Treatment of basal cell carcinoma with curettage alone

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1 DERMATOLOGIC SURGERY Treatment of basal cell carcinoma with curettage alone JamesO.Barlow,MD,MarkJ.Zalla,MD,AmberKyle,MD,DavidJ.DiCaudo,MD, Katherine K. Lim, MD, and James A. Yiannias, MD Scottsdale, Arizona Background: Although curettage and electrodesiccation (C&E) is widely used to treat basal cell carcinoma, whether electrodesiccation improves outcome is unknown. Objective: We sought to compare cure rates of curettage alone with those of C&E. Methods: We conducted a retrospective records review of patients treated with curettage alone at 5-year follow-up or longer that extracted data about tumor location, size, histologic subtype, biopsy specimen margin involvement, and recurrence, as well as data about the medical history of patients treated in a dermatology clinic in a tertiary-care academic medical institution. Results: Biopsy-proven tumors (302) amenable to treatment with C&E and treated by a single investigator with curettage alone had a 5-year cure rate of 96.03%, with minimal complications (hypopigmentation, scarring). Tumors involving more than 50% of the deep edge of the shave biopsy specimen had an increased risk of recurrence. Limitations: This is a retrospective study based on historic controls. Conclusion: For nonaggressive basal cell carcinoma, curettage alone has a cure rate similar to the published rates for C&E. ( J Am Acad Dermatol 2006;54: ) Curettage and electrodesiccation (C&E) in 3 cycles is a widely accepted technique for treatment of basal cell carcinoma (BCC). Curettage takes advantage of the soft friable nature of most BCC. Multiple passes with successively smaller curettes can effectively remove BCC from the surrounding dermis. As an additional destructive technique, electrodesiccation between cycles of curettage provides hemostasis and is thought to improve the effectiveness of curettage. However, this improved effectiveness has not been documented. Electrodesiccation has been associated with considerable postoperative hypopigmentation and From the Department of Dermatology, Mayo Clinic. Drs Zalla and Kyle are currently in private practice in Florence, Ky, and Torrance, Calif, respectively. Funding sources: None. Conflicts of interest: None identified. Reprints not available from the authors. Correspondence to: Katherine K. Lim, MD, Department of Dermatology, Mayo Clinic, E Shea Blvd, Scottsdale, AZ /$32.00 ª 2006 by the American Academy of Dermatology, Inc. doi: /j.jaad hypertrophic scarring. 1,2 In addition, it has the potential to interact with implanted cardiac devices and delay healing. 3-7 Viral particles and potential carcinogens also have been identified in the smoke plumes of electrocautery devices Reymann 11 and McDaniel 2 have reported similar cure rates and better cosmesis for patients treated with curettage alone than for those treated with C&E (Table I). On the basis of these reports, we have practiced curettage alone since 1993 and have noted similar improvement in cosmesis (Fig 1). However, comparisons are difficult because many studies of C&E have lacked either the clinical or pathologic correlation that likely affects cure rates. 1,12-18 The same is true of curettage alone. 2,11 We present a clinical and pathologic review of BCC treated with curettage alone and report on 5-year recurrence rates and the clinical and pathologic predictors of recurrence. METHODS The records of all patients with biopsy-proven BCC clinically amenable to curettage alone who were treated by a single physician (M. J. Z.) at our institution between August 1993 and October 1998 were identified and reviewed retrospectively. Data 1039

2 1040 Barlow et al JAM ACAD DERMATOL JUNE 2006 Table I. Reported 5-year recurrence rates for basal cell carcinoma Reference No. of patients 5-y recurrence rate, % Electrodesiccation and curettage Kopf et al 1 Faculty ( ) Residents ( ) Residents ( ) Silverman et al 12 2, Spiller and Spiller Whiting Crissey 15 1, Knox et al Tromovitch Sweet Curettage alone Reymann McDaniel Data from Rowe et al. 19 on patient demographics, tumor characteristics, and potential medical risk factors for BCC were extracted from medical records. All tumors with at least 5-year follow-up were included. The 5-year cure rate was compared with published cure rates for BCC treated with C&E. 1,2,11-18 This study was approved by our institutional review board. Criteria for clinically amenable tumors included discrete primary tumors with a predominantly nodular or superficial clinical appearance. Tumors were excluded if they were recurrent, involved the mucous membranes or eyelids, had been biopsied by punch, or had clinically suspected sclerotic or infiltrative features. Tumors treated with curettage and considered adequately treated on clinical grounds but subsequently found to have aggressive features histologically were included in the study if patients preferred to observe rather than to undergo retreatment with excision or Mohs micrographic surgery. Tumors were usually treated immediately after a shave biopsy and were considered adequately treated if the dermis appeared grossly normal after curettage. Any tumors that: (1) extended to subcutaneous tissue or for which a clinically normal base could not be reached after curettage; or (2) had predominantly micronodular, infiltrative, or morpheaform features and clinical margins that were considered suspect underwent further therapy with excision or Mohs micrographic surgery. Recurrence was defined as biopsy-confirmed involvement by BCC at a previous treatment site. The biopsy of previously treated sites was performed only when recurrence was suspected. Fig 1. Close-up view of 35-year-old woman s chest showing hypopigmentation at site of basal cell carcinoma treated with curettage and electrodesiccation (arrowhead ). Less evident are 3 additional, much fainter, scars in same field after treatment with curettage alone (arrows). Technique A representative portion of each tumor was obtained by traditional shave biopsy for histologic analysis. A single disposable 4- to 6-mm curette was used from the periphery to the center of the tumor. Then the base of the treatment site was wiped clean with cotton gauze and re-examined. Thorough curettage was performed in at least 3 directions to treat the base and a 2- to 5-mm peripheral margin until only normal dermis remained. Prominent follicular ostia at the base of the wound were treated with smaller curettes when necessary. A normal base was characterized by a uniform appearance and the texture of firm collagen without residual irregularity. After curettage, 20% aluminum chloride was used to obtain hemostasis, and patients were instructed in twice-daily cleansing with water followed by application of an antibiotic ointment and a dressing. Histopathologic examination The same dermatopathologist (D. J. D.) retrospectively reviewed all biopsy specimens. All BCC subtypes present were recorded sequentially. Each tumor was then assigned a predominant and a histologically most aggressive subtype from among those present. The predominant subtype was defined as the subtype that comprised the majority of the specimen. The histologically most aggressive subtype present was ranked from most to least aggressive and as morpheaform, infiltrative, basosquamous, micronodular, reticulated, nodular, or superficial. Tumor involvement of the edges of the biopsy specimen was recorded. Involvement of the lateral edge was defined as the presence of BCC at the most lateral portion of the dermoepidermal junction on any section. BCC involving the base was defined as the presence of tumor in the deep edge of the specimen, the extent of which was

3 JAM ACAD DERMATOL VOLUME 54, NUMBER 6 Barlow et al 1041 Table II. Characteristics of patients* with basal cell carcinoma Characteristic Finding Age, y Mean 70.7 SD Range Sex, No. (%) Male 83 (64) Female 49 (36) Follow-up, y Mean 6.44 SD 1.49 Range Recurrence by sex, y No. (%) Male 10/87 (11.5) Female 2/49 (4.1) Increased medical risk for BCC, No. Immunosuppressive medication Patients 7 Tumors 19 Recurrences 1 Arsenic Patients 2 Tumors 9 Recurrences 1 Radiation Patients 6 Tumors 38 Recurrences 1 Lymphoma or leukemia Patients 2 Tumors 3 Recurrences 0 Total patients at high risk Patients 17/136 Tumors 69/302 Recurrences 3/69 Odds ratio.84 z BCC, Basal cell carcinoma. *N = 136. y P =.16. z P =.99. classified by 1 of 5 categories (0%, 1%-24%, 25%-49%, 50%-74%, and 75%-100%). Statistical analysis The primary analysis was the rate of tumor recurrence at 5-year follow-up in patients treated with curettage alone. Recurrence rates among variables were calculated using the Fisher exact test. A P value less than or equal to.05 was considered significant. RESULTS The retrospective records review identified 136 patients (49 women and 87 men) with 302 tumors. Table III. Tumor characteristics of basal cell carcinoma Total BCC (N = 302) Recurrence (N = 15) Characteristic No. % No. % Follow-up 5-y* Overall y Size z Diameter, cm \ [ Location Head and neck k{ High-risk areas # Low-risk areas** Trunk Extremities BCC, Basal cell carcinoma. *95% Confidence interval, (P =.05). y 95% Confidence interval, (P =.05). z Mean diameter, 0.69 cm (SD, 0.38 cm; range, cm). Mean area (length 3 width), 0.61 cm 2 (SD, 0.76 cm 2 ; range, cm 2 ). P =.6. k Face (low-risk vs high-risk areas), P =.14 (confidence interval, e3 to 16). { Head and neck vs trunk and extremities, P =.17 (confidence interval, 2-9). # Nose, cutaneous lip, ear, eyelid. **Cheek, forehead, neck, temple, chin, scalp. In all, 58 patients (43%) had more than one tumor and 28 patients (21%) had more than two tumors. As shown in Table II, the mean age was 70.7 years, and the mean clinical follow-up was 6.44 years. The mean tumor diameter was 0.69 cm (SD, 0.38; range, cm), for a mean tumor area of 0.61 cm 2. Patient age and sex (Table II) and tumor size were not associated with recurrence. A small percentage of tumors occurred in patients with medical risk factors for BCC and had no increased risk of recurrence (Table II). In 12 of the 136 patients, 15 recurrences were identified, 12 of which developed within 5 years. These patients had subsequent treatment with Mohs micrographic surgery (n = 9), shave biopsy followed by curettage (n = 3), excision (n = 2), or cryosurgery (n = 1). The 5-year recurrence and cure rates for the 302 individual tumors were 3.97% and 96.03%, respectively (Table III). Overall recurrence and cure rates for all available follow-up were 4.97% and 95.03%, respectively. The small sample size precluded identifying an association between individual tumor locations and recurrence (P =.6) (Table III). Individual sites were

4 1042 Barlow et al JAM ACAD DERMATOL JUNE 2006 Table IV. Histologic analysis of basal cell carcinoma subtypes* Predominant subtype Most aggressive subtype Total BCC (N = 302) Recurrence (N = 15) Total BCC (N = 302) Recurrence (N = 15) Subtype identified No. % No. % No. % No. % Superficial Nodular Reticulated Micronodular Infiltrative Morpheaform Basosquamous or metatypical BCC, Basal cell carcinoma. *P [.05. Table V. Recurrence rates for basal cell carcinoma by histologic analysis of tumors Recurrence Subtype No. % P value All subtypes* (N = 648).66 Nonaggressive 28/ Aggressive 10/ Predominant subtype (N = 302).07 Nodular 11/ Other 4/ Most aggressive subtype.26 (N = 302) Nodular 6/ Other 9/ Margin positivity (N = 302) Lateral y 6/ Deep.04 z 0% 1/ %-24% 1/ %-49% 0/ %-74% 4/ %-100% 9/ *Mean number of subtypes per tumor (2.15), P [.05. y 9 of 186 tumors (5.28%) had no lateral margin positivity. z [50% vs \50% Deep margin positivity (ie, 2/134 tumors with 0%-49% deep margin positivity had recurrence [1.5%] vs 13/168 [7.7%] tumors with 50%-100% deep margin positivity). categorized into two groups: those on the head or neck and those on the trunk or extremities. Again, no significant association could be identified (P =.17) (Table III). The pathologic review of BCC subtypes focused on: (1) the presence of individual subtypes regardless of proportion; (2) a predominant subtype; or (3) a histologically most aggressive subtype (Tables IV and V). Most tumors (75.1%) had more than one subtype. In the 302 tumors, 648 individual subtypes were identified (median, 2.15 subtypes/tumor; SD, 0.88), of which 150 (23%) were aggressive. The presence of an individual BCC subtype, regardless of its proportion of the total tumor, was not a significant predictor of recurrence. When these 648 subtypes were further classified as nonaggressive (superficial, nodular, pigmented, reticulated, ulcerated, or fibroepithelioma of Pinkus) or aggressive (micronodular, infiltrative, morpheaform, basosquamous, or metatypical) (Table IV), no statistically significant difference was found in recurrence (Table V). The predominant subtype analysis identified primarily nodular (n = 150) and superficial (n = 106) subtypes, which accounted for 85% of tumors. The remaining predominant subtypes included micronodular (n = 25), reticulated (n = 10), infiltrative (n = 6), basosquamous or metatypical (n = 4), and morpheaform (n = 1) (Table IV). The small number of tumors with predominantly micronodular, infiltrative, morpheaform, or basosquamous subtypes precluded identifying an association with increased risk of recurrence. The predominant subtype of the 15 recurrent tumors was nodular (11 of 15). These nodular tumors had a recurrence rate of 7.33%, which was not significantly different from that of the other predominant subtypes. Micronodular histologic foci (n = 90) were the most commonly identified most aggressive subtype observed in the 302 tumors, followed by nodular (n = 79) and superficial (n = 68), accounting for 78.5% of the tumors (Table IV). Infiltrative, morpheaform, and basosquamous tumor foci were uncommonly identified in the 302 tumors. However, 4 of the 15 recurrent tumors showed infiltrative, morpheaform, or basosquamous foci in the original biopsy specimen. When the most aggressive subtypes in the recurrent tumors were compared, no statistically significant difference was found. The rates of tumor recurrence were similar for patients with or without lateral margin positivity (Table V). However, the extent of deep margin

5 JAM ACAD DERMATOL VOLUME 54, NUMBER 6 Barlow et al 1043 involvement was significantly associated with tumor recurrence (P \.04). In particular, the higher rates of tumor recurrence occurred in tumors with a higher percentage of deep margin positivity (Table V). DISCUSSION In this retrospective study, the 5-year cure rate of 96.03% for the 302 tumors treated by curettage alone is comparable with published cure rates for C&E. Although a prospective study would be ideal, our strict 5-year cure rate is almost identical to the 95.3% rate McDaniel 2 reported in a life-table analysis of 644 tumors treated by curettage alone. Because life-table analysis compensates for the bias of patients lost to follow-up, it is considered the most accurate predictor of the actual rate of tumor recurrence. 2,12,19-21 We chose the strict 5-year rate for ease of comparison with previous studies of C&E. In a review of all studies (Table I) of recurrence rates for primary BCC reported between 1947 and 1985 for C&E, Rowe et al 19 found a 5-year cumulative recurrence rate of 7.7% (274/3573 tumors). These results included those of Reymann 11 and McDaniel 2 for curettage alone and included the 18.8% recurrence rate reported by Kopf et al 1 for treatment of BCC with C&E by residents at New York University Skin and Cancer Unit. When the studies of McDaniel, 2 Reymann, 11 and Kopf et al 1 were excluded, the overall 5-year C&E recurrence rate decreased to 4.8% (92/1935), almost identical to what we found for curettage alone. We did not find tumor location, size, or histologic subtype to be predictive of recurrence, perhaps reflecting small sample size, treatment of smaller and less aggressive tumors in high-risk areas, and a selection bias for use of Mohs micrographic surgery in known higher-risk sites of the face. 22 The lack of association with tumor location and size has been observed in analyses of other treatment techniques. 1,2,11-18,22-25 However, our recurrence rate of 5.5% (1/18) on the nose is identical to that found by Spiller and Spiller 13 for C&E. In addition, Silverman et al 12 noted a recurrence rate of only 4.5% for BCC of less than 6 mm in high-risk sites after C&E and concluded that it was an effective treatment for small BCC in any anatomical site. Smaller tumors have been reported to recur less often than larger ones after C&E. 12,13,22,23 Although size was not a risk factor in our study, tumors in highrisk sites tended to be smaller and more discrete, whereas larger tumors in high-risk sites were predominantly superficial. After treating more than 5000 tumors with curettage alone, Reymann 11 noted that the size of superficial BCC is not important. Table VI. Criteria for basal cell carcinoma amenable to treatment with curettage alone Criterion Primary tumor Nodular or superficial subtype Discrete borders Size \6 mm In high-risk area (nose, nasolabial folds, eyelids, medial canthi, ear, lips) \2 cm Elsewhere Any size, if superficial Not involving free margin of eyelid, mucosal lip, or subcutaneous fat Accurate selection of tumors is probably the most important determinant of cure with C&E. 22 Criteria for appropriate tumor selection for curettage alone are listed in Table VI. In view of data from previous studies and our own, 11-13,22,23,25 selection of tumors in high-risk areas for treatment with curettage alone should be limited to superficial tumors (any size) and to discrete tumors of less than 6 mm with suspected nodular pathology. Although subtype was not a risk factor in our study, other studies of histologically aggressive tumors have demonstrated an increased risk of recurrence. 22 In general, neither curettage alone nor C&E is believed to be a reliable treatment for most recurrent or ill-defined tumors, or for most micronodular, infiltrative, morpheaform, or metatypical BCC, which would be best treated by excisional methods such as Mohs micrographic surgery. The experience of the surgeon also affects cure rates 1,13,21,26,27 and is an independent risk factor for recurrence. 12 Part of the experience necessary to achieve a good cure rate either with curettage alone or C&E is meticulous technique and the ability to recognize a normal dermal base. The technique includes multiple, firm passes with the curette across the entire base and 2 to 5 mm beyond the periphery of the tumor in various directions, following each pass with wiping to facilitate inspection for dermal irregularity and prominent follicular ostia, which should be thoroughly explored using successively smaller curettes when necessary. 28,29 Although not used for this study, light electrodesiccation, when necessary, may help loosen the epidermis and allow easier curettage of hyperkeratotic tumors or lesions on atrophic skin; even in this setting, the curette remains the primary treatment instrument. For better visualization, magnifying loupes are helpful. 13 A normal base consists of firm collagen devoid of friable tissue and gritty foci indicating residual micronodular, infiltrative, or morpheaform tumor. Wispy, white collagen fibers are often

6 1044 Barlow et al JAM ACAD DERMATOL JUNE 2006 Table VII. Advantages and disadvantages of curettage alone Advantages Simple Cost-effective Requires less equipment Improved cosmesis and lower risk of scarring vs C&E No risk of electrical interference or viral plume Potentially faster healing than C&E C&E, Curettage and electrodesiccation. Disadvantages Technique-dependent Requires training and appropriate tumor selection Slower healing than sutured wounds Not reliable for larger tumors in high-risk areas, tumors with aggressive pathology, or recurrent tumors observed when the curette is passed over a dry field of normal dermis. Bleeding in the normal base is characterized by pinpoint dots of blood rather than blood that wells up or puddles. 25 Thus, wiping the wound base after each pass with the curette can facilitate assessment of both the type of bleeding and the appearance of the collagen. To reach a normal dermal base, we recommend at least 3 cycles of curettage in different directions. Although standard vertical sections for histologic analysis show only a small percentage of the biopsy specimen margins, most tumors (264/302; 87.4%) in this study involved at least one edge of the biopsy specimen. The reliability of the negative edges of a shave biopsy specimen is highly unpredictable, but positive edges may provide additional insight on recurrence. Lateral margin positivity in 110 (36.4%) of the 302 tumors was not a significant predictor of recurrence. However, the extent of deep margin involvement was a significant predictor of recurrence (P \.04), with 13 of 15 recurring tumors (86.7%) having more than 50% of their deep edge positive for BCC. This involvement of the base suggests the possibility of substantial residual tumor, the subtype of which could be different from that observed within the biopsy specimen. Because the clinicopathologic correlation is so important in determining proper treatment, we strongly recommend reviewing one s own pathology slides whenever possible to identify the histologic subtype and extent of margin involvement. Two other factors may influence cure rates with both curettage alone and C&E: the use of hemostatic agents and the method of wound care. We used 20% aluminum chloride for hemostasis. Monsel s solution and 30% aluminum chloride have both been shown to delay wound healing 30 and to contribute to tissue necrosis, perhaps increasing wound depth and enhancing the cure rate. Using only pressure for hemostasis with curettage alone, Reymann 11 had a somewhat higher recurrence rate than what we report. In addition, moist care has been shown to improve wound appearance and to speed healing. 31 Some early studies of C&E used dry care, which may have increased wound depth and enhanced cure rates but negatively affected wound healing. 13,32 Treatment with curettage alone appears to have fewer risks than treatment with C&E (Table VII). The primary risks of C&E are hypertrophic scarring or keloids 15 and hypopigmentation. 1,2,11,15,33-35 Hypertrophic scarring after curettage alone developed in only one of our patients (0.3%), and we noted less significant hypopigmentation compared with that found in sites treated with C&E, evidenced by healing in patients treated with both methods (Fig 1). Other authors have reported similar findings and have recommended avoiding or minimizing electrodesiccation. 2,11,13,25,33-35 Although differences in cosmesis remain to be documented, the results of this study indicate that, for appropriately selected BCC, high cure rates can be achieved with curettage alone and that no electrodesiccation is needed. REFERENCES 1. Kopf AW, Bart RS, Schrager D, Lazar M, Popkin GL. Curettageelectrodesiccation treatment of basal cell carcinomas. Arch Dermatol 1977;113: McDaniel WE. Therapy for basal cell epitheliomas by curettage only: further study. Arch Dermatol 1983;119: Levine PA, Balady GJ, Lazar HL, Belott PH, Roberts AJ. Electrocautery and pacemakers: management of the paced patient subject to electrocautery. Ann Thorac Surg 1986;41: Nercessian OA, Wu H, Nazarian D, Mahmud F. Intraoperative pacemaker dysfunction caused by the use of electrocautery during a total hip arthroplasty. 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