Treatment Of Low Risk Basal Cell Carcinoma (BCC)

Primary treatment options for low-risk BCC include:
- Curettage and electrodesiccation:
  - In areas without hair growth:
    - Provided that the treatment be changed to excision if the adipose is reached
- Standard excision:
  - With 4 mm clinical margins
- RT for nonsurgical candidates:
  - If margins are positive after excision:
    - Patients should receive adjuvant therapy
- Mohs micrographic surgery (MMS)
- Resection with complete circumferential peripheral and deep margin assessment (CCPDMA) with frozen or permanent section
- Standard reexcision for area L regions (trunk, extremities):
  - Is recommended:
    - Whereas radiation may be administered to nonsurgical candidates

Several randomized studies and meta-analyses have compared superficial therapies for low-risk BCC, including:
- Topical therapies such as imiquimod or 5-fluorouracil (5-FU)
- Photodynamic therapy (PDT) with methyl aminolevulinate (MAL) or 5-aminolevulinic acid (ALA),
- Cryotherapy
5-FU:
- Is an antineoplastic antimetabolite
Imiquimod:
- Is a synthetic immune response modifier:
  - That enhances cell-mediated immune response via the induction of proinflammatory cytokines
For the treatment of superficial BCC:
- 5-FU can be applied daily to the tumor and several millimeters of surrounding skin for a period of at least 4 weeks:
  - After a 2- to 3-week interval:
    - The area is then evaluated, often by biopsy, to ensure adequate therapy
PDT:
- Involves the application of a photosensitizing agent on the skin, followed by irradiation with a light source
Cryosurgery:
- Destroys tumor cells by freeze-thaw cycles, but a key limitation is poorer cosmetic outcomes compared with other treatment options
- Contraindications to cryosurgery for BCC include:
  - Indistinct borders
  - Recurrent tumor
  - Certain tumor location overlying nerves
  - Size greater than 1 cm on the face
  - Certain pathologic features of:
    - Morpheaform, sclerosing, infiltrative, or perineural invasion
  - Patient characteristics, including:
    - Dark skin type
    - Cosmetically sensitive patient
    - Previous poor response to cryotherapy
    - Raynaud phenomenon
- Imiquimod and 5-FU:
  - Have been found to be effective in treating superficial BCC in randomized studies:
    - The efficacy and cosmetic results of some of these comparison studies are demonstrated in the table
    - One study indicates that PDT has similar efficacy as cryotherapy but better cosmetic outcomes
    - Another study demonstrates that PDT, imiquimod, and 5-FU have similar efficacy and cosmetic outcomes:
      - Although the risk of recurrence may be somewhat higher with PDT versus imiquimod
    - The National Comprehensive Cancer Network panel agrees that these superficial therapies:
      - May be effective for anatomically challenging locations where surgery or radiation is contraindicated or impractical:
        
        But the cure rates of these approaches are lower compared with surgery