9.1 Cryotherapy and electrodessication and curettage for basal cell carcinoma

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Clinical practice guidelines for keratinocyte cancer > 9.1 Cryotherapy and electrodessication and curettage for basal cell carcinoma


Background

Certain basal cell carcinomas (BCCs) may be successfully treated by cryosurgery.

Electrodessication and curettage (EDC) is anecdotally reported to be effective for superficial BCCs on the trunk and limbs. It is useful in the treatment of BCCs on the legs of older patients as an alternative to skin grafting. Unpredictable cosmetic results restrict its use on the face to situations where the cosmetic result is not a high priority. It has the advantages of being rapid to perform, tissue conserving, and not being contraindicated in patients taking anticoagulant medication.
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Overview of evidence (non-systematic literature review)

Cryotherapy for basal cell carcinoma

Small (<2cm) superficial BCCs are ideally treated with cryotherapy if appropriate selection criteria are applied.

Patients with pale skin types are less likely to have pigmentation disturbances after treatment with cryotherapy than those with pigmented skin.

Evidence sources (cryotherapy)

No randomised controlled studies have compared cryotherapy with surgical excision or other treatment modalities in the treatment of BCC.

Many large series by specialist clinics have demonstrated cure rates with cryotherapy equivalent to those achieved with other treatment modalities.[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]

Tumour selection (cryotherapy)

Investigators emphasise the importance of careful tumour selection to achieve acceptable results.[5][15][18][22] Histological confirmation of the BCC and analysis for high-risk features is strongly recommended.[5][23][24][25]

Cryosurgery is most effective for primary well-defined lesions of non-aggressive subtypes at sites other than the head and neck.[6][7][9][10][15] Patients in whom cryotherapy can achieve equivalent outcomes to surgical excision include those with appropriately selected small (<2cm) superficial BCC and less pigmented skin types where there is a low risk of post-treatment pigmentation disturbances.

In general, cryotherapy is contraindicated for sclerosingscar-like (morphoeic) or ill-defined BCCs[5][8][9][13][18][19][26] and relatively contraindicated for high-risk facial sites such as lips, alar creases, inner canthi and periauricular regions.[15][24][27]
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Technique (cryotherapy)

Repeated freeze–thaw cycles with margins of 3–5mm are recommended.[5][15][24][28][29][30]

Thermocouple needles may be used to monitor the temperature at the base of lesions, and may be useful for thicker lesions. However, several clinical parameters correlate well with adequate-depth freeze and are more routinely employed.[24][25][27][28][29][31][32][33]

Cure rates (cryotherapy)

Cure rates for BCC by cryosurgery are technique-dependent. Cure rates consistently exceed 95% in specialty clinics where optimal selection and treatment protocols are used.[1][3][4][5][6][7][9][10][12][13][15][16][18][26] Suboptimal cryotherapy technique results in unacceptably low clearance rates.[2] One extensive review of multiple series reported a 5-year recurrence rate for cryosurgery of 7.5%, which is comparable to that of other standard treatment modalities.[1]

Most large series utilise liquid nitrogen in an open-spray technique with repeated freeze-thaw cycles.[3][5][7][8][10][12][13][15][16][17][18][20][26] However, superficial BCCs have been successfully treated with single freeze-thaw cycle cryotherapy, achieving cure rates of 96%.[6][9] Thermocouple needle monitoring of the temperature produced at the base of tumours (–40°C to –60°C) may be employed.[3][7][9][10][19][20][26]

Tumour features influencing outcome (cryotherapy)

Certain microscopic features are associated with a greater depth of invasion and a higher risk of recurrence (see: Pathology).[34] Clinical features are fundamental in choosing those BCCs suitable for cryosurgery. Primary BCCs constitute the great majority of tumours treated in reported series.[1][6][7][8][9][13][15][26] In general, such tumours are well-defined and non-sclerosingscar-like (morphoeic) (morphoeic) in subtype. Most series exclude ill-defined or sclerosingscar-like (morphoeic) BCCs in their selection criteria due to unacceptably high recurrence rates.[5][8][9][13][17][18][20][21][26]

The size of a BCC also determines its response to cryosurgery. In general, the greater the diameter of a tumour, the lower the cure rate.[6][14][16][17][20][21] Recurrent BCCs respond less well to cryosurgery, with lower cure rates.[3][6] Mohs micrographic surgery is the preferred treatment for such lesions (see: Mohs micrographic surgery).[1][35]

Site criteria are also essential in selecting BCCs suitable for cryosurgery. Tumours on the trunk and limbs respond with consistently high cure rates of greater than 97%.[7][10][15]

Less optimal results are achieved for sites on the head and neck,[2][3][4][6][14][17][19][20] although acceptable cure rates have been reported for selective cancers in specialist clinics with significant cryotherapy experience.[7][8][12][13][15][18][21][26]
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Role of curettage

Curettage is often combined with cryosurgery and may help improve the cure rate.[8][13][16][29][30][36][37][38][39]

A single-centre, randomised study that compared curettage followed by cryotherapy, with surgical excision, in the treatment of BCC reported no statistically significant difference in 5-year recurrence rates between groups.[37]

Curettage provides a sample for histology, facilitates cryotherapy of larger tumours by reducing the tissue volume to be ablated,[16] and may offer some advantages at sites such as nose and ears to define the full extent of tumour growth prior to cryosurgery.[8][9][11][12][13]

Follow-up (curettage)

Routine follow-up is essential for all patients treated by cryosurgery.

Most recurrences will become evident within 5 years[7][16] and many within 2 years.[5][18] However, some BCCs have recurred as late as 10–12 years after treatment.[1][24]

Training and supervision (curettage)

Cryosurgery should be performed only by operators with appropriate supervised training in the procedures.
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Electrodessication and curettage for basal cell carcinoma

Small (<2cm) nodular and superficial BCCs are suited to treatment with EDC.

Following EDC, healing with acceptable scarring is more likely for BCC in concave areas, compared with convex areas, and for older (>70 years) patients than younger patients.

Evidence sources (EDC)

No randomised controlled studies have compared EDC with surgical excision or other treatment modalities in the treatment of BCC.

Observational studies such as case series have reported outcomes of EDC in the treatment of BCC.[40][41]

Cure rates (EDC)

Cryotherapy achieves high cure rates for primary basal cell carcinoma in sites other than face and ears if tumour selection and treatment protocols are optimal. Cure rates of approximately 95% or higher have been reported for tumours smaller than 1cm in some sites (Table 9).

Tumour selection (EDC)

Lesion selection by site and size is critical (Table 9).

Electrodessication and curettage is used for all sizes of lesion on low-risk areas (neck, trunk and limbs).[42] Higher recurrence rates have been reported with previously treated lesions.[42][40][41]

Sclerosingscar-like (morphoeic) (morphoeic) BCCs are not treated with EDC, as they are not curettable due to the lack of a gelatinous stroma. Excisional data does confirm that histological type is a significant factor in recurrence; sclerosingscar-like (morphoeic) and other infiltrating types of BCC characterised histologically by small cell clumps show higher recurrence rates.[41]
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Scarring (EDC)

Basal cell carcinomas in concave areas heal with reduced scarring post EDC compared with those in convex areas.

Older (>70 years) patients often have better scar outcomes post EDC, compared with younger patients.


Table 9 Control rates for basal cell carcinomas treated by serial curettage by diameter[42][40][41]
Lesion: size/location Cure rate at 5 years
<1cm all sites 98.77%
<1cm nose 93.55%
>2cm all sites 84%
>2cm ears 67%
All sizes excluding head > 96%
<1cm cheek, forehead and temple 94.7%
>1cm as above [5][43] 77.3%
<0.5cm nasal, paranasal, periorbital, lips, chin, jawline and ears[5][43] 94.7%
>0.5cm as above 77.3%

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Contraindications (EDC)

Electrodessication and curettage is not appropriate for:

  • lesions in high-risk areas (nasal, paranasal, lips, eyelids, chin, jawline and ears), or at least not for lesions larger than 5mm at these sites[42]
  • lesions larger than 10mm on middle-risk sites (face, forehead, temples and scalp)[42]
  • clinically sclerosingscar-like (morphoeic) lesions[41]
  • recurrent lesions.[42][40]

    Training and supervision (EDC)

Electrodessication and curettage should be performed only by operators with appropriate supervised training in the procedures.[42]

Follow-up (EDC)

Long-term follow-up is essential after treatment of BCC with EDC, as late recurrences may occur.

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Practice Point

Practice pointQuestion mark transparent.png

PP 9.1.1. Long-term follow-up is essential after treatment of basal cell carcinoma with cryotherapy, as late recurrences may occur.

Key point(s)
  • For patients with primary basal cell carcinomas in sites other than face and ears, with optimal tumour selection and treatment protocols, cryotherapy may be considered as a treatment option.
  • Cryotherapy is not recommended for basal cell carcinomas at high-risk facial sites, where it achieves lower cure rates.
  • Cryotherapy is not recommended for the treatment of basal cell carcinomas larger than 2cm in diameter.
  • Cryotherapy is contraindicated for ill-defined or sclerosingscar-like (morphoeic) (morphoeic or infiltrative) basal cell carcinomas at any site.

Notes on the recommendations

Follow-up of patients after treatment is individually tailored according to patient factors, tumour factors, anatomic site and the perceived adequacy of treatment.
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References

  1. 1.01.11.21.31.41.5 Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 1989 Mar;15(3):315-28 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2646336.
  2. 2.02.12.2 Hall VL, Leppard BJ, McGill J, Kesseler ME, White JE, Goodwin P. Treatment of basal-cell carcinoma: comparison of radiotherapy and cryotherapy. Clin Radiol 1986 Jan;37(1):33-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3514075.
  3. 3.03.13.23.33.43.5 Zacarian SA. Cryosurgery of cutaneous carcinomas. An 18-year study of 3,022 patients with 4,228 carcinomas. J Am Acad Dermatol 1983 Dec;9(6):947-56 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/6643791.
  4. 4.04.14.2 Fraunfelder FT, Zacarian SA, Limmer BL, Wingfield D. Cryosurgery for malignancies of the eyelid. Ophthalmology 1980 Jun;87(6):461-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7413134.
  5. 5.005.015.025.035.045.055.065.075.085.095.10 Holt PJ. Cryotherapy for skin cancer: results over a 5-year period using liquid nitrogen spray cryosurgery. Br J Dermatol 1988 Aug;119(2):231-40 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3166941.
  6. 6.06.16.26.36.46.56.66.7 Graham GF. Statistical data on malignant tumors in cryosurgery: 1982. J Dermatol Surg Oncol 1983 Mar;9(3):238-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/6826880.
  7. 7.07.17.27.37.47.57.67.77.8 Kuflik EG, Gage AA. The five-year cure rate achieved by cryosurgery for skin cancer. J Am Acad Dermatol 1991 Jun;24(6 Pt 1):1002-4 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1820761.
  8. 8.08.18.28.38.48.58.68.7 Nordin P. Curettage-cryosurgery for non-melanoma skin cancer of the external ear: excellent 5-year results. Br J Dermatol 1999 Feb;140(2):291-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10233225.
  9. 9.09.19.29.39.49.59.69.79.8 Graham GF. Cryosurgery. Clin Plast Surg 1993 Jan;20(1):131-47 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8420702.
  10. 10.010.110.210.310.410.5 Kuflik EG. Cryosurgical treatment for large malignancies on the upper extremities. J Dermatol Surg Oncol 1986 Jun;12(6):575-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3711418.
  11. 11.011.1 Kingston T, Jackson A, August P. Cryosurgery in the treatment of skin cancer. Br J Cancer 1988;119 (suppl):33-39.
  12. 12.012.112.212.312.4 Kuflik EG. Treatment of basal- and squamous-cell carcinomas on the tip of the nose by cryosurgery. J Dermatol Surg Oncol 1980 Oct;6(10):811-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7229166.
  13. 13.013.113.213.313.413.513.613.713.8 Nordin P, Larkö O, Stenquist B. Five-year results of curettage-cryosurgery of selected large primary basal cell carcinomas on the nose: an alternative treatment in a geographical area underserved by Mohs' surgery. Br J Dermatol 1997 Feb;136(2):180-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9068728.
  14. 14.014.114.2 Gonçalves JC. Fractional cryosurgery for skin cancer. Dermatol Surg 2009 Nov;35(11):1788-96 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19732116.
  15. 15.015.115.215.315.415.515.615.715.815.9 McLean DI, Haynes HA, McCarthy PL, Baden HP. Cryotherapy of basal-cell carcinoma by a simple method of standardized freeze-thaw cycles. J Dermatol Surg Oncol 1978 Feb;4(2):175-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/624804.
  16. 16.016.116.216.316.416.516.6 Spiller WF, Spiller RF. Treatment of basal-cell carcinomas by a combination of curettage and cryosurgery. J Dermatol Surg Oncol 1977 Jul;3(4):443-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/893768.
  17. 17.017.117.217.317.4 McIntosh GS, Osborne DR, Li AK, Hobbs KE. Basal cell carcinoma--a review of treatment results with special reference to cryotherapy. Postgrad Med J 1983 Nov;59(697):698-701 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/6647186.
  18. 18.018.118.218.318.418.518.618.7 Biro L, Price E, Brand A. Cryosurgery for basal cell carcinoma of the eyelids and nose: five-year experience. J Am Acad Dermatol 1982 Jun;6(6):1042-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7096667.
  19. 19.019.119.219.3 Biro L, Price E. Basal-cell carcinomas of eyelids: experience with cryosurgery. J Dermatol Surg Oncol 1979 May;5(5):397-401 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/458007.
  20. 20.020.120.220.320.420.5 Kuflik EG. Cryosurgery for basal-cell carcinomas on and around eyelids. J Dermatol Surg Oncol 1978 Dec;4(12):911-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/730935.
  21. 21.021.121.221.3 Fraunfelder FT, Zacarian SA, Wingfield DL, Limmer BL. Results of cryotherapy for eyelid malignancies. Am J Ophthalmol 1984 Feb;97(2):184-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/6696028.
  22. Motley RJ, Gould DJ, Douglas WS, Simpson NB. Treatment of basal cell carcinoma by dermatologists in the United Kingdom. British Association of Dermatologists Audit Subcommittee and the British Society for Dermatological Surgery. Br J Dermatol 1995 Mar;132(3):437-40 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7718462.
  23. Drake LA, Ceilley RI, Cornelison RL, Dobes WA, Dorner W, Goltz RW, et al. Guidelines of care for basal cell carcinoma. The American Academy of Dermatology Committee on Guidelines of Care. J Am Acad Dermatol 1992 Jan;26(1):117-20 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1732317.
  24. 24.024.124.224.324.4 Torre D. Cryosurgery of basal cell carcinoma. J Am Acad Dermatol 1986 Nov;15(5 Pt 1):917-29 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3782532.
  25. 25.025.1 Zacarian SA, Adham MI. Cryotherapy of cutaneous malignancy. Cryobiology 1966 Jan;2(4):212-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/5907605.
  26. 26.026.126.226.326.426.526.6 Fraunfelder FT, Farris HE Jr, Wallace TR. Cryosurgery for ocular and periocular lesions. J Dermatol Surg Oncol 1977 Jul;3(4):422-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/893764.
  27. 27.027.1 Kuflik EG. Cryosurgery updated. J Am Acad Dermatol 1994 Dec;31(6):925-44; quiz 944-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7962774.
  28. 28.028.1 Sinclair RD, Dawber RP. Cryosurgery of malignant and premalignant diseases of the skin: a simple approach. Australas J Dermatol 1995 Aug;36(3):133-42 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7487739.
  29. 29.029.129.2 August PJ. Cryotherapy of nonmelanoma skin cancer. Clin Dermatol 1995 Nov;13(6):589-92 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8882770.
  30. 30.030.1 Telfer NR, Colver GB, Morton CA, British Association of Dermatologists.. Guidelines for the management of basal cell carcinoma. Br J Dermatol 2008 Jul;159(1):35-48 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18593385.
  31. Zacarian S. Cryotherapy of skin cancer: fundamentals of techniques and application. Cutis 1975 [cited 2018 Oct];16:449-460.
  32. Bokey EL, Ojerskog B, Chapuis PH, Dent OF, Newland RC, Sinclair G. Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection. Br J Surg 1999 Sep;86(9):1164-70 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10504371.
  33. Young R, Sinclair R. Practical cryosurgery. Aust Fam Physician 1997 Sep;26(9):1045-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9382718.
  34. Miller SJ. Biology of basal cell carcinoma (Part I). J Am Acad Dermatol 1991 Jan;24(1):1-13 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1999506.
  35. Murray C, Sivajohanathan D, Hanna TP, Bradshaw S, Solish N, Moran B, et al. Patient Indications for Mohs Micrographic Surgery: A Systematic Review. J Cutan Med Surg 2019;2019 Jan Feb;23(1):75-90 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/30033747.
  36. Graham G, Garnett A, Kuflik E, Lubritz R. Guidelines of care for cryosurgery. American Academy of Dermatology Committee on Guidelines of Care. J Am Acad Dermatol 1994 Oct [cited 2018 Oct];31(4):648-53 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8089292.
  37. 37.037.1 Kuijpers DI, Thissen MR, Berretty PJ, Ideler FH, Nelemans PJ, Neumann MH. Surgical excision versus curettage plus cryosurgery in the treatment of basal cell carcinoma. Dermatol Surg 2007 May;33(5):579-87 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17451581.
  38. Peikert JM. Prospective trial of curettage and cryosurgery in the management of non-facial, superficial, and minimally invasive basal and squamous cell carcinoma. Int J Dermatol 2011 Sep;50(9):1135-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22126880.
  39. Lindemalm-Lundstam B, Dalenbäck J. Prospective follow-up after curettage-cryosurgery for scalp and face skin cancers. Br J Dermatol 2009 Sep;161(3):568-76 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19624544.
  40. 40.040.140.240.3 Menn H, Robins P, Kopf AW, Bart RS. The recurrent basal cell epithelioma. A study of 100 cases of recurrent, re-treated basal cell epitheliomas. Arch Dermatol 1971 Jun;103(6):628-31 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/5555851.
  41. 41.041.141.241.341.4 Emmett AJ. Surgical analysis and biological behaviour of 2277 basal cell carcinomas. Aust N Z J Surg 1990 Nov;60(11):855-63 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2241644.
  42. 42.042.142.242.342.442.542.6 Silverman MK, Kopf AW, Grin CM, Bart RS, Levenstein MJ. Recurrence rates of treated basal cell carcinomas. Part 2: Curettage-electrodesiccation. J Dermatol Surg Oncol 1991 Sep;17(9):720-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1820764.
  43. 43.043.1 De Lanza MP, Ralfs I, Dawber RP. Cryosurgery for Bowen's Disease of the skin. Br J Cancer 1980;18:14. 103(18) p14.

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