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BASAL CELL CARCINOMA: TREATMENT

BASAL CELL CARCINOMA: TREATMENT


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  • - AHMED MOURAD
  • - M.D. | PGY-2 DERMATOLOGY
  • - UNIVERSITY OF CALGARY

So, you have been diagnosed with a basal cell carcinoma on your skin. The good news is that basal cell carcinomas are often readily treatable with therapies that result in a positive long-term outcome and even cure. These include both surgical and non-surgical options.

Your treatment may vary depending on the type of basal cell carcinoma that you have and where your basal cell carcinoma is on your body. This will be discussed in detail with your dermatologist after reviewing your history and examining you.

We ask Dr. Ivan Litvinov, a Dermatologist at the McGill University Health Centre and the President-Elect of the Skin Research Group of Canada the following questions:

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Standard surgical excision:

The BCC is removed in a precise fashion usually with 4-5mm of an unaffected skin border around it. This procedure is usually performed under local anesthesia, which involves an injection of a freezing agent directly to the skin before the procedure.

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What are the advantages of this therapy?

Surgical excisions are more precise than other non-surgical options. We send all skin that we remove to a specialized physicians -- dermatopathologists. They look at your skin under the microscope to ensure that we have removed the BCC in its entirety.


What are the disadvantages of this therapy?

This type of therapy can result in scarring of the skin – and the degree of scarring that you get may vary. Standard surgical excision is often used for non-critical areas of the body, head and neck. It is not as precise as the “Mohs Micrographic Surgery”, which we will discuss in detail next. The most appropriate surgical option (standard excision vs Mohs) will be decided on with your dermatologist.


Mohs Micrographic Surgery

Mohs micrographic surgery is a specialized surgical treatment allowing for superb cure rates (>99%). The areas of skin in Mohs surgery are cut in small horizontal sections, which allows the surgeons, who are also experts in dermatopathology, to view all areas of the BCC closely under the microscope before deciding that all cancer is removed and the wound can be closed. The Mohs surgeons are also experts in plastic reconstruction giving the patients the best healing, often, without a visible scar.

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What are the advantages of this therapy?

Because small areas of the skin are taken out and examined at each time, this surgery allows for the most amount of unaffected skin tissue to be preserved. This is why we use Mohs surgery in cosmetically sensitive areas such as the face!


What are the disadvantages of this therapy?

Mohs surgery can be time consuming compared to other treatments. It usually involves a full-day or multi-day procedure depending on the type and involvement of the BCC that you have.

Most often, dermatologists decide to treat basal cell carcinomas with the two types of surgical therapy discussed above. If you are deemed not a surgical candidate by your physician or prefer to avoid surgical therapies, there are other non-surgical treatments used for basal cell carcinomas. Please keep in mind that these therapies are more appropriate for low-risk basal cell carcinomas such as superficial type BCCs or basal cell carcinomas in less crucial parts of the body. Your dermatologist will decide if non-surgical options are appropriate for you based on the characteristics of your carcinoma and will consider your preferences for treatment.

Topical Therapies - Imiquimod and Fluorouracil

What are the advantages of this therapy?

These therapies are non-invasive, and usually do not cause scarring. We elect to use these topical therapies when our patients are not surgical candidates or when the cancer is very thin.

What are the disadvantages of this therapy?

miquimod and fluorouracil both can cause an exuberant inflammatory reactions to the skin (redness, pain and skin irritation), once applied. People look like they are having a major infection – cellulitis, but they don’t. It is just how the cream works. Naturally, during these times people may feel very uncomfortable. These topical therapies are usually not appropriate for high-risk basal cell carcinomas.

Electrodessication and Curettage (ED&C)

Dr. Litvinov, is there a role for ED&C to treat BCCs?

Great question! ED&C has a limited role in treating BCC and usually reserved for treating of low-risk BCCs or patients who do not wish to have full surgery. Often, this type of therapy can result in incomplete tumor removal (~90% success rate) and has higher recurrence rates than the other discussed therapies! For these reasons sometimes we prefer other therapies.

Skin Radiation Therapy

Radiation therapy is often used in patients who are not surgical candidates. For instance, elderly patients with dementia who would not be able to stay still on an operating table under local anesthesia. Radiation therapy may buy them another 10-15 years which is an optimal outcome in tis case. It involves applying external beam of radiation which is used to inactivate the basal cell carcinoma cells.

What are the advantages of this therapy?

Radiation therapy is a non-invasive therapy. It can be used sometimes in patients who are not candidates for surgery, or in some rare cases, used in combination after surgery for skin cancers.

What are the disadvantages of this therapy?

It is sometimes difficult to control exactly how much of the skin is treated, and may require repeat treatments. Sometimes, excessive scarring and radiation site reactions can occur. This therapy is not commonly used to treat basal cell carcinomas except in special circumstances.

  • - Bolognia, Jean, Julie V. Schaffer, and Lorenzo Cerroni. Dermatology. Philadelphia, Pa: Elsevier, 2018. Print
  • - Kang, Sewon, Masayuki Amagai, Anna L. Bruckner, Alexander H. Enk, David J. Margolis, Amy J. McMichael, and Jeffrey S. Orringer: Fitzpatrick’s Dermatology. 9th Edition: McGraw Hill, 2019. Print


SQUAMOUS CELL CARCINOMA: TREATMENT

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Squamous cell carcinomas (SCC) are common cancers arising from a specific type of skin cell called a “keratinocyte”. If you have been diagnosed a squamous cell carcinoma on your skin, the following information will be helpful for you to understand the types of therapies used to treat this condition.

Your treatment may vary depending on the type of squamous cell carcinoma that you have and its location on your body. This specific type of therapy will be discussed with you in detail by your dermatologist after reviewing your history and examining you.

We ask Dr. Ivan Litvinov, a Dermatologist at the McGill University health Center and President-Elect of the Skin Research Group of Canada the following questions:

Standard surgical excision:

The SCC is removed in a precise fashion under local anesthesia.

What are the advantages of this therapy?

Surgical excisions are more precise than other non-surgical options. We send all skin that we remove to specialized physicians -dermatopathologist. They look at your skin under the microscope to ensure that we have removed the entirety of the SCC.

What are the disadvantages of this therapy?

This type of therapy can result in scarring of the skin – and the degree of scarring that you get may vary. Standard surgical excision is often used for non-critical areas of the body, head and neck. It is not as precise as “Mohs Micrographic Surgery”, which we discuss in detail below. The most appropriate surgical option (standard excision vs Mohs) will be decided on with your dermatologist.

Mohs Micrographic Surgery

Mohs micrographic surgery is a specialized surgical treatment allowing for superb cure rates. The areas of removed affected skin are cut in small horizontal sections, which allow all areas of the SCC to be closely examined under the microscope. It can be used in high-risk squamous cell carcinomas in areas where cosmesis (appearance) and function is important.

What are the advantages of this therapy?

Because small areas of the skin are taken out and examined at a time, this surgery allows for the most amount of unaffected skin tissue to be preserved. This is why we use Mohs surgery in cosmetically sensitive areas such as the face!

What are the disadvantages of this therapy?

Mohs surgery can be time consuming. It is usually a full-day or multi-day procedure depending on the type and involvement of SCC you have.

Non-surgical treatment options of squamous cell carcinomas include electrodessication and curettage (ED&C), cryotherapy, skin radiation therapy, photodynamic therapy, and topical field therapy.

Electrodessication and Curettage (ED&C) – literally means scrape and burn the cancer.

ED&C is a procedure used to remove skin cancer including SCC. First, a layer of the abnormal cells is removed using a curette. Then electrocautery is used cauterize the wound and the wound is let to heal without any sutures.

ED&C is often used for low-risk squamous cell carcinomas. If the squamous cell carcinoma has advanced or deep involvement, then surgical excision is more appropriate.

What are the advantages of this therapy?

ED&C is a relatively quick office procedure, and usually results in positive cosmetic outcomes.

What are the disadvantages of this therapy?

The cure rates are lower than surgical options and not suitable for high-risk squamous cell carcinomas.


Cryotherapy (Liquid Nitrogen Therapy)

Cryotherapy is used to deactivate SCC by using an extremely cold substance called liquid nitrogen. Liquid nitrogen is applied to the SCC tumor to freeze it. The frozen area sometimes is allowed to thaw and be frozen again for a total of 2-3 freeze-thaw cycles.

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What are the advantages of this therapy?

Cryotherapy is a convenient office based procedure. It does not require sutures.

What are the disadvantages of this therapy?

Because the skin is frozen to such a low temperature, it is common to experience pain, swelling, and leakage from the site which can last days to weeks. The part of the SCC skin that was frozen with this therapy sometimes leaves behind a healing ulcer which is a normal part of therapy. You could also experience discoloration of the skin, and scarring at the site.

Skin Radiation Therapy

Radiation therapy is often used in patients who are not surgical candidates and, particularly for SCC, it is reserved for older patients who are not surgical candidates, or who have high-risk tumors.

What are the advantages of this therapy?

Radiation therapy is a non-invasive therapy. It can be used sometimes in patients who are not candidates for surgery, or in some rare cases, used after surgery.

What are the disadvantages of this therapy?

It is sometimes difficult to control exactly how much of the skin is treated, and may require repeat treatments. Sometimes, excessive scarring and radiation site reactions can occur.


Photodynamic Therapy (PDT)

o Photodynamic therapy is a non-invasive procedure where (1) a “photosensitizing” topical drug is administered to the area of interest, then (2) visible light is applied to the area to cause destruction to the active area. It can be used in thin squamous cell carcinomas where surgery is not an option or where multiple thin and early SCCs are present. Photodynamic therapy is also used to treat actinic keratosis (pre-cancerous lesions of sun damage), and bowen’s disease (low-risk variant of squamous cell carcinoma).

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What are the advantages of this therapy?

Photodynamic therapy is non-invasive and does not cause scarring. It treats the thin cancer and the surrounding field of skin where other precancerous lesions might be.

What are the disadvantages of this therapy?

Patients can often experience sensitivity to light, and uncommonly, discoloration of the skin. This therapy should not be used if you have a condition called porphyria.

Topical Therapies - Imiquimod and Fluorouracil creams

Imiquimod and fluorouracil are a type of topical medication used to treat many cancerous and pre-cancerous conditions of the skin. They are used to treat a condition called Bowen’s disease which is considered to be a low-risk variant of squamous cell carcinoma

Imiquimod or fluorouracil can be used to modify your body’s immune system response to the area of skin the creams are applied to. They are usually applied once to twice daily for a total duration of 3-6 weeks, or until a response is seen.

What are the advantages of these therapies?

These therapies are non-invasive and usually do not cause scarring. We elect to use these medications when our patients are not candidates for surgery.

What are the disadvantages of these therapies?

Both imiquimod and fluorouracil can cause a vigorous inflammatory reaction to the skin (redness, pain and skin irritation) once applied.

  1. Bolognia, Jean, Julie V. Schaffer, and Lorenzo Cerroni. Dermatology. Philadelphia, Pa: Elsevier, 2018. Print
  2. Kang, Sewon, Masayuki Amagai, Anna L. Bruckner, Alexander H. Enk, David J. Margolis, Amy J. McMichael, and Jeffrey S. Orringer: Fitzpatrick’s Dermatology. 9th Edition: McGraw Hill, 2019. Print