- Email: [email protected]
Recurrent basal cell carcinoma treated with cryosurgery
THERAPY Recurrent basal cell carcinoma treated with cryosurgery Emanuel G. Kuflik, MD, a and Andrew A. Gage, MD b Newark, New Jersey, and
Buffalo, New York Background: Although there are reports of cure rates achieved by cryosurgery for primary basal cell carcinomas (BCCs), there are few data on the cryosurgical treatment of recurrent BCCs. Objective: Our purpose was to discuss case selection, cryosurgical management, and results of therapy. Methods: Cryosurgery was performed in 54 patients with 56 recurrent BCCs. The treatment consisted of aggressive freezing including an adequate margin of surrounding tissue. Results: Wound healing was favorable and the cosmetic results were excellent. Two recurrences were found and were referred for Mohs micrographic surgery. Conclusion: We conclude that cryosurgical treatment of selected recurrent BCCs yields results that compare favorably with other methods of treatment. (J Am Acad Dermatol 1997;37:82-4.)
Although the different clinical types of basal cell carcinomas (BCCs) can be managed by a variety of techniques, there are fewer options for recurrent (previously treated) tumors.i, 2 Although the cryosurgical management of recurrent lesions has been included in some published series, we believe that they should be evaluated separately from primary lesions. 3, 4 We review the results of cryosurgical treatment of recurrent BCCs.
MATERIAL AND METHODS One of us (E. K.) treated 54 patients with 56 recurrent BCCs between 1984 and 1993. The group consisted of 33 men and 21 women ranging in age from 33 to 90 years. The lesions measured between 0.6 and 4.4 cm; 66% were 2 cm or less. The lesions were located on various areas of the body although 68% were on the head. The previous treatments included curettage and electrodesiccation (43), surgical exci-
From the Department of Dermatology, University of Medicine and Dentistry, New Jersey Medical School, Newark, a and the Department of Surgery, School of Medicine and Biochemical Sciences, State University of New York at Buffalo.b Reprint requests: Emanuel G. Kuflik, MD, 150 E. Kennedy Blvd., Lakewood, NJ 08701. Copyright © 1997 by the American Academy of Dermatology, Inc. 0190-9622/97/$5.00 + 0 16/1/81274
82
sion (11), radiation therapy (1), and 5-fluorouracil (1). Recurrence was usually detected within 1 to 3 years of the initial treatment. The diagnosis was confirmed by histopathologic examination in all cases. The options in therapy were discussed with the patients, who shared in selecting cryosurgery as treatment. Treatment consisted of aggressive cryosurgery by means of liquid nitrogen and the open-spray technique.5, 6 A local anesthetic was injected before treatment, and some lesions were debulked with a curette. 7 Several indicators of effective therapeutic technique were monitored, including the width and depth of the frozen target site, the duration of freezing, the lateral spread of frost, the duration of thawing, and the tissue temperature.8, 9 The duration of freezing (freeze time) ranged between 45 seconds and 3 minutes depending on the size of the lesion, and the lateral spread of frost measured 5 mm beyond the obvious limits of the tumor. The tissue temperature at the base of the lesion as measured with one or more thermocouples reached -50 ° to -60 ° C. Tissue cooling was then halted and the tissue was permitted to thaw for several minutes. Repetition of the freeze-thaw cycle was performed in all cases. After the procedure, a dry gauze dressing was applie& The patients were advised to wash the wound four times daily with mild soap and water during the exudative phase of wound healing. An eschar formed in 7 to 14 days and was allowed to fall off spontaneously. Wound healing occurred in 6 to 8 weeks.
Journal of the American Academy of Dermatology Volume 37, Number 1
RESULTS Wound healing was generally favorable and acceptable to the patients. The cosmetic results were excellent and were no different from our experience with the use of cryosurgery for the treatment of primary skin cancer. There was, as expected, a variable amount of hypopigmentation. Two patients in this study had a recurrence after cryosurgical treatment and were referred for Mohs micrographic surgery. The first had been initially treated by curettage and electrodesiccafion. The other had an ulcerated tumor on the helix of the ear that had been originally treated by scalpel excision. The recurrences were noted after 3 and 7 years, respectively. The follow-up period after cryosurgery was as complete as possible, considering the mobility of the population and death in the elderly patients. Fourteen patients were observed for 5 to 10 years, four for 4 years, four for 3 years, four for 2 years, and 15 for more than 1 year. Nine patients were observed for less than 1 year, and there was no follow-up after treatment in four patients. We were informed of nine patients who died. DISCUSSION
A recurrent BCC may develop at any time, and its appearance may be either different or similar to the primary tumor. 1° Sometimes there are indistinct or undetectable deep or lateral margins that cause difficulty in identifying the extent of the tumor. Treatment involves several variables including the characteristics and aggressiveness of the tumor, size, anatomic location, invasivehess, skills of the physician, patient selection, and esthetic results. 2 Thus treatment needs to be individualized, and often consists of wide surgical excision, radiation therapy, or Mohs micrographic surgery.11 Although cure rates up to 98% have been reported after cryosurgical treatment of new BCCs, 12-15 data specifically concerning the treatment of recurrent BCCs are sparse. The authors reported an overall cure rate of 88.4% in a series of 164 recurrent BCCs. 16 It is well known that the cure rate for recurrent lesions, with any modality, is lower than for primary tumors; cryosurgery is no exception. 2 We believe cryosurgery can be an alternative choice in the
Kuflik and Gage 83
management of selected small to medium-sized recurrent BCCs and large recurrent superficial ones on the trunk. 3, 4, 17-19 If cryosurgical treatment is performed aggressively, eradication of a recurrent lesion can be achieved. This modality is not recommended for physicians with little or no experience in cryosurgical treatment of malignancies. Cryosurgery is indicated for recurrent tumors only when the margins are well defined. Those with indistinct or ill-defined borders, as well as deeply penetrating lesions, are not suitable candidates. A similar problem exists when a recurrent tumor occurs in a scar or in a wound that was closed with a skin flap because the entire area must be suspected of containing cancerous tissue. Several preoperative biopsy specimens can be obtained to delineate the margins of a tumor. In addition, postoperative biopsy specimens can determine the adequacy of treatment. Because complete destruction of BCC tissue is possible with cryosurgery, it should be attainable in a recurrent lesion as well as in a primary one. The biologic alterations resulting from cryosurgery are caused by rapid heat loss, leading to freezing of the tissue and subsequent necrosis. 2° The method of heat transfer that occurs when liquid nitrogen touches the skin, as with the spray technique, is referred to as boiling heat transfer. 8 Another method is conduction heat transfer, which occurs when a cold metal probe is applied to the skin, as in the contact technique of treatment. Both techniques are useful, but spray techniques have special utility in skin cancer. The mechanisms of injury from deep freezing include direct effects on the cells and vascular stasis that develops in the tissue after thawing or rewarming. 2° Rapid cooling is desirable, but thawing should proceed slowly. Cryosurgery produces selective destruction of tissue, and good results are achieved because cellular components are susceptible to cold injury, whereas stromal components are more resistant. It was found that BCC tumor cells were no longer histologically evident 3 days after deep freezing. 21 The stroma provides the structural framework for later repair of the cryogenic wound. In the treatment of recurrent BCCs, some therapeutic modifications are needed. Successful treatment should feature aggressive freezing, meaning that a greater depth and lateral spread of
84
Kuflik and Gage
freeze must be achieved, and repetition o f the freeze-thaw cycle is performed. We recognize that m a n y physicians experienced in cryosurgery do not use t h e r m o c o u p l e s in c u t a n e o u s cryosurgery and have achieved g o o d results. Nevertheless, we r e c o m m e n d that thermocouples be used for recurrent lesions. Temperatures o f - 5 0 ° to - 6 0 ° C should be produced in all regions o f the tumor, including the lateral and deep margins. 22 Freezing to between - 2 0 ° and - 3 0 ° C, as p e r f o r m e d for benign lesions, is not sufficient for invasive cancer. A wide lateral spread o f freeze, 0.5 to 1 c m (i.e., at least a 5 m m rim of apparently n o r m a l - a p p e a r i n g tissue s u r r o u n d i n g the lesion), is r e c o m m e n d e d , although the site of the lesion sometimes precludes such extensive freezing. The two cases that recurred after cryosurgery illustrate how long the follow-up period should be. Although m o s t recurrences are noted during the first 3 years after treatment, a recurrence m a y be encountered as long as 12 years later. 23 These lesions could h a v e b e e n treated again with cryosurgery, but after discussion with the patients M o h s micrographic surgery was chosen. Although m a n y patients were lost to follow-up before 3 years for reasons already cited, our data support the conclusion that cryosurgery is an effective modality for selected recurrent BCCs. S o m e advantages of cryosurgery include its suitability for patients w h o are p o o r surgical risks, the elderly, patients w h o are fearful of undergoing surgery, or w h e n other methods are impractical or undesirable. REFERENCES
1. Schwartz RA. Basal cell epithelioma (basal cell carcinoma). In: Schwartz RA, editor. Skin cancer: recognition and management. New York: Springer-Verlag; 1988. p. 57-69. 2. Lang PG, Maize JC. Basal cell carcinoma. In: Friedman RJ, Rigel DS, Kopf AW, et al., editors. Cancer of the skin. Philadelphia: WB Saunders; 1991. p. 57-8.
Journal of the American Academy of Dermatology July 1997
3. Kuflik EG. Cryosurgery for carcinoma of the eyelids: a 12-year experience. J Dermatol Surg Oncol 1985;11:243-6. 4. Kuflik EG. Cryosurgery for tumors of the ear. J Dermatol Surg Oncol 1985; 11:1165-8. 5. Kuffik EG, Gage AA. Cryosurgical treatment for skin cancer. New York: Igaku-Shoin; 1990. p. 97-111. 6. Kuflik EG. Treatment of basal cell carcinoma with the open-spray technique. J Dermatol Surg Oncol 1980; 12:125-6. 7. Kuflik EG. Debulking large tumors. J Dermatol Surg Oncol 1982;8:431-3. 8. Knflik EG. Cryosurgery updated. J Am Acad Dermatol 1994;31:925-44. 9. Torre D. Depth dose in cryosurgery. J Dermatol Surg Oncol 1983;9:219-25. 10. Koplin L, Zarem HA. Recurrent basal cell carcinoma: review concerning the incidence, behavior and management of recurrent basal cell carcinoma with emphasis on the incompletely excised lesion. Plast Reconstr Surg 1980;65:656-64. 11. Rowe DE, Carroll RJ, Day CL. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 1989;15:424-31. 12. Kuflik EG, Gage AA. The five-year cure rate achieved by cryosurgery for skin cancer. J Am Acad Dermatol 1991 ;24:1002-4. 13. Graham G. Cryosurgery. Clin Plast Surg 1993;20:13147. 14. Holt P. Cryotherapy for skin cancer: results over a 5year period using liquid nitrogen spray cryotherapy. Br J Dermatol 1988;119:231-40. 15. Zacarian SA. Cryosurgery of cutaneous carcinomas: an 18-year study of 3022 patients with 4228 carcinomas. J Am Acad Dermatol 1983;9:947-56. 16. Kuflik EG, Gage AA. Cryosurgical treatment for skin cancer. New York: Igaku-Shoin; 1990. p. 243-54. 17. Gage AA. Cryosurgery for difficult problems in cutaneous cancer. Cutis 1975;16:465-70. 18. Kuflik EG. Cryosurgical treatment of large basal-cell carcinomas on the trunk. J Dermatol Surg Oncol 1983;9:226-30. 19. Kuflik EG, Gage AA. Cryosurgical treatment of skin cancer. New York: Igaku-Shoin; 1990. p. 207-8. 20. Knflik EG, Gage AA. Cryosurgical treatment of skin cancer. New York: Igaku-Shoin; 1990. p. 35-51. 21. von Sebastian G, Scholz A. Histopathologie der basaliom-kryolasion. Dermatol Monatsschr 1983;169:917. 22. Gage AA. What temperature is lethal for cells? J Dermatol Surg Oncol 1979;5:459-64. 23. Torre D. Cryosurgery of basal cell carcinoma. J Am Acad Dermatol 1986;15:917-29.
Buffalo, New York Background: Although there are reports of cure rates achieved by cryosurgery for primary basal cell carcinomas (BCCs), there are few data on the cryosurgical treatment of recurrent BCCs. Objective: Our purpose was to discuss case selection, cryosurgical management, and results of therapy. Methods: Cryosurgery was performed in 54 patients with 56 recurrent BCCs. The treatment consisted of aggressive freezing including an adequate margin of surrounding tissue. Results: Wound healing was favorable and the cosmetic results were excellent. Two recurrences were found and were referred for Mohs micrographic surgery. Conclusion: We conclude that cryosurgical treatment of selected recurrent BCCs yields results that compare favorably with other methods of treatment. (J Am Acad Dermatol 1997;37:82-4.)
Although the different clinical types of basal cell carcinomas (BCCs) can be managed by a variety of techniques, there are fewer options for recurrent (previously treated) tumors.i, 2 Although the cryosurgical management of recurrent lesions has been included in some published series, we believe that they should be evaluated separately from primary lesions. 3, 4 We review the results of cryosurgical treatment of recurrent BCCs.
MATERIAL AND METHODS One of us (E. K.) treated 54 patients with 56 recurrent BCCs between 1984 and 1993. The group consisted of 33 men and 21 women ranging in age from 33 to 90 years. The lesions measured between 0.6 and 4.4 cm; 66% were 2 cm or less. The lesions were located on various areas of the body although 68% were on the head. The previous treatments included curettage and electrodesiccation (43), surgical exci-
From the Department of Dermatology, University of Medicine and Dentistry, New Jersey Medical School, Newark, a and the Department of Surgery, School of Medicine and Biochemical Sciences, State University of New York at Buffalo.b Reprint requests: Emanuel G. Kuflik, MD, 150 E. Kennedy Blvd., Lakewood, NJ 08701. Copyright © 1997 by the American Academy of Dermatology, Inc. 0190-9622/97/$5.00 + 0 16/1/81274
82
sion (11), radiation therapy (1), and 5-fluorouracil (1). Recurrence was usually detected within 1 to 3 years of the initial treatment. The diagnosis was confirmed by histopathologic examination in all cases. The options in therapy were discussed with the patients, who shared in selecting cryosurgery as treatment. Treatment consisted of aggressive cryosurgery by means of liquid nitrogen and the open-spray technique.5, 6 A local anesthetic was injected before treatment, and some lesions were debulked with a curette. 7 Several indicators of effective therapeutic technique were monitored, including the width and depth of the frozen target site, the duration of freezing, the lateral spread of frost, the duration of thawing, and the tissue temperature.8, 9 The duration of freezing (freeze time) ranged between 45 seconds and 3 minutes depending on the size of the lesion, and the lateral spread of frost measured 5 mm beyond the obvious limits of the tumor. The tissue temperature at the base of the lesion as measured with one or more thermocouples reached -50 ° to -60 ° C. Tissue cooling was then halted and the tissue was permitted to thaw for several minutes. Repetition of the freeze-thaw cycle was performed in all cases. After the procedure, a dry gauze dressing was applie& The patients were advised to wash the wound four times daily with mild soap and water during the exudative phase of wound healing. An eschar formed in 7 to 14 days and was allowed to fall off spontaneously. Wound healing occurred in 6 to 8 weeks.
Journal of the American Academy of Dermatology Volume 37, Number 1
RESULTS Wound healing was generally favorable and acceptable to the patients. The cosmetic results were excellent and were no different from our experience with the use of cryosurgery for the treatment of primary skin cancer. There was, as expected, a variable amount of hypopigmentation. Two patients in this study had a recurrence after cryosurgical treatment and were referred for Mohs micrographic surgery. The first had been initially treated by curettage and electrodesiccafion. The other had an ulcerated tumor on the helix of the ear that had been originally treated by scalpel excision. The recurrences were noted after 3 and 7 years, respectively. The follow-up period after cryosurgery was as complete as possible, considering the mobility of the population and death in the elderly patients. Fourteen patients were observed for 5 to 10 years, four for 4 years, four for 3 years, four for 2 years, and 15 for more than 1 year. Nine patients were observed for less than 1 year, and there was no follow-up after treatment in four patients. We were informed of nine patients who died. DISCUSSION
A recurrent BCC may develop at any time, and its appearance may be either different or similar to the primary tumor. 1° Sometimes there are indistinct or undetectable deep or lateral margins that cause difficulty in identifying the extent of the tumor. Treatment involves several variables including the characteristics and aggressiveness of the tumor, size, anatomic location, invasivehess, skills of the physician, patient selection, and esthetic results. 2 Thus treatment needs to be individualized, and often consists of wide surgical excision, radiation therapy, or Mohs micrographic surgery.11 Although cure rates up to 98% have been reported after cryosurgical treatment of new BCCs, 12-15 data specifically concerning the treatment of recurrent BCCs are sparse. The authors reported an overall cure rate of 88.4% in a series of 164 recurrent BCCs. 16 It is well known that the cure rate for recurrent lesions, with any modality, is lower than for primary tumors; cryosurgery is no exception. 2 We believe cryosurgery can be an alternative choice in the
Kuflik and Gage 83
management of selected small to medium-sized recurrent BCCs and large recurrent superficial ones on the trunk. 3, 4, 17-19 If cryosurgical treatment is performed aggressively, eradication of a recurrent lesion can be achieved. This modality is not recommended for physicians with little or no experience in cryosurgical treatment of malignancies. Cryosurgery is indicated for recurrent tumors only when the margins are well defined. Those with indistinct or ill-defined borders, as well as deeply penetrating lesions, are not suitable candidates. A similar problem exists when a recurrent tumor occurs in a scar or in a wound that was closed with a skin flap because the entire area must be suspected of containing cancerous tissue. Several preoperative biopsy specimens can be obtained to delineate the margins of a tumor. In addition, postoperative biopsy specimens can determine the adequacy of treatment. Because complete destruction of BCC tissue is possible with cryosurgery, it should be attainable in a recurrent lesion as well as in a primary one. The biologic alterations resulting from cryosurgery are caused by rapid heat loss, leading to freezing of the tissue and subsequent necrosis. 2° The method of heat transfer that occurs when liquid nitrogen touches the skin, as with the spray technique, is referred to as boiling heat transfer. 8 Another method is conduction heat transfer, which occurs when a cold metal probe is applied to the skin, as in the contact technique of treatment. Both techniques are useful, but spray techniques have special utility in skin cancer. The mechanisms of injury from deep freezing include direct effects on the cells and vascular stasis that develops in the tissue after thawing or rewarming. 2° Rapid cooling is desirable, but thawing should proceed slowly. Cryosurgery produces selective destruction of tissue, and good results are achieved because cellular components are susceptible to cold injury, whereas stromal components are more resistant. It was found that BCC tumor cells were no longer histologically evident 3 days after deep freezing. 21 The stroma provides the structural framework for later repair of the cryogenic wound. In the treatment of recurrent BCCs, some therapeutic modifications are needed. Successful treatment should feature aggressive freezing, meaning that a greater depth and lateral spread of
84
Kuflik and Gage
freeze must be achieved, and repetition o f the freeze-thaw cycle is performed. We recognize that m a n y physicians experienced in cryosurgery do not use t h e r m o c o u p l e s in c u t a n e o u s cryosurgery and have achieved g o o d results. Nevertheless, we r e c o m m e n d that thermocouples be used for recurrent lesions. Temperatures o f - 5 0 ° to - 6 0 ° C should be produced in all regions o f the tumor, including the lateral and deep margins. 22 Freezing to between - 2 0 ° and - 3 0 ° C, as p e r f o r m e d for benign lesions, is not sufficient for invasive cancer. A wide lateral spread o f freeze, 0.5 to 1 c m (i.e., at least a 5 m m rim of apparently n o r m a l - a p p e a r i n g tissue s u r r o u n d i n g the lesion), is r e c o m m e n d e d , although the site of the lesion sometimes precludes such extensive freezing. The two cases that recurred after cryosurgery illustrate how long the follow-up period should be. Although m o s t recurrences are noted during the first 3 years after treatment, a recurrence m a y be encountered as long as 12 years later. 23 These lesions could h a v e b e e n treated again with cryosurgery, but after discussion with the patients M o h s micrographic surgery was chosen. Although m a n y patients were lost to follow-up before 3 years for reasons already cited, our data support the conclusion that cryosurgery is an effective modality for selected recurrent BCCs. S o m e advantages of cryosurgery include its suitability for patients w h o are p o o r surgical risks, the elderly, patients w h o are fearful of undergoing surgery, or w h e n other methods are impractical or undesirable. REFERENCES
1. Schwartz RA. Basal cell epithelioma (basal cell carcinoma). In: Schwartz RA, editor. Skin cancer: recognition and management. New York: Springer-Verlag; 1988. p. 57-69. 2. Lang PG, Maize JC. Basal cell carcinoma. In: Friedman RJ, Rigel DS, Kopf AW, et al., editors. Cancer of the skin. Philadelphia: WB Saunders; 1991. p. 57-8.
Journal of the American Academy of Dermatology July 1997
3. Kuflik EG. Cryosurgery for carcinoma of the eyelids: a 12-year experience. J Dermatol Surg Oncol 1985;11:243-6. 4. Kuflik EG. Cryosurgery for tumors of the ear. J Dermatol Surg Oncol 1985; 11:1165-8. 5. Kuffik EG, Gage AA. Cryosurgical treatment for skin cancer. New York: Igaku-Shoin; 1990. p. 97-111. 6. Kuflik EG. Treatment of basal cell carcinoma with the open-spray technique. J Dermatol Surg Oncol 1980; 12:125-6. 7. Kuflik EG. Debulking large tumors. J Dermatol Surg Oncol 1982;8:431-3. 8. Knflik EG. Cryosurgery updated. J Am Acad Dermatol 1994;31:925-44. 9. Torre D. Depth dose in cryosurgery. J Dermatol Surg Oncol 1983;9:219-25. 10. Koplin L, Zarem HA. Recurrent basal cell carcinoma: review concerning the incidence, behavior and management of recurrent basal cell carcinoma with emphasis on the incompletely excised lesion. Plast Reconstr Surg 1980;65:656-64. 11. Rowe DE, Carroll RJ, Day CL. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 1989;15:424-31. 12. Kuflik EG, Gage AA. The five-year cure rate achieved by cryosurgery for skin cancer. J Am Acad Dermatol 1991 ;24:1002-4. 13. Graham G. Cryosurgery. Clin Plast Surg 1993;20:13147. 14. Holt P. Cryotherapy for skin cancer: results over a 5year period using liquid nitrogen spray cryotherapy. Br J Dermatol 1988;119:231-40. 15. Zacarian SA. Cryosurgery of cutaneous carcinomas: an 18-year study of 3022 patients with 4228 carcinomas. J Am Acad Dermatol 1983;9:947-56. 16. Kuflik EG, Gage AA. Cryosurgical treatment for skin cancer. New York: Igaku-Shoin; 1990. p. 243-54. 17. Gage AA. Cryosurgery for difficult problems in cutaneous cancer. Cutis 1975;16:465-70. 18. Kuflik EG. Cryosurgical treatment of large basal-cell carcinomas on the trunk. J Dermatol Surg Oncol 1983;9:226-30. 19. Kuflik EG, Gage AA. Cryosurgical treatment of skin cancer. New York: Igaku-Shoin; 1990. p. 207-8. 20. Knflik EG, Gage AA. Cryosurgical treatment of skin cancer. New York: Igaku-Shoin; 1990. p. 35-51. 21. von Sebastian G, Scholz A. Histopathologie der basaliom-kryolasion. Dermatol Monatsschr 1983;169:917. 22. Gage AA. What temperature is lethal for cells? J Dermatol Surg Oncol 1979;5:459-64. 23. Torre D. Cryosurgery of basal cell carcinoma. J Am Acad Dermatol 1986;15:917-29.