With a confirmed diagnosis of basal cell carcinoma, the dermatologist has several options, both surgical and non-surgical, in his/her treatment armamentarium. The best option and most appropriate treatment is determined by several different factors (including the tumor’s location, size, and characteristics) but is also dictated by the health and needs of the patient. Almost all BCCs are treated with one of the following:
1. Simple Surgical Excision: uses a scalpel to remove clinically apparent cancer along with some surrounding healthy tissue. The specimen is then observed under the microscope to ensure that all tumor margins were removed with that sample. When compared to curettage (see below), healing is generally faster and results in a better aesthetic outcome; however, it is more time consuming, more costly, and requires more sacrifice of normal tissue.
2. Mohs Micrographic Surgery: is performed by a specially trained dermatologist and involves cutting out visible tumor and then successive layers of skin one at a time until cancer cells are no longer appreciated under the microscope. This surgery provides the best cure rates overall and is usually performed on high-risk areas such as the face and ears. Primary disadvantages include increased expense and time requirement.
3. Electrodessication and Curettage: uses a looped-blade (curette) to vigorously scrape the tumor away from the surrounding normal tissue. It’s a blind technique and cannot assess tumor margins, so use is limited when located on face or ears. No sutures are involved, thus healing is by granulation, which can result in an unpleasant white atrophic scar. With that said, this method is quick, simple, and cheap.
4. Cryosurgery: uses liquid nitrogen to freeze the cancer cells. It requires two freeze-thaw cycles with tissue temperature dropping to -50°C (-58°F). Patients must be willing to accept the immediate post-swelling, resultant necrosis (or death) of treated tissue that scabs over, and the unpredictable scarring associated with this treatment modality. Another disadvantage is that tumor margins cannot be examined.
5. Radiation Therapy: uses high-energy X-rays to destroy cancer cells and prevent the growth of new ones. This treatment modality is especially useful in patients who cannot tolerate surgery such as the elderly or debilitated. Short-term cosmetic results seem promising and even better than aesthetic results from surgical excision; however, results often become disfiguring in the long-term. Tumor margins cannot be examined.
6. Topical Therapy: includes cancer-fighting medications that the patient can put on the cancerous lesion at home. Two commonly used drugs are 5-fluorouracil 5% cream and imiquimod 5% cream. Topical therapy is mostly reserved for superficial basal cell carcinomas only. The current recommended dosing frequency is 5x per week for 6 weeks, but treatment can last anywhere from 6-16 weeks. Cosmetic results for both medications range anywhere from good to excellent. The main disadvantages are their high price (5-fluorouracil is cheaper) and their limited use.
REFERENCES:
Carucci JA and Leffell DJ. Basal Cell Carcinoma. In Wolff K, Goldsmith LA, Katz SI, et al: Fitzpatrick’s Dermatology in General Medicine, 7th ed. New York: McGraw-Hill Companies. 2003.
Habif TP, Campbell JL, Quitadamo MJ, and Zug KA. Basal Cell Carcinoma. In Fathman EM and Giesel EB: Skin Disease: Diagnosis and Treatment. St. Louis: Mosby. 2001.
Ramsey ML and Sewell LD. Basal Cell Carcinoma. [document on the Internet]. WebMD: eMedicine; 2009. [updated 2009 September 11; cited 2009 December 15]. Available from: http://emedicine.medscape.com/article/1100003-overview
AAD. Basal Cell Carcinoma. [document on the Internet]. American Academy of Dermatology; 2009. [updated 2009 September 1; cited 2009 December 15]. Available from: http://www.aad.org/public/publications/pamphlets/sun_basal.html