicenter retrospective study of BCC excisions submitted to the respective Departments of Pathology at 4 major university medical centers
Outcome measure was presence of histologic evidence of tumor present in surgical margins of excision specimens (incomplete excision)
Clinician experience was defined as the number of excisions that a clinician performed during the study interval
The analytic sample pool included 1459 tumors that met all inclusion and exclusion criteria
Analyses included univariate and multivariate techniques involving the entire sample and separate subsample analyses that excluded 2 outlying dermatologistsResults: Tumor was present at the surgical margins in 243 (16.6%) of 1459 specimens. A patient's sex, age, and tumor size were not significantly related to the presence of tumor in the surgical margin
Physician experience did not demonstrate a significant difference either in the entire sample (P < .09) or in the subsample analysis (P > .30)
Tumors of the head and neck were more likely to be incompletely excised than truncal tumors in all the analyses (P < .03)Compared with dermatologists, otolaryngologists (P < .02) and plastic surgeons (P < .008) were more likely to incompletely excise tumors; however, subsample analysis for plastic surgeons found only a trend toward significance (P < .10).
Dermatologists and general surgeons did not differ in the likelihood of performing an incomplete excision (P > .4)The physician specialty may affect the quality of care in the surgical management of BCC
BASEMENT MEMBRANE
- Evaluation of basement membrane status in aggressive skin carcinomas with skull base invasion: a case-control study.
Cernea CR, Ferraz AR, de Castro IV, Sotto MN, Logullo AF, Potenza AS, Bacchi CE.
Department of Head and Neck Surgery, University of Sao Paulo Medical School, 01422-000 Sao Paulo, Brazil.
Ann Diagn Pathol. 2005 Jun;9(3):130-3. Abstract quote
Some skin carcinomas may be very aggressive. Breached of basement membrane (BM) has been in some situations associated with tumor aggressiveness.
In this study, the status of BM in invasion was evaluated in basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) with skull base invasion, and it was compared with tumor's good outcome. Integrity or breached of BM was visualized using immunohistochemistry technique with anti-type IV collagen antibody. The pattern of BM was classified as intact, breached, or absent in 24 BCCs and 11 SCCs with skull base invasion. Control group (good outcome) included 23 BCCs and 10 SCCs. Breached BM and absence of BM were respectively noted in 33.33% and 45.83% of BCCs with skull base invasion, compared with 8.33% and 17.395% in the control group ( P < .001). Regarding SCCs, ruptured and absent BMs were, respectively, noted in 36.36% and 63.64% of BCCs with skull base invasion, compared with 30% and 30% in the control group ( P = .075).
In this study, destruction of BM was significantly more common in BCCs with skull base invasion, in comparison with those with good outcome. In SCC, this difference was not statistically significant.bcl-2
bcl-2 protein expression in aggressive and non-aggressive basal cell carcinomas.Ramdial PK, Madaree A, Reddy R, Chetty R.
Department of Pathology, Faculty of Medicine, University of Natal, Durban, South Africa.
J Cutan Pathol 2000 Jul;27(6):283-91 Abstract quote bcl-2, the well known anti-apoptotic gene, cloned more than a decade ago, promotes cell viability without promoting cell proliferation. With few exceptions, high bcl-2 protein expression is associated with a favourable outcome in epithelial tumours. bcl-2 immunoreactivity in basal cell carcinomas (BCCs) is contradictory, with 67-100% immunopositivity being reported. Although BCCs are traditionally regarded as low-grade, indolent tumours, aggressive BCCs (A-BCCs) are mutilative, locally destructive tumours that often recur. bcl-2 protein expression as a predictor of BCC aggressiveness is poorly documented in the English-language literature.
The bcl-2 protein immunoprofile of 50 clinically non-aggressive (NA-BCCs) and 25 clinically A-BCCs was investigated. Of the latter, 17 manifested with one, two or three recurrences. bcl-2 protein expression in each of the recurrences was also evaluated. bcl-2 expression was scored as follows: 0-5% positive cells=negative, 6-25%=1+, 26-50%=2+, 51-75%=3+, >75%=4+. "High" labeling encompassed 3+ or 4+ labeling while "low" labeling referred to 1 + or 2 + labeling. Although bcl-2 positivity was noted in all BCCs, low bcl-2 labeling was a statistically significant feature of A-BCCs (p < 0.01). High bcl-2 labeling of NA-BCCs was a reflection of the bcl-2 labeling of the dominant constituent nodular or superficial subtypes. Micronodular BCCs revealed 2+ or 3+ labeling. Initial and recurrent A-BCCs with a pure or predominantly infiltrative component, demonstrated 1+ or 2+ bcl-2 labeling.
The differential bcl-2 expression in the various clinicopathological subtypes of BCCs suggests that, despite the common derivation of these tumours from a primitive basaloid stem cell and a limited potential for metastasis, they form a heterogeneous group of tumours that differ markedly in histologic and biological behaviour.
While the superficial and nodular BCCs are indolent slow-growing tumours with high bcl-2 labeling, the aggressive BCCs are infiltrative, desmoplastic tumours with low bcl-2 labeling. In mixed tumours, heterogeneity of labeling is a distinctive feature and is contributed to in part by the labeling trends of the different histological subtypes. The micronodular BCC shows varied bcl-2 labeling but in combined tumours occupies a niche intermediate between the non-aggressive nodular and superficial and the aggressive infiltrative subtypes.
The initial and subsequent biopsies of recurrent, adequately excised BCCs share a pure or mixed, predominantly infiltrative, stroma-rich histomorphology with low bcl-2 labeling, reflecting the immunoprofile of a more aggressive growth pattern.
Clin Plast Surg 1997;24:673-686
Micronodular, infiltrative, or sclerosing histologic subtypes are associated with more aggressive local behavior
Mixed pattern most common
Histologic pattern analysis of basal cell carcinoma. Study of a series of 1039 consecutive neoplasms.Sexton M, Jones DB, Maloney ME.
Department of Pathology, M. S. Hershey Medical Center, Pennsylvania State University, Hershey.
J Am Acad Dermatol 1990 Dec;23(6 Pt 1):1118-26 Abstract quote This study attempts to define histologic patterns in 1039 consecutive cases of basal cell carcinoma and to correlate these patterns with adequacy of margins of surgical excision.
Five major histologic patterns were identified: nodular, 218 cases (21%); superficial, 181 cases (17%); micronodular, 151 cases (15%); infiltrative, 77 cases (7%); and morpheic, 11 cases (1%). A mixed pattern (two or more major histologic patterns) was present in 401 cases (38.5%).
Our study indicates that nodular and superficial basal cell carcinomas can be completely removed by simple surgical excision in a high percentage of cases (93.6% and 96.4%, respectively) whereas the micronodular, infiltrative, and morpheic basal cell carcinomas have a higher incidence of positive tumor margins (18.6%, 26.5%, and 33.3%, respectively) after excision.
Mixed patterns that consisted of combinations of the nodular, micronodular, or infiltrative types exhibited a behavior similar to the pattern that resulted in a greater chance of incomplete surgical removal.
Correlation of histologic subtypes of primary basal cell carcinoma and number of Mohs stages required to achieve a tumor-free plane.Orengo IF, Salasche SJ, Fewkes J, Khan J, Thornby J, Rubin F.
Harvard Medical School, Boston, Massachusetts, USA.
J Am Acad Dermatol 1997 Sep;37(3 Pt 1):395-7 Abstract quote BACKGROUND: Certain histologic subtypes of basal cell carcinoma (BCC) behave more aggressively and require more aggressive treatment.
OBJECTIVE: The aim of this study was to see whether certain subtypes of BCC require more Mohs stages to achieve tumor-free margins.
METHODS: A retrospective study of 342 primary BCCs treated with Mohs micrographic surgery (MMS) was performed identifying the histologic subtype of BCC present and the number of stages required to clear the tumor.
RESULTS: The aggressive subtypes (infiltrative, morpheaform, micronodular, and mixed) were most frequently found when high numbers of Mohs stages were required for cure.
CONCLUSION: The more aggressive subtypes of BCC require more MMS stages to achieve tumor-free margins, which is consistent with the concept that these subtypes usually require more aggressive treatment from the start.
IMMUNE STATUS OF PATIENT Histologic patterns of basal cell carcinoma based upon patient immunostatus.
Oram Y, Orengo I, Griego RD, Rosen T, Thornby J.
Department of Dermatology, VA Medical Center, Houston, Texas, USA.
Dermatol Surg 1995 Jul;21(7):611-4 Abstract quote BACKGROUND. The biologic behavior of basal cell carcinoma (BCC) seems to be dictated by the histologic subtype. Moreover, BCCs in immunosuppressed patients appear to show a more aggressive biologic behavior.
OBJECTIVE. The purpose of this study was to retrospectively investigate different histologic subtypes of BCC to determine whether a particular subtype would predominate in immunosuppressed patients.
METHODS. The histologic patterns of 112 primary BCCs from 77 immunosuppressed patients and 60 primary BCCs from 46 patients who are endogenously immunocompromised, due to diabetes mellitus and/or chronic renal failure, were examined. The results were compared with 488 primary BCCs of 318 immunocompetent patients.
RESULTS. The nodular subtype was the predominant pattern among all patients. However, a statistical difference was found in the immunosuppressed patients in that there was a lower percentage of nodular pattern (P = .0038), and a higher percentage of infiltrative pattern (P = .0002). The higher frequency of the infiltrative pattern in the immunosuppressed group was particularly prominent among chronic alcoholics.
CONCLUSION. In immunosuppressed patients, the higher frequency of the infiltrative subtype of BCC, particularly among chronic alcoholics, may have a predictive role in the management of these cases.
RECURRENCE Clin Geriatr Med 1997;13:339-361
5-9% have multiple recurrences, after surgical treatment
Recurrences dependent upon type of treatment
Recurrent basal cell carcinoma after incomplete resection.Robinson JK, Fisher SG.
Division of Dermatology, Cardinal Bernardin Cancer Center, Loyola University Stritch School of Medicine, 2160 S First Ave, Room 341, Maywood, IL 60153, USA.
Arch Dermatol 2000 Nov;136(11):1318-24 Abstract quote
BACKGROUND: Because the probability of basal cell carcinoma (BCC) recurrence was thought to be 30% to 50%, surgical tradition became not to perform additional resection when the margin was positive.
OBJECTIVE: To determine whether there is an association among age or sex of the patient, anatomic location, histologic type, or reconstructive procedures and the signs and symptoms of the recurrence, interval between incomplete resection and Mohs micrographic surgery (MMS), or extent of MMS resection.
DESIGN: During 20 years, all patients with incompletely excised BCC of the head referred for MMS were sequentially prospectively accrued into the cohort.
SETTING: An outpatient MMS practice.
PATIENTS: Nine hundred ninety-four patients.
MAIN OUTCOME MEASURES: Interval to tumor recurrence, interval to MMS, and extent of MMS as determined by mean surface area resected, depth of resection, and number of tumor nests.
RESULTS: The interval to signs or symptoms of recurrence and to MMS from incomplete resection was greater for men, patients older than 65 years, those having a tumor on the nose or cheek, those with aggressive or fibrosing BCC, and those who underwent flap reconstruction (P =.001). The extent of MMS resection was greater for those with flap and split-thickness skin graft repairs. The number of tumor nests identified by MMS was significantly greater in those treated with split-thickness skin graft and flap (P =.001).
CONCLUSION: Because it is more difficult to control recurrent BCC, treating tumor remaining at the margin of resection in the immediate postoperative period could result in less extensive surgery.
5 Year Recurrence Rate (Average) 8.7% 8.7% 8.7% 1% 8.7% May be as high as 50% 19% at 1 year METASTASIS Very rare
0.05-0.1%
- Metastatic basal cell carcinoma: four case reports, review of literature, and immunohistochemical evaluation.
Ionescu DN, Arida M, Jukic DM.
Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15232, USA.
Arch Pathol Lab Med. 2006 Jan;130(1):45-51. Abstract quote
CONTEXT: Metastatic basal cell carcinoma (BCC) is relatively rare and is seldom considered a complication in the routine treatment and follow-up of patients with BCC. Although multiple studies have tried to distinguish aggressive from nonaggressive BCCs, to our knowledge, no consistent clinical, histopathologic, or immunohistochemical features have yet been reported.
OBJECTIVE: To report 4 cases of metastatic BCCs and to evaluate these in addition to known nonmetastatic BCCs with specific immunostains in an attempt to find distinct morphologic or immunohistochemical patterns that could be helpful in identifying aggressive BCCs.
DESIGN: We reviewed 4 cases of metastatic BCCs and recorded the clinical and morphologic findings. We then searched our archives for 14 cases of BCC that followed the usual nonaggressive course. We evaluated these 18 cases with immunohistochemical stains for Ki-67, p53, and bcl-2.
RESULTS: In metastasizing BCC, Ki-67 staining was slightly higher in metastatic sites than in primary sites (average 63% and 51%, respectively). p53 was expressed in 3 of 4 primary sites and 2 of 4 metastatic sites. Bcl-2 was positive in both primary and metastatic sites in 3 of 4 cases. In the 14 cases of nonaggressive BCC, staining for Ki-67 averaged 38%, p53 was positive in 11 cases, and Bcl-2 staining was noted in 13 cases.
CONCLUSIONS: Overall, in the small sample that we evaluated, the immunohistochemical markers for Ki-67, p53, and Bcl-2 did not distinguish between metastatic and nonaggressive BCCs.
- Lethal basal cell carcinoma secondary to cerebral invasion.
Kovarik CL, Stewart D, Barnard JJ.
Department of Dermatology, University of Texas Southwestern Medical School, Dallas 75390, USA.
J Am Acad Dermatol. 2005 Jan;52(1):149-51. Abstract quote
Intracranial invasion by a basal cell carcinoma on the scalp is extremely rare.
We present an autopsy case of a 57-year-old woman who developed a large destructive basal cell carcinoma with extension through the calvarium and compression of the dura.
We compare 7 similar cases reported in the literature and review the risks for development of these aggressive fatal basal cell carcinomas on the scalp.
Basal cell carcinoma with pulmonary and lymph node metastasis causing death.Robinson JK, Dahiya M.
Departments of Medicine and Pathology, Loyola University Stritch School of Medicine, Maywood, Ill.
Arch Dermatol 2003 May;139(5):643-8 Abstract quote BACKGROUND: The incidence of metastatic basal cell carcinoma ranges from 0.003% to 0.55%. The 230 reported cases most often occurred in long-standing recurrent lesions and appeared in regional nodes or the lungs.
OBSERVATIONS: The stromal dependence of the tumor provides an explanation for the nonmetastasizing nature of basal cell carcinoma. The dense fibrous stroma of the lymph node in the case of metastatic basal cell carcinoma reported in the present study is similar to other reported cases with metastases to lymph nodes, bone, bone marrow, glands, and subcutaneous tissue.
CONCLUSIONS: This metastatic basal cell carcinoma demonstrated lymphatic and hematogenous dissemination to the lungs and lymph nodes. A dense accumulation of microvessels was present at the boundary of the tumor nests and dermal stroma and in the stroma surrounding the tumor in the lymph node.PERINEURAL INVASION
Perineural spread of basal cell carcinomas treated with Mohs micrographic surgery.Ratner D, Lowe L, Johnson TM, Fader DJ.
Cancer 2000 Apr 1;88(7):1605-13 Abstract quote BACKGROUND: Perineural spread is a well-documented feature of cutaneous tumors and may portend a more aggressive course. The incidence of perineural invasion in basal cell carcinoma (BCC) is reportedly 1%. The authors sought to determine whether perineural spread occurs more commonly than previously thought.
METHODS: The authors prospectively evaluated 434 patients with BCC treated with Mohs surgery, assessing the presence or absence of perineural inflammation and invasion in tumors requiring more than one stage of surgery. They also documented the demographic features, clinical characteristics, histologic subtype, and operative data in each case.
RESULTS: Seventy-eight BCCs required more than one stage of Mohs surgery. Perineural inflammation, perineural tumor invasion, or both were present in 29 of the 78 tumors (37%), or 6.7% of all 434 prospectively evaluated cases. Twenty-one of the 78 tumors (26.9%) exhibited perineural inflammation, 3 (3.8%) demonstrated perineural invasion, and 5 (6.4%) exhibited both. Tumors with perineural invasion required 5.3 surgical stages on average for clearance, in contrast to tumors without perineural invasion, which required 2.2 stages. Tumors with perineural inflammation, inflammation plus tumor invasion, and invasion alone were, respectively, 138%, 149%, and 194% greater in area preoperatively than tumors without perineural involvement, and their mean defect areas after Mohs surgery were, respectively, 151%, 121%, and 605% larger than those of tumors without perineural involvement.
CONCLUSIONS: The incidence of perineural invasion among cases of BCC appears higher than previously recognized. Tumor aggressiveness appears to correlate with the presence of perineural invasion. Surgery with horizontal frozen-section margin control enables easy detection of perineural involvement and should therefore be strongly considered for the treatment of high risk BCC patients.
Incidence of perineural invasion in histologically aggressive types of basal cell carcinoma.
Brown CI, Perry AE.
Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
Am J Dermatopathol 2000 Apr;22(2):123-5 Abstract quote
Basal cell carcinoma is generally an indolent form of skin cancer. Morpheaform, infiltrative, and sclerosing types are more aggressive tumors. The incidence of perineural invasion in aggressive types of basal cell carcinoma has not been previously described. We studied aggressive basal cell carcinomas for the presence of perineural invasion.
Between 1995 and 1998, the histopathologic diagnosis of basal cell carcinoma was made on 5,097 specimens at Dartmouth-Hitchcock Medical Center. Of this total, 507 were classified as sclerosing, infiltrative, or morpheaform. Perineural invasion was found in 15 of the 507 cases. Of these 15 cases, 12 were from the face, and 3 from the back; 13 were recurrent, and 2 were primary lesions. The mean age of patients at diagnosis was 71 years. We found 9.9% of all basal cell carcinomas at our institution to be aggressive types.
We found an incidence of perineural invasion of 3% in the aggressive basal cell carcinoma types. This incidence approaches that reported by others for cutaneous squamous cell carcinomas.PERSISTENCE AFTER INCOMPLETE EXCISION
The significance of tumor persistence after incomplete excision of basal cell carcinoma.Berlin J, Katz KH, Helm KF, Maloney ME.
Department of Dermatology, Cleveland Clinic Foundation, Cleveland, OH, USA.
J Am Acad Dermatol 2002 Apr;46(4):549-53 Abstract quote BACKGROUND: Physicians inevitably receive a pathology report after excision of a basal cell carcinoma that indicates that it is incompletely excised. The physician and patient are then left with the dilemma of whether immediate re-excision or close clinical follow-up is indicated.
OBJECTIVE: Our purpose was to identify characteristics of incompletely excised basal cell carcinomas that are at low risk for recurrence.
METHODS: We retrospectively reviewed the charts and pathology slides of all incompletely excised basal cell carcinomas from 1991 to 1994 in a university hospital tumor registry.
RESULTS: Incompletely excised basal cell carcinomas of superficial or nodular subtype, less than 1 cm in diameter, located anywhere except the nose or ears, with less than 4% marginal involvement on the initial inadequate excision had no evidence of tumor persistence.
CONCLUSION: When physicians receive a pathology report indicating the incomplete excision of a basal cell carcinoma, they face the dilemma of further management. The majority of patients should undergo immediate re-excision or Mohs micrographic surgery because tumor persistence was found in 28% of cases. Occasionally, for a small group of select patients, close clinical follow-up may be indicated if the risk of recurrence is very low.
Effects of biopsy-induced wound healing on residual basal cell and squamous cell carcinomas: rate of tumor regression in excisional specimens.Swetter SM, Boldrick JC, Pierre P, Wong P, Egbert BM.
Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, and Department of Dermatology, Stanford University Medical Center, Stanford, CA, USA.
J Cutan Pathol 2003 Feb;30(2):139-46 Abstract quote BACKGROUND: Wound healing following a partial biopsy of basal cell (BCC) and squamous cell carcinomas (SCC) may induce tumor regression.
METHODS: Nonmelanoma skin cancer (NMSC) biopsy and re-excision specimens from 1994 to 2001 were reviewed for histologic evidence of scar vs. presence of residual tumor in excision specimens. Regressed and non-regressed tumors were analyzed to assess the influence of anatomic location, biopsy technique (punch vs. shave), histologic subtype of BCC or SCC, time interval between biopsy and excision, and patient age.
RESULTS: Nine hundred and ten excisions were performed for transected BCC or SCC, 217 (24%) of which showed scar with no residual tumor. Logistic regression analysis revealed significant differences in the regressed vs. non-regressed subsets. SCCs were more likely to regress than BCCs (40% vs. 20%, respectively, p < 0.00001). Independent of the NMSC type, tumors regressed more often following shave rather than punch biopsy (34% vs. 15%, respectively, p < 0.00001), as did tumors on the trunk and extremities compared with head and neck cases (31% vs. 21%, respectively, p < 0.01).
CONCLUSIONS: In our series, 24% of NMSCs transected on the initial biopsy showed no residual tumor in the excision specimens, implying that some event in the interval between biopsy and excision may lead to the eradication of residual tumor. The exact mechanism is unclear, but wound healing likely plays an important role.
TRISOMY 6
Trisomy 6 in basal cell carcinomas correlates with metastatic potential: a dual color fluorescence in situ hybridization study on paraffin sections.Nangia R, Sait SN, Block AW, Zhang PJ.
Department of Pathology, The University of Michigan Medical School, Ann Arbor, Michigan 48109-0602, USA.
Cancer 2001 May 15;91(10):1927-32 Abstract quote BACKGROUND: Most basal cell carcinomas (BCCs) are indolent lesions; a few become locally aggressive or even metastatic. Little is known about the molecular and genetic alterations in this malignant transformation. Conventional karyotyping in BCC has revealed a high frequency of nonclonal, structural rearrangements, with few cases that show multiple, unrelated, small clones suggestive of a multicellular origin. Trisomy 6 was described recently in a few BCCs, but the biologic significance of the appearance of trisomy 6 in BBCs was not clear.
METHODS: Thirty cases including 4 metastatic, 4 locally aggressive, and 22 conventional nonaggressive BCCs were studied. Fluorescence in situ hybridization (FISH) was performed on 4 microm tissue sections, using alpha-centromeric enumeration probes for chromosome 6 (SpectrumGreen, Vysis Inc., Downers Grove, IL) and chromosome 4 (SpectrumOrange, Vysis Inc., Downers Grove, IL, used as disomic cell control). Trisomy 6 was semiquantitated within tumor cells and nonneoplastic cells in each case.
RESULTS: Trisomy 6 was identified in all 4 metastatic BCCs within tumor cells and in corresponding BCCs at the primary cutaneous site in 2 of these 4 cases. Two locally aggressive BCCs, 1 of which had preceding radiation exposure, also showed trisomy 6. All nonaggressive BCCs and nonneoplastic cells were disomic for chromosome 6.
CONCLUSIONS: Trisomy 6 has been identified as a cytogenetic aberration representative of tumor cells in aggressive and metastatic BCC. None of the nonaggressive BCCs in this study demonstrated trisomy 6. Acquisition of trisomy 6 by tumor cells in BCC may lead to the emergence of metastatic potential. Additional studies to define the underlying mechanisms may be valuable in preventing aggressive behavior in BCC.
TREATMENT CHARACTERIZATION N Engl J Med 1992;327:1649-1662
Estimated cost of treating non-melanoma skin cancers in the United States is about $500 million/year
J Am Acad Dermatol 1998;39:698-703
1996 dollars of following treatments:
$1167 $1243 $1400 $1973 $4558 TREATMENT TYPES SURGICAL
- Basal cell carcinoma treated with Mohs surgery in Australia I. Experience over 10 years.
Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R.
Oculoplastic & Orbital Division, Department of Ophthalmology & Visual Sciences, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia.
J Am Acad Dermatol. 2005 Sep;53(3):445-51. Abstract quote
BACKGROUND: Only a few prospective studies have been published on surgical treatments for cutaneous basal cell carcinoma (BCC).
OBJECTIVE: Our purpose was to report the clinical findings of all patients with BCC treated with Mohs micrographic surgery (MMS) in Australia between 1993 and 2002.
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. The main outcome measures were patient demographics, reason for referral, duration of tumor, site, preoperative tumor size, recurrences before MMS, histologic classification of malignancy, and postoperative defect size.
RESULTS: The study included 11,127 patients (47% females and 53% males) with a mean age of 62 years (range, 15-98 years). In 43.8% of cases BCC was a recurrent tumor. Most of the tumors (98.3%) were on the head and neck area, most commonly on the nose (39%), cheek and maxilla (16.5%), periocular area (12.7%), and auricular region (11.4%). The most common histologic subtypes were infiltrating (30.7%), nodulocystic (24.2%), and superficial (13.6%). Previously recurrent tumors were larger than primary tumors (P < .001), had a larger postexcision defect and more subclinical extension, and required more levels of excision (P < .001).
LIMITATIONS: Data were missing for some outcome measures.
CONCLUSION: This large prospective series of BCC managed by MMS is characterized by a high percentage of high-risk tumors. Most tumors were located in the mid-facial area and the histologic subtype was mainly infiltrating or nodulocystic. That previously recurrent tumors were larger and demonstrated a more extensive subclinical extension compared with primary tumors emphasizes the importance of initial tumor eradication with margin control.
- Basal cell carcinoma treated with Mohs surgery in Australia II. Outcome at 5-year follow-up.
Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R.
Oculoplastic and Orbital Division, Department of Ophthalmology and Visual Sciences, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia.
J Am Acad Dermatol. 2005 Sep;53(3):452-7. Abstract quote
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.
- Basal cell carcinoma treated with Mohs surgery in Australia III. Perineural invasion.
Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R.
Oculoplastic and Orbital Division, Department of Ophthalmology and Visual Sciences, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia.
J Am Acad Dermatol. 2005 Sep;53(3):458-63. Abstract quote
BACKGROUND: Perineural invasion (PNI) is an important factor may possibly influence the aggressiveness of basal cell carcinoma (BCC).
OBJECTIVE: Our purpose was to evaluate the incidence, features, and outcomes of BCC with PNI in patients treated with Mohs micrographic surgery (MMS).
METHOD: This prospective, multicenter case series included all patients in Australia treated with MMS for BCC with PNI, who were monitored by the Skin and Cancer Foundation Australia between 1993 and 2002. The parameters recorded were patient demographics, reason for referral, duration of tumor, site, preoperative tumor size, recurrence before MMS, histologic subtypes, postoperative defect size, and recurrence at 5 years after MMS.
RESULTS: Two-hundred eighty-three patients were diagnosed with PNI. Most cases occurred in male patients (61%; P = .006) and in previously recurrent tumors (60.4%; P < .001). The infiltrating, morpheic, and basosquamous subtypes were more likely to be associated with PNI (P < .0001). Tumor sizes before excision and postoperative defect sizes were significantly larger in cases with PNI compared with cases with no PNI (P < .001 for both parameters), as was the mean number of Mohs excision levels. Seventy-eight patients completed a 5-year follow-up period after MMS, and 6 of them (7.7%) were diagnosed with recurrence.
LIMITATIONS: Data were missing for some outcome measures.
CONCLUSION: PNI is an uncommon feature of BCC. When present, PNI is associated with larger, more aggressive tumors, and the risk of 5-year recurrence is higher. This emphasizes the importance of tumor excision with margin control and long-term patient monitoring.
- Randomized, controlled surgical trial of preoperative tumor curettage of basal cell carcinoma in Mohs micrographic surgery.
Huang CC, Boyce S, Northington M, Desmond R, Soong SJ.
Department of Dermatology, University of Alabama at Birmingham, AL 35294-0009, USA.
J Am Acad Dermatol. 2004 Oct;51(4):585-91. Abstract quote
BACKGROUND: The use of preoperative tumor curettage in Mohs micrographic surgery has never been prospectively systematically assessed.
OBJECTIVE: To assess the utility of preoperative tumor curettage in Mohs micrographic surgery for primary or recurrent, well-defined basal cell carcinoma less than 2 cm in diameter located on the head or neck.
METHODS: Patients were randomized to either preoperative tumor curettage or control group and were compared in terms of percent surface area increase from tumor surface area to wound surface area, absolute surface area increase, number of tissue layers removed, types of repairs performed, and postoperative complications. Multivariate analysis was performed to see if tumor location, appearance (exophytic or flat), or histology affected any of the above.
RESULTS: The preoperative tumor curettage group had a 399% (95% confidence interval [CI] 346-452) mean surface area increase from tumor to wound surface area versus 263% (95% CI 216-311) for control group (P=.0002). The preoperative tumor curettage group had a mean absolute surface area increase of 1.78 cm2 (95% CI 1.57-1.99) versus 1.40 cm2 (95% CI 1.15-1.65) for control group (P=.02). The preoperative tumor curettage group had fewer tissue layers removed (P=.3). Preoperative tumor curettage had no effect on types of repairs performed or number or type of postoperative complications. Tumor appearance and histology had no effect on any of the above end points.
CONCLUSION: Preoperative tumor curettage was associated with significantly greater percent surface area increase and absolute surface area increase from tumor surface area to wound surface area. This difference did not affect type of repair performed or postoperative complications.Kenneth H. Katz, MD, etal.
J Am Acad Dermatol 2001;45:231-8 Abstract quote
Background: Areas of dense inflammation are commonly removed during Mohs micrographic surgery for basal cell carcinoma because of the concern that they may mask areas of tumor.
Objective: Our purpose was to determine whether inflammation masks tumor during Mohs surgery for primary basal cell carcinoma.
Methods: Twenty-five consecutive cases of primary basal cell carcinoma with areas of dense inflammation encountered during Mohs surgery were sectioned and stained with hematoxylin and eosin and Ber-EP4. Results: In no cases did the dense inflammation mask residual tumor.
Conclusion: Dense inflammation does not mask primary basal cell carcinoma during Mohs surgery and should be carefully evaluated before additional surgery is performed.
Predictors of extensive subclinical spread in nonmelanoma skin cancer treated with mohs micrographic surgery.Batra RS, Kelley LC.
Department of Dermatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215.
Arch Dermatol 2002 Aug;138(8):1043-51 Abstract quote BACKGROUND: In nonmelanoma skin cancer, the clinically visible portion may represent a small fraction of microscopic tumor spread. Previous studies have examined individual risk factors for subclinical spread based on patient and tumor characteristics. However, these risk factors have not been prioritized or studied in combination.
OBJECTIVE: To identify the most predictive risk factors for extensive subclinical tumor spread.
DESIGN: Retrospective analysis of 1131 Mohs micrographic surgical cases. Variables analyzed included patient age, sex, and immune status and lesion size, location, histologic subtype, and recurrence. Logistic regression was applied to identify important combinations of tumor characteristics and to quantify relative odds of spread.
SETTING: Academic referral center.
PATIENTS: Consecutive sample of all referred patients treated by a single Mohs micrographic surgeon in a 3-year period.
MAIN OUTCOME MEASURE: Number of Mohs micrographic surgical layers required to clear a tumor, with 3 or more layers defined as extensive subclinical spread.
RESULTS: The highest-risk tumors, with odds ratios greater than 6.0, were basosquamous and morpheaform basal cell carcinoma (BCC) on the nose, morpheaform BCC on the cheek, and those with a preoperative size greater than 25 mm. Other important risk factors were recurrent and nodular BCC on the nose; location on the eyelid, temple, or ear helix; neck tumors and recurrent BCC in men; and tumor size greater than 10 mm. Patients younger than 35 years were at lower risk. Increasing age and immunocompromise were not significant predictors.
CONCLUSION: Identification of lesions likely to exhibit extensive subclinical spread can help guide management to ensure complete tumor eradication and thereby reduce the risk of recurrence and its associated morbidity and cost.
RADIATION
Radiotherapy of recurrent basal and squamous cell skin carcinomas: a study of 249 re-treated carcinomas in 229 patients.Caccialanza M, Piccinno R, Grammatica A.
Department of Photoradiotherapy, Institute of Dermatological Sciences of the University, Ospedale Maggiore, IRCCS, Via Pace 9, 20122 Milan, Italy.
Eur J Dermatol 2001 Jan-Feb;11(1):25-8 Abstract quote It is of great practical utility to assess which is the best therapeutic choice in the management of basal and squamous cell skin carcinomas recurring after different treatments (RBSCSC).
To this aim, we have performed a retrospective review of 249 recurrent lesions in 229 patients treated with dermatological radiotherapy in the period 1982-1999. The total doses of ionizing radiations administered ranged from 45 to 70 Gy, with different dose fractionations, according to the technique employed. The five-year cure-rate was 83.62%. Cosmetic results were evaluated as "good" or "acceptable" in 92.62% of the treated lesions in complete remission. So far no complications or sequelae to the radiological treatment have been observed.
Our results suggest two considerations about the choice in the treatment of RBSCSC (following non radiological therapies): 1. radiotherapy is a safe treatment and the most effective after Mohs surgery; 2. radiotherapy is a first-line treatment in those patients who cannot undergo extensive surgery for a variety of different reasons (age, general health conditions, etc.).
PHARMACOLOGIC IMIQUIMOD 5% CREAM Imiquimod 5% cream in the treatment of superficial basal cell carcinoma: Results of a multicenter 6-week dose-response trial
Robin Marks, etal.
J Am Acad Dermatol 2001;44:807-13 Abstract quote
Background: Superficial basal cell carcinoma (sBCC) is an increasingly common tumor in fair-skinned populations throughout the world. Imiquimod, an immune response modifier that induces cytokines including interferons, has been shown in preliminary studies to have an effect when applied topically to BCC.
Objective: We conducted a multicenter, randomized, open-label dose-response trial of imiquimod 5% cream in the treatment of primary sBCC assessing efficacy and safety of different dose regimens.
Methods: Ninety-nine patients were randomized to 6 weeks' application of imiquimod in 1 of 4 treatment regimens: twice every day, once every day, twice daily 3 times/week, once daily 3 times/week. The treatment site was excised and examined histologically 6 weeks after cessation of imiquimod.
Results: Intention-to-treat analysis revealed 100% (3/3) histologic clearance in the twice-daily regimen, 87.9% (29/33) clearance in the once every day regimen, 73.3% (22/30) clearance in the twice-daily 3 times/week regimen, and 69.7% (23/33) clearance in the once-daily 3 times/week regimen. Dose-related inflammatory skin reactions at the site of application were common. The majority were well tolerated and only 1 patient withdrew from the trial as a result of a medication-related skin reaction.
Conclusion: Imiquimod 5% cream appears to have potential as a patient-administered treatment option in sBCC.
Imiquimod 5% cream for the treatment of superficial basal cell carcinoma: A double-blind, randomized, vehicle-controlled study.Geisse JK, Rich P, Pandya A, Gross K, Andres K, Ginkel A, Owens M.
Solano Dermatology Associates, Vallejo; Northwest Cutaneous Research Specialists, Portland; University of Texas Southwestern Medical Center, Dallas; Skin Surgery Medical Group, Inc, San Diego; and 3M Pharmaceuticals, St Paul.
J Am Acad Dermatol 2002 Sep;47(3):390-8 Abstract quote BACKGROUND: Imiquimod 5% cream may provide an effective nonsurgical treatment for superficial basal cell carcinoma (sBCC) based on results of previous studies.
OBJECTIVE: The objective of this phase II dose-response study was to explore various dosing regimens using imiquimod 5% cream for sBCC to find the most effective frequency of dosing with tolerable side effects.
METHODS: Patients (n = 128) were dosed twice daily, once daily, 5 times a week, or 3 times a week in this 12-week, randomized, double-blind, vehicle-controlled study. At 6 weeks after treatment, the entire tumor area was clinically evaluated, excised, and examined exhaustively for histologic evidence of residual sBCC.
RESULTS: Complete response rates were 100% (10/10), 87.1% (27/31), 80.8% (21/26), and 51.7% (15/29) for patients in the twice daily, once daily, 5 times a week, and 3 times a week imiquimod groups, respectively, and 18.8% (6/32) in the vehicle group.
CONCLUSION: Imiquimod 5% cream was effective in the treatment of sBCC. Daily or 5 times a week dosing for 12 weeks demonstrated high efficacy results with acceptable safety profiles.
Efficacy of topical 5% imiquimod cream for the treatment of nodular Basal cell carcinoma: comparison of dosing regimens.Shumack S, Robinson J, Kossard S, Golitz L, Greenway H, Schroeter A, Andres K, Amies M, Owens M.
St George Dermatology and Skin Cancer Center, Level 3, 22 Belgrave St, Kogarah, Australia 2217.
Arch Dermatol 2002 Sep;138(9):1165-71 Abstract quote OBJECTIVE: To establish a safe and efficacious dosing regimen for the treatment of primary nodular basal cell carcinoma (BCC) using 5% imiquimod cream.
DESIGN: Two phase 2 studies were conducted: a 6-week, randomized, open-label, dose-response study evaluating 4 dosing regimens and a 12-week, randomized, vehicle-controlled, double-blind, dose-response study evaluating 4 dosing regimens.
SETTING: Twenty-four public and private dermatology clinics in Australia and New Zealand (6-week study) and the United States (12-week study) participated.
PATIENTS: The study populations comprised 99 patients enrolled in the 6-week study and 92 patients in the 12-week study. Patients were at least 18 years old and had a biopsy-confirmed diagnosis of nodular BCC.
INTERVENTIONS: In the 6-week study, imiquimod was applied once daily for 3 or 7 days per week or twice daily for 3 or 7 days per week. In the 12-week study, imiquimod or placebo cream (vehicle) was applied once daily for 3, 5, or 7 days per week, or twice daily for 7 days per week. The entire tumor area was excised 6 weeks after treatment and examined histologically for evidence of remaining BCC.
MAIN OUTCOME MEASURE: The proportion of patients having no histologic evidence of BCC in the posttreatment excision specimen.
RESULTS: Dosing once daily for 7 days per week resulted in the highest clearance rate, with 25 (71%) of 35 and 16 (76%) of 21 patients showing clearance of their tumor in the 6- and 12-week studies, respectively.
CONCLUSIONS: Topical 5% imiquimod cream is well tolerated and most effective in treating nodular BCC when applied once daily for 7 days per week for either 12 or 6 weeks.
Treatment of diffuse Basal cell carcinomas and basaloid follicular hamartomas in nevoid Basal cell carcinoma syndrome by wide-area 5-aminolevulinic Acid photodynamic therapy.
Oseroff AR, Shieh S, Frawley NP, Cheney R, Blumenson LE, Pivnick EK, Bellnier DA.
Author Affiliations: Departments of Dermatology and Pathology and Photodynamic Therapy Center, Roswell Park Cancer Institute, Department of Dermatology, State University of New York at Buffalo, and Biostatistical Consulting Services, Buffalo.
Arch Dermatol. 2005 Jan;141(1):60-7. Abstract quote
OBJECTIVE: To report the use of wide-area 5-aminolevulinic acid photodynamic therapy to treat numerous basal cell carcinomas (BCCs) and basaloid follicular hamartomas (BFHs).
DESIGN: Report of cases.
SETTING: Roswell Park Cancer Institute.Patients Three children with BCCs and BFHs involving 12% to 25% of their body surface areas.Interventions Twenty percent 5-aminolevulinic acid was applied to up to 22% of the body surface for 24 hours under occlusion. A dye laser and a lamp illuminated fields up to 7 cm and 16 cm in diameter, respectively; up to 36 fields were treated per session.
MAIN OUTCOME MEASURES: Morbidity, patient response, and light dose-photodynamic therapy response relationship and durability.
RESULTS: Morbidity was minimal, with selective phototoxicity and rapid healing. After 4 to 7 sessions, with individual areas receiving 1 to 3 treatments, the patients had 85% to 98% overall clearance and excellent cosmetic outcomes without scarring. For laser treatments, a sigmoidal light dose-response relationship predicted more than 85% initial response rates for light doses 150 J/cm(2) or more. Responses were durable up to 6 years.
Conclusion 5-Aminolevulinic acid photodynamic therapy is safe, well tolerated, and effective for extensive areas of diffuse BCCs and BFHs and appears to be the treatment of choice in children.
Photodynamic therapy using topical methyl aminolevulinate vs surgery for nodular basal cell carcinoma: results of a multicenter randomized prospective trial.
Rhodes LE, de Rie M, Enstrom Y, Groves R, Morken T, Goulden V, Wong GA, Grob JJ, Varma S, Wolf P.
Department of Dermatology, Royal Liverpool University Hospital, Liverpool, England.
Arch Dermatol. 2004 Jan;140(1):17-23. Abstract quote
BACKGROUND: Photodynamic therapy (PDT) is increasingly used as a noninvasive treatment for nodular basal cell carcinoma (BCC), without a sound evidence base.
OBJECTIVE: To compare topical PDT, with the use of the sensitizer methyl aminolevulinate, and standard excision surgery in nodular BCC.
DESIGN: Prospective, randomized study.
SETTING: University dermatology departments.
PATIENTS: A total of 101 adults with previously untreated nodular BCC.
INTERVENTIONS: Patients received methyl aminolevulinate PDT (n = 52) or surgery (n = 49). The PDT was given twice, 7 days apart, with methyl aminolevulinate cream (160 mg/g) and 75 J/cm(2) red light (570-670 nm). Thirteen patients with a noncomplete response to PDT at 3 months (24% lesions) were retreated.
OUTCOME MEASURES: Primary end point was clinically assessed lesion clearance at 3 months after treatment. Secondary end points were sustained response rate at 12 months and cosmetic outcome at 3 and 12 months. Cosmesis and lesion recurrence were further assessed at 24 months.
RESULTS: Data from 97 patients (105 lesions) were included in the 3-month per-protocol analysis. Complete response rates did not differ significantly between groups (51/52 [98%] lesions with surgery vs 48/53 [91%] lesions with methyl aminolevulinate PDT; difference [95% confidence interval], 4.8% (-3.4% to 13.0%]; P =.25). At 12 months, tumor-free rates were 50 (96%) of 52 lesions with surgery vs 44 (83%) of 53 with methyl aminolevulinate PDT (P =.15). More patients treated with methyl aminolevulinate PDT than surgery had an excellent or good cosmetic outcome at all time points (significant at 12 and 24 months on patient assessment, P<.05, and at 3, 12, and 24 months on investigator evaluation, P<.001). At 24 months, 5 lesions that had initially cleared with methyl aminolevulinate PDT had recurred, compared with 1 after surgery.
CONCLUSIONS: Methyl aminolevulinate PDT is an effective treatment for nodular BCC, and while there is a trend for higher recurrence with this modality, it conveys the advantage over surgery of better cosmesis.
Photodynamic therapy of multiple nonmelanoma skin cancers with verteporfin and red light-emitting diodes: two-year results evaluating tumor response and cosmetic outcomes.
Lui H, Hobbs L, Tope WD, Lee PK, Elmets C, Provost N, Chan A, Neyndorff H, Su XY, Jain H, Hamzavi I, McLean D, Bissonnette R.
Division of Dermatology, University of British Columbia and Vancouver General Hospital, Vancouver, Canada.
Arch Dermatol. 2004 Jan;140(1):26-32. Abstract quote
BACKGROUND: Efficient treatment of patients with multiple synchronous nonmelanoma skin cancers represents a therapeutic challenge.
OBJECTIVE: To study the safety and efficacy of photodynamic therapy (PDT) with verteporfin and red light in the treatment of multiple nonmelanoma skin cancers.
DESIGN: Open-label, randomized, multicenter, dose-ranging phase 2 study conducted at 4 North American university-based dermatology clinics.
PATIENTS: Fifty-four patients with 421 multiple nonmelanoma skin cancers including superficial and nodular basal cell carcinoma and squamous cell carcinoma in situ (Bowen disease).
METHODS: A single intravenous infusion of 14 mg/m(2) of verteporfin followed 1 to 3 hours later by exposure of tumors to 60, 120, or 180 J/cm(2) of red light (688 +/- 10 nm) from a light-emitting diode panel.
MAIN OUTCOME MEASURES: Pathologic response of treated sites was assessed at 6 months. Clinical and cosmetic responses were assessed and graded at 6 weeks, 3 months, and 6 months after verteporfin PDT, with optional follow-up visits at 12, 18, and 24 months.
RESULTS: The histopathologic response, defined as absence of tumor on biopsy specimens 6 months after verteporfin PDT, ranged from 69% at 60 J/cm(2) to 93% at 180 J/cm(2). At 24 months of follow-up (276 tumors in 31 patients), the clinical complete response rate ranged from 51% at 60 J/cm(2) to 95% at 180 J/cm(2). No significant systemic adverse events were observed; most events occurred at the treated tumor sites and included events such as pain. Overall, 65% (95% confidence interval, 58%-71%) of tumors were judged to have good to excellent cosmesis at 24 months.
CONCLUSION: A single course of verteporfin PDT showed treatment benefit for patients with multiple nonmelanoma skin cancers.Arch Dermatol 2001;137:319-324
Background:
Photodynamic therapy (PDT) using topical -aminolevulinic acid (-ALA) is an effective treatment for Bowen disease and certain basal cell carcinomas (BCCs), but its place in clinical practice remains to be established. Patients with large and/or multiple lesions of Bowen disease or BCC can represent a considerable therapeutic challenge. We suggest that -ALA PDT may be of particular benefit in such patients.Observation:
In an open study, 35 (88%) of 40 large patches of Bowen disease, all with a maximum diameter greater than 20 mm, cleared following 1 to 3 treatments of -ALA PDT, although 4 patches recurred within 12 months. -Aminolevulinic acid PDT was also used to treat 40 large BCCs, with an identical 88% initial clearance (after 1-3 treatments), with 4 recurrences within 34 months (range, 12-60 months). In 10 further patients with multiple (3) patches of Bowen disease, 44 (98%) of 45 patches cleared following -ALA PDT, although 4 lesions recurred over 12 months. In 3 patients with multiple BCCs, PDT cleared 52 (90%) of 58 lesions, with 2 recurrences during 41 months (range, 12-52 months). Treatments were well tolerated, with only 5 patients with solitary large lesions requiring local anesthesia.Conclusions:
-Aminolevulinic acid PDT is an effective tissue-sparing modality achieving good cosmesis. We propose that -ALA PDT be considered as a first-line therapy for large and/or multiple areas of Bowen disease and superficial BCCs.
Photodynamic therapy vs. cryosurgery of basal cell carcinomas: results of a phase III clinical trial.Wang I, Bendsoe N, Klinteberg CA, Enejder AM, Andersson-Engels S, Svanberg S, Svanberg K.
Departments of Oncology and Dermatology and Venereology, Lund University Hospital, SE-221 85 Lund, Sweden.
Br J Dermatol 2001 Apr;144(4):832-40 Abstract quote BACKGROUND: A previously reported randomized clinical trial showed treatment of Bowen's disease using photodynamic therapy (PDT) with topically applied delta-aminolaevulinic acid (ALA) to be at least as effective as cryosurgery and to be associated with fewer adverse effects.
OBJECTIVES: To compare ALA-PDT and cryotherapy in the treatment of histopathologically verified basal cell carcinomas (BCCs) in a non-blinded, prospective phase III clinical trial.
METHODS: One lesion from each of 88 patients was included. The BCCs were divided into superficial and nodular lesions. The follow-up period was restricted to 1 year with close follow-up for the first 3 months. Efficacy was assessed as the recurrence rate 12 months after the first treatment session, verified by histopathology. Tolerability was evaluated as the time of healing, pain and discomfort during and after the treatment, and final cosmetic outcome.
RESULTS: Histopathologically verified recurrence rates in the two groups were statistically comparable and were 25% (11 of 44) for ALA-PDT and 15% (six of 39) for cryosurgery. However, clinical recurrence rates were only 5% (two of 44) for PDT and 13% (five of 39) for cryosurgery. Additional treatments, usually one, had to be performed in 30% of the lesions in the PDT group. The healing time was considerably shorter and the cosmetic outcome significantly better with PDT. Pain and discomfort during the treatment session and in the following week were low, and were equivalent with the two treatment modalities.
CONCLUSIONS: In terms of efficacy, ALA-PDT is comparable with cryosurgery as a treatment modality for BCCs. Retreatments are more often required with PDT than with cryosurgery. This can easily be performed due to the shorter healing time, less scarring and better cosmetic outcome that follows ALA-PDT.
SENTINEL LYMPH NODE BIOPSY
- Metastatic basal cell carcinoma diagnosed by sentinel lymph node biopsy.
Harwood M, Wu H, Tanabe K, Bercovitch L.
Department of Dermatology, Brown Medical School, Providence, Rhode Island, USA.
J Am Acad Dermatol. 2005 Sep;53(3):475-8. Abstract quote
Although commonly used in the treatment of melanoma, sentinel lymph node biopsy has not yet been successfully used to detect lymphatic metastasis of basal cell carcinoma because of exceedingly low rates of metastasis.
We describe the use of lymphatic mapping and sentinel lymph node biopsy in a patient after basal cell carcinoma was identified within a lymphatic vessel in the primary excisional specimen. As a result, the patient was found to have clusters of basal cell carcinoma in a sentinel lymph node resected from the right deltopectoral groove. Although metastatic basal cell carcinoma is exceedingly rare, we conclude that sentinel lymph node biopsy may be useful for certain high-risk lesions, such as lesions demonstrating histologic evidence of lymphatic invasion.
Further experience is necessary to determine the clinical usefulness of sentinel node biopsy in these patients and its effect on patient survival.Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.
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