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Combined curettage and excision: A treatment method for primary basal cell carcinoma
Dermatologic surgery I
I
Combined curettage and excision: A treatment method for primary basal cell carcinoma Timothy M. Johnson, MD, a Theodore A. Tromovitcb, MD, b and Neil A. Swanson, M D c
Ann Arbor, Michigan; San Francisco, California; and Portland, Oregon A retrospective study of 403 primary basal cell carcinomas treated with aggressive curettage followed immediately by excision revealed microscopic tumor present in the curettage margin in 64 (15.9%) of the patients and in the excisional marghn in 12 (2.5%) after curettage and excision. In 92% (11 of 12) of patients with persistent tumor after the combined curettage and excision technique the tumors were of the aggressive growth (fibrosing, sclerosing, scirrhous, and morpheaform) variety of basal cell carcinoma. Both lateral and deep margins were involved with tumor. The short-term cure rate was 97.6% for the combined technique. Excluding aggressive growth BCCs, the use of curettage aUows the surgeon to define tumor borders better before excision. This proves expeciaUy beneficial in tumors with clinically indistinct borders. (J AM ACAD DERMATOL1991;24:613-7.)
Tromovitch and Allende 1 first discussed the method of curettage and excision (C&E) for the treatment of primary basal cell carcinoma (BCC) in 1970. First the tumor is curetted to define the actual tumor size and shape. The curettage defect is then immdiately excised with 2 to 3 m m margins. We studied retrospectively all charts and biopsy specimens covering a 10-year period at the University of California, San Francisco in which the combined technique of curettage immediately followed by excision (C&E) was used for treatment of primary BCC. Five aspects were reviewed: (1) the recurrence rate in patients followed up more than 1 year, (2) the success of removal of tumor by aggressive curettage alone, (3) the success of the combined technique of curettage and excision in removing the tumor, (4) the types of BCC incompletely removed by curettage alone and curettage immediately followed by excision, and (5) which margins tended to be missed by the curettage alone and curettage immediately followed by excision (C&E).
From the Departments of Dermatology, Otorhinolaryngology, and Surgery (Divisionof Plastic Surgery), University of Michigan Medical Center,a the Department of Dermatology, University of California School of Medicine,b and the Departments of Dermatology,Otolaryngology, and Surgery, (Division of Plastic Surgery), Oregon Health Sciences UniversityY Reprint requests: Timothy M. Johnson, MD, University of Michigan Medical Center, Department of Dermatology, 1910 Taubman Center, Ann Arbor, MI 48109-0314.
METHODS
Clinical margins of the biopsy-proved BCC were identiffed and marked. A large curet (4 or 5 ram) was used first to curet the tumor vigorously after local anesthesia with lidocaine. This was followed by the use of a small curet (1 or 2 ram) to remove small pockets of tumor missed by the larger curet. Spot hemostasis was obtained by electrodesiecation. The wound was then prepped and draped in the usual sterile manner. An excision with a 2 mm border around the curetted and clinical margin along appropriate skin tension lines was performed. The wound was then closed in a layered fashion. RESULTS Specimens from 403 patients in whom biopsyproved BCCs were removed by curettage and excision were reviewed. Vertical step sections from the excision were prepared. This resulted in a specimen with a crater surrounded on both sides by normalappearing epidermis (Fig. 1). Tumors found to be incompletely excised were retreated with Mobs surgery. The recurrence rate was based on patients whose charts contained sufficient follow-up data and who had been followed up for at least 1 year. A total of 217 patients were included. One hundred eighty-six of the original 403 patients were either followed up less than 1 year or lacked sufficient follow-up data to be included in the recurrence rate tabulation. Of the remaining 205 patients with clear margins after C&E, 5 (2.4%) had a recurrence. Two tumors recurred in the first year after C&E, two in the sec613
614
Journal of the American Academy of Dermatology
Johnson et al.
Fig. 1. Ulcer crater present after curettage reveals persistent BCC with an aggressive growth pattern in the deep margin with normal adjacent epidermis. (Hematoxylin-eosinstain; x
25.)
O
Fig. 2. Summary of residual tumor types. ond year, and one in the fourth year. The mean year of follow-up was 3.1 years. Fig. 2 represents the histologic type of BCC that remained in the margins after curettage alone and curettage followed by excision. Vertical step sectioning revealed residual tumor in the curettage margins
in 64 of 403 patients (15.9%). Histologic typing showed the majority of residual tumors to have an aggressive growth pattern (48 of 64 -- 75%). Less commonly observed were nodular (9), adenoid (5), or cystic (3) histologic variants. Excluding aggressive growth BCCs, 339 of 355 (95%) appeared to be
Volume 24 Number 4 April 1991
Combined curettage and excision
615
35 30 25 i, do
B 20 rt
15 10 5
Deep
Deep and Lateral
Lateral
Margin involved post curet
~
post excision
Fig. 3. Summary of margins involved by residual tumor.
removed by curettage alone. In 12 of 403 (2.5%) patients, tumor persisted in the excisional margin after the combined C & E technique. Of the 64 patients with tumor present after curettage alone, 52 (81%) had tumor completely removed microscopically by the addition of excision. Of the patients with tumor present histologically in the excisional margins after both curettage and excision, 92% (11 of 12) had tumors with an aggressive growth pattern and one with a nodular pattern. Fig. 3 represents the margins involved in patients with residual tumor. Vertical step sectioning of the excisional tissue after curettage revealed residual tumor present in the lateral (31 ) and deep (33) curet margins; 10 slides revealed tumor in both lateral and deep margins. Twelve patients had residual tumor present in the excisional margin after the combined C & E technique. The most common margin involved was deep (6), although lateral extension (3) or a combination of both deep and lateral (3) margin involvement also occurred. DISCUSSION Rowe et al., 2 in a review of all studies (since 1947) reporting recurrence rates for treatment of primary basal cell carcinoma, found an average short-term recurrence rate (follow-up less than 5 years) of 4.2%
and a long-term recurrence rate (follow-up more than 5 years) of 8.7% for non-Mohs modalities irrespective of treatment method used. According to Rowe et al., 2 the short-term recurrence rate for Mohs surgery is 1.4% and the long-term rate, 1.0%. Therefore the long-term cure rate for primary BCC with use of non-Mohs treatment modalities should be more that 91 to 92%, whereas with Mohs surgery it approaches 99%. This is in contrast to the recurrence rate for treatment of recurrent (previously treated) BCC, in which the short-term recurrence rate for Mohs surgery is 5.6% whereas the long-term recurrence rate for all non-Mohs modalities is 19.9%. 3 Proper patient (tumor) selection is probably the most important determinant of cure. Proper selection is based on tumor size, histologic type, primary versus recurrent nature, and location. Several authors have recommended 2 cm 4"6 or 4 cm 7 as the maximal size of tumors to treat with curettage and electrodesiccation. Others s have shown that recurrence rates with this technique increase as tumors increase in size from <0.2 to >3 cm. Wolf and Zitelli 9 found that a minimum margin of 4 m m was necessary to eradicate tumor in 95% of patients for tumors with well-defined borders less than 2 cm in diameter. Other authors recommend
Journal of the American Academy of Dermatology
616 Johnson et al. margins of 2 mm, t~ 2 to 3 ram, t~ 3 to 4 mm, ~2 3 to 5 mm, TM 14 and 5 mm. ~s, 16 Albrightl7 suggests 2 to 3 m m margins for tumors --<5 m m or less, 10 m m margins for tumors > 2 cm, and 1 cm margins for "most other lesions." Salasche and AmonettO 8 reported the average subclinical extension for primary, small, nodular, exophytic lesions of a year or less duration to be 2.1 + 0.4 ram. There are several reports in the literature that question the belief that all tumor must be removed to achieve an acceptable cure rate. Gooding et al. 19 and Shanoff et al. 2~ state that BCC will recur in about 33% of cases within 5 years when tumor is at or near the surgical margin. Pascal et al. 2t and Lauritzen et al. 22 report a recurrence rate from 33% to 48% within t 0 years when tumor is at or near the surgical margin. Prediction of whether tumor actually remained in the patient is unclear with the histologic methods used by these authors. W e continue to support the desire for complete tumor removal. McDanie123 reported 214 BCCs treated with curettage alone, with 164 followed at least 2 years. The short-term (<5 years) recurrence rate was 3.6%, which compares favorably with other nonMobs therapies for BCC. N o additional recurrences were reported in 121 of the 164 tumors followed for longer than 5 years. The tumors treated were mostly small, well-defined nodular lesions. Rowe et al. 2 reviewed 37 reports of BCC treated by surgical excision alone and found a short-term (<5 years) recurrence rate of 2.8% with a long-term (>5 years) recurrence rate of 10.1%. Some of these reports included larger and less well-defined tumors. Our study shows a short-term recurrence rate of 2.4% for combined C & E with a mean follow-up of 3. l years. W e do not advocate this technique as the treatment of choice for all BCCs, but we believe this to be a good treatment for selected, low-risk skin cancers. This combined technique is especially beneficial in treating lesions with ill-defined borders and lesions for which excision is the treatment option of choice. The curet adds to the accuracy of the visual determination of the edges and better defines the actual tumor size and shape before excision. This allows maximal conservation of normal tissue without compromising the cure rate. Tumor type plays an important role in behavior, treatment, and cure rate. In particular, aggressive growth and superficial multicentric BCCs often present with clinically indistinct borders what make treatment more difficult. Furthermore, the BCC
that shows an aggressive growth-fibrosing pattern may extend in connective tissue along cartilage and periosteum, around nerves, and in tissue planes, making complete removal more difficult. Several authors18, 24, 25 have shown that aggressive growth histology is a risk factor for recurrence of BCC. Salasche and AmonettO 8 reported the subclinical extension of primary morpheaform tumors to be 7.2 _+3.8 ram, whereas Burg et al. 26 reported 9.3 mm subclinical extension in these tumors. The value of histologic typing of a BCC before treatment is well recognized. Tumors that have an aggressive growth pattern are difficult to remove with a curet because of the fibrous component and the fact that the curet cannot reach small tumor pockets. Our study supports these observations. Because the vast majority of lesions with persistent tumor showed an aggressive growth pattern, the infiltrative nature of this variant of BCC is confirmed and suggests the need for wider local excision or Mohs surgery in its treatment. In the C & E technique, the use of large and small curets is valuable. If a biopsy has not been pertbrmed before treatment, a small piece of the tumor can be removed by shave or punch biopsy before curettage for histologic confirmation. In addition, severe dermatoheliosis may be difficult to distinguish from BCC with a curet. This, however, is usually not a common problem. The small curet can often find small pockets of tumor missed by the larger instrument. The defect left after curettage can be excised most often with a fusiform excision and layered closure. We recommend margins of 2 to 4 m m based on risk dependent on tumor size, location, and histology. The use of geometric excisions closed with local flaps or skin grafts can often aid in the cosmetic result. Aggressive growth tumors need wider excisional margins or Mobs surgery: C &E is not the best technique for these types of BCC. We emphasize that this combined technique is proposed for treatment of properly selected primary basal cell carcinoma. Data support Mobs surgery as the treatment of choice with the highest success rate in treating recurrent and large tumors, aggressive growth lesions, and tumors in high-risk locations (Hzone of the face). 2' 3, 25, 27, 28 REFERENCES
1. TromovitchTA, Allende M. Curette-excisiontechniques for skin cancer. Cutis 1970;6:1349-52. 2. RoweDE, Carroll RJ, Day CI. Long-termrecurrencerates in previouslyuntreated(primary)basal cell carcinoma:ira-
Volume 24 Number 4 April 1991
3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
plications for patient follow-up. J Dermatol Surg Oncol 1989;15:315-28. Rowe DE, Carroll R J, Day CL. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 1989;15:424-31. Knox JM, Lyles TW, Shapiro, et al. Curettage and electrodesiccation in the treatment of skin cancer. Arch Dermatol 1960;82:197-204. Williamson GS, Jackson R. Treatment of basal cell carcinoma by curettage and electrodesiccation. Can Med Assoc J 1962;86:855-62. Simpson JR. The treatment of rodent ulcers by curettage and cauterization. Br J Dermatol 1966;78:147-8. Crissey JT. Curettage and electrodesiccation as a method of treatment of epithcliomas of the skin. J Surg Oncol 1971;3:287-90. Suhge d'Aubermont PC, Bennett RG. Failure of curettage and electrodesiccation for removal of basal cell carcinoma. Arch Dermatol 1984; 120:1456-60. Wolf D J, ZiteUi JA. Surgical management of basal cell carcinoma. Arch Dermatol 1987;123:340-4. Epstein E. How accurate is the visual assessment of basal cell carcinoma margins? Br J Dermatol 1973;37:89. Griffith BH, McKinney P. An appraisal of the treatment of basal cell carcinoma of the skin. Plast Reconstr Surg 1973;51:565-71. Pillsbury DM, Shelly WB, Kligman AM. Dermatology. Philadelphia: WB Saunders, 1956:1141-52. Jansen GT. Treatment ofbasal cell epitheliomas and actinic keratoses. J A M A 1976;235:I152-4. Bart RS, Schrager D, Kopf A, et al. Scalpel excision of basal cell carcinomas. Arch Dermatol 1978;114:739-42. Weatherly-White RCA, Levasoy MA. The integument, ln: Hill GJ (ed). Outpatient surgery. Philadelphia: WB Saunders, 1980:322.
Combined curettage and excision
617
16. Macomber WB, Wank MKH, Sullivan IG. Cutaneous epithelioma. Plast Reconstr Surg 1959;24:545-62. 17. Albright SD. Treatment of skin cancer using multiple modalities. J AM ACAD DERMATOL1982;7:143-71. 18. Salasche S J, Amonette RA. Morpheaform basal cell epitheliomas. J Dermatol Surg Oncol 1981;7:387-94. 19. Gooding CA, White F, Yatsuhash M. Significance of marginal extension in excised basal cell carcinoma. N Engl J Med 1965;273:923-4. 20. Shanoff LB, Spira M, Hardy SB. Basal cell carcinoma: a statistical approach to rational management. Plast Reconstr Surg 1967;39:619-24. 21. Pascal RR, Hobby LW, Lattes R, et al. Prognosis of incompletely excised vs completely excised basal cell carcinoma. Plast Reconstr Surg 1968;41:328-32. 22. Lauritzen RE, Johnson RE, Spratt JS. Pattern of recurrence in basal cell carcinoma. Surgery 1965;57:813-6. 23. McDaniel WE. Surgical therapy for basal cell epitheliomas by curettage only. Arch Dermol 1978;114:1491-2. 24. Siegle R J, MacMillan J, Pollack SV. Infiltrative basal cell carcinoma: a nonsclerosing subtype. J Dermatol Surg Oncol 1986;12:830-6. 25. LangPG, MaizeJC. Histologicevolutionofrecurrent basal cell carcinoma and treatment implications. J AM ACAD DERMATOL 1986;14:186-96. 26. Burg G, Hirsch RD, Konz B, et al. Histographic surgery: accuracy of visual assessment of the margins of basal cell epithelioma. J Dermatol Surg Oncol 1975;1:21-4. 27. Swanson NA, Grekin RC. Mohs surgery: techniques, indications, and applications in head and neck surgery. Head Neck Surg 1983;6:683-92. 28. Salasche SJ. Curettage and electrode.~iccation in the treatment of midfaclal basal cell epithelioma. J AM ACADDERMA'rOL 1983;8:496-503.
I
Combined curettage and excision: A treatment method for primary basal cell carcinoma Timothy M. Johnson, MD, a Theodore A. Tromovitcb, MD, b and Neil A. Swanson, M D c
Ann Arbor, Michigan; San Francisco, California; and Portland, Oregon A retrospective study of 403 primary basal cell carcinomas treated with aggressive curettage followed immediately by excision revealed microscopic tumor present in the curettage margin in 64 (15.9%) of the patients and in the excisional marghn in 12 (2.5%) after curettage and excision. In 92% (11 of 12) of patients with persistent tumor after the combined curettage and excision technique the tumors were of the aggressive growth (fibrosing, sclerosing, scirrhous, and morpheaform) variety of basal cell carcinoma. Both lateral and deep margins were involved with tumor. The short-term cure rate was 97.6% for the combined technique. Excluding aggressive growth BCCs, the use of curettage aUows the surgeon to define tumor borders better before excision. This proves expeciaUy beneficial in tumors with clinically indistinct borders. (J AM ACAD DERMATOL1991;24:613-7.)
Tromovitch and Allende 1 first discussed the method of curettage and excision (C&E) for the treatment of primary basal cell carcinoma (BCC) in 1970. First the tumor is curetted to define the actual tumor size and shape. The curettage defect is then immdiately excised with 2 to 3 m m margins. We studied retrospectively all charts and biopsy specimens covering a 10-year period at the University of California, San Francisco in which the combined technique of curettage immediately followed by excision (C&E) was used for treatment of primary BCC. Five aspects were reviewed: (1) the recurrence rate in patients followed up more than 1 year, (2) the success of removal of tumor by aggressive curettage alone, (3) the success of the combined technique of curettage and excision in removing the tumor, (4) the types of BCC incompletely removed by curettage alone and curettage immediately followed by excision, and (5) which margins tended to be missed by the curettage alone and curettage immediately followed by excision (C&E).
From the Departments of Dermatology, Otorhinolaryngology, and Surgery (Divisionof Plastic Surgery), University of Michigan Medical Center,a the Department of Dermatology, University of California School of Medicine,b and the Departments of Dermatology,Otolaryngology, and Surgery, (Division of Plastic Surgery), Oregon Health Sciences UniversityY Reprint requests: Timothy M. Johnson, MD, University of Michigan Medical Center, Department of Dermatology, 1910 Taubman Center, Ann Arbor, MI 48109-0314.
METHODS
Clinical margins of the biopsy-proved BCC were identiffed and marked. A large curet (4 or 5 ram) was used first to curet the tumor vigorously after local anesthesia with lidocaine. This was followed by the use of a small curet (1 or 2 ram) to remove small pockets of tumor missed by the larger curet. Spot hemostasis was obtained by electrodesiecation. The wound was then prepped and draped in the usual sterile manner. An excision with a 2 mm border around the curetted and clinical margin along appropriate skin tension lines was performed. The wound was then closed in a layered fashion. RESULTS Specimens from 403 patients in whom biopsyproved BCCs were removed by curettage and excision were reviewed. Vertical step sections from the excision were prepared. This resulted in a specimen with a crater surrounded on both sides by normalappearing epidermis (Fig. 1). Tumors found to be incompletely excised were retreated with Mobs surgery. The recurrence rate was based on patients whose charts contained sufficient follow-up data and who had been followed up for at least 1 year. A total of 217 patients were included. One hundred eighty-six of the original 403 patients were either followed up less than 1 year or lacked sufficient follow-up data to be included in the recurrence rate tabulation. Of the remaining 205 patients with clear margins after C&E, 5 (2.4%) had a recurrence. Two tumors recurred in the first year after C&E, two in the sec613
614
Journal of the American Academy of Dermatology
Johnson et al.
Fig. 1. Ulcer crater present after curettage reveals persistent BCC with an aggressive growth pattern in the deep margin with normal adjacent epidermis. (Hematoxylin-eosinstain; x
25.)
O
Fig. 2. Summary of residual tumor types. ond year, and one in the fourth year. The mean year of follow-up was 3.1 years. Fig. 2 represents the histologic type of BCC that remained in the margins after curettage alone and curettage followed by excision. Vertical step sectioning revealed residual tumor in the curettage margins
in 64 of 403 patients (15.9%). Histologic typing showed the majority of residual tumors to have an aggressive growth pattern (48 of 64 -- 75%). Less commonly observed were nodular (9), adenoid (5), or cystic (3) histologic variants. Excluding aggressive growth BCCs, 339 of 355 (95%) appeared to be
Volume 24 Number 4 April 1991
Combined curettage and excision
615
35 30 25 i, do
B 20 rt
15 10 5
Deep
Deep and Lateral
Lateral
Margin involved post curet
~
post excision
Fig. 3. Summary of margins involved by residual tumor.
removed by curettage alone. In 12 of 403 (2.5%) patients, tumor persisted in the excisional margin after the combined C & E technique. Of the 64 patients with tumor present after curettage alone, 52 (81%) had tumor completely removed microscopically by the addition of excision. Of the patients with tumor present histologically in the excisional margins after both curettage and excision, 92% (11 of 12) had tumors with an aggressive growth pattern and one with a nodular pattern. Fig. 3 represents the margins involved in patients with residual tumor. Vertical step sectioning of the excisional tissue after curettage revealed residual tumor present in the lateral (31 ) and deep (33) curet margins; 10 slides revealed tumor in both lateral and deep margins. Twelve patients had residual tumor present in the excisional margin after the combined C & E technique. The most common margin involved was deep (6), although lateral extension (3) or a combination of both deep and lateral (3) margin involvement also occurred. DISCUSSION Rowe et al., 2 in a review of all studies (since 1947) reporting recurrence rates for treatment of primary basal cell carcinoma, found an average short-term recurrence rate (follow-up less than 5 years) of 4.2%
and a long-term recurrence rate (follow-up more than 5 years) of 8.7% for non-Mohs modalities irrespective of treatment method used. According to Rowe et al., 2 the short-term recurrence rate for Mohs surgery is 1.4% and the long-term rate, 1.0%. Therefore the long-term cure rate for primary BCC with use of non-Mohs treatment modalities should be more that 91 to 92%, whereas with Mohs surgery it approaches 99%. This is in contrast to the recurrence rate for treatment of recurrent (previously treated) BCC, in which the short-term recurrence rate for Mohs surgery is 5.6% whereas the long-term recurrence rate for all non-Mohs modalities is 19.9%. 3 Proper patient (tumor) selection is probably the most important determinant of cure. Proper selection is based on tumor size, histologic type, primary versus recurrent nature, and location. Several authors have recommended 2 cm 4"6 or 4 cm 7 as the maximal size of tumors to treat with curettage and electrodesiccation. Others s have shown that recurrence rates with this technique increase as tumors increase in size from <0.2 to >3 cm. Wolf and Zitelli 9 found that a minimum margin of 4 m m was necessary to eradicate tumor in 95% of patients for tumors with well-defined borders less than 2 cm in diameter. Other authors recommend
Journal of the American Academy of Dermatology
616 Johnson et al. margins of 2 mm, t~ 2 to 3 ram, t~ 3 to 4 mm, ~2 3 to 5 mm, TM 14 and 5 mm. ~s, 16 Albrightl7 suggests 2 to 3 m m margins for tumors --<5 m m or less, 10 m m margins for tumors > 2 cm, and 1 cm margins for "most other lesions." Salasche and AmonettO 8 reported the average subclinical extension for primary, small, nodular, exophytic lesions of a year or less duration to be 2.1 + 0.4 ram. There are several reports in the literature that question the belief that all tumor must be removed to achieve an acceptable cure rate. Gooding et al. 19 and Shanoff et al. 2~ state that BCC will recur in about 33% of cases within 5 years when tumor is at or near the surgical margin. Pascal et al. 2t and Lauritzen et al. 22 report a recurrence rate from 33% to 48% within t 0 years when tumor is at or near the surgical margin. Prediction of whether tumor actually remained in the patient is unclear with the histologic methods used by these authors. W e continue to support the desire for complete tumor removal. McDanie123 reported 214 BCCs treated with curettage alone, with 164 followed at least 2 years. The short-term (<5 years) recurrence rate was 3.6%, which compares favorably with other nonMobs therapies for BCC. N o additional recurrences were reported in 121 of the 164 tumors followed for longer than 5 years. The tumors treated were mostly small, well-defined nodular lesions. Rowe et al. 2 reviewed 37 reports of BCC treated by surgical excision alone and found a short-term (<5 years) recurrence rate of 2.8% with a long-term (>5 years) recurrence rate of 10.1%. Some of these reports included larger and less well-defined tumors. Our study shows a short-term recurrence rate of 2.4% for combined C & E with a mean follow-up of 3. l years. W e do not advocate this technique as the treatment of choice for all BCCs, but we believe this to be a good treatment for selected, low-risk skin cancers. This combined technique is especially beneficial in treating lesions with ill-defined borders and lesions for which excision is the treatment option of choice. The curet adds to the accuracy of the visual determination of the edges and better defines the actual tumor size and shape before excision. This allows maximal conservation of normal tissue without compromising the cure rate. Tumor type plays an important role in behavior, treatment, and cure rate. In particular, aggressive growth and superficial multicentric BCCs often present with clinically indistinct borders what make treatment more difficult. Furthermore, the BCC
that shows an aggressive growth-fibrosing pattern may extend in connective tissue along cartilage and periosteum, around nerves, and in tissue planes, making complete removal more difficult. Several authors18, 24, 25 have shown that aggressive growth histology is a risk factor for recurrence of BCC. Salasche and AmonettO 8 reported the subclinical extension of primary morpheaform tumors to be 7.2 _+3.8 ram, whereas Burg et al. 26 reported 9.3 mm subclinical extension in these tumors. The value of histologic typing of a BCC before treatment is well recognized. Tumors that have an aggressive growth pattern are difficult to remove with a curet because of the fibrous component and the fact that the curet cannot reach small tumor pockets. Our study supports these observations. Because the vast majority of lesions with persistent tumor showed an aggressive growth pattern, the infiltrative nature of this variant of BCC is confirmed and suggests the need for wider local excision or Mohs surgery in its treatment. In the C & E technique, the use of large and small curets is valuable. If a biopsy has not been pertbrmed before treatment, a small piece of the tumor can be removed by shave or punch biopsy before curettage for histologic confirmation. In addition, severe dermatoheliosis may be difficult to distinguish from BCC with a curet. This, however, is usually not a common problem. The small curet can often find small pockets of tumor missed by the larger instrument. The defect left after curettage can be excised most often with a fusiform excision and layered closure. We recommend margins of 2 to 4 m m based on risk dependent on tumor size, location, and histology. The use of geometric excisions closed with local flaps or skin grafts can often aid in the cosmetic result. Aggressive growth tumors need wider excisional margins or Mobs surgery: C &E is not the best technique for these types of BCC. We emphasize that this combined technique is proposed for treatment of properly selected primary basal cell carcinoma. Data support Mobs surgery as the treatment of choice with the highest success rate in treating recurrent and large tumors, aggressive growth lesions, and tumors in high-risk locations (Hzone of the face). 2' 3, 25, 27, 28 REFERENCES
1. TromovitchTA, Allende M. Curette-excisiontechniques for skin cancer. Cutis 1970;6:1349-52. 2. RoweDE, Carroll RJ, Day CI. Long-termrecurrencerates in previouslyuntreated(primary)basal cell carcinoma:ira-
Volume 24 Number 4 April 1991
3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
plications for patient follow-up. J Dermatol Surg Oncol 1989;15:315-28. Rowe DE, Carroll R J, Day CL. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 1989;15:424-31. Knox JM, Lyles TW, Shapiro, et al. Curettage and electrodesiccation in the treatment of skin cancer. Arch Dermatol 1960;82:197-204. Williamson GS, Jackson R. Treatment of basal cell carcinoma by curettage and electrodesiccation. Can Med Assoc J 1962;86:855-62. Simpson JR. The treatment of rodent ulcers by curettage and cauterization. Br J Dermatol 1966;78:147-8. Crissey JT. Curettage and electrodesiccation as a method of treatment of epithcliomas of the skin. J Surg Oncol 1971;3:287-90. Suhge d'Aubermont PC, Bennett RG. Failure of curettage and electrodesiccation for removal of basal cell carcinoma. Arch Dermatol 1984; 120:1456-60. Wolf D J, ZiteUi JA. Surgical management of basal cell carcinoma. Arch Dermatol 1987;123:340-4. Epstein E. How accurate is the visual assessment of basal cell carcinoma margins? Br J Dermatol 1973;37:89. Griffith BH, McKinney P. An appraisal of the treatment of basal cell carcinoma of the skin. Plast Reconstr Surg 1973;51:565-71. Pillsbury DM, Shelly WB, Kligman AM. Dermatology. Philadelphia: WB Saunders, 1956:1141-52. Jansen GT. Treatment ofbasal cell epitheliomas and actinic keratoses. J A M A 1976;235:I152-4. Bart RS, Schrager D, Kopf A, et al. Scalpel excision of basal cell carcinomas. Arch Dermatol 1978;114:739-42. Weatherly-White RCA, Levasoy MA. The integument, ln: Hill GJ (ed). Outpatient surgery. Philadelphia: WB Saunders, 1980:322.
Combined curettage and excision
617
16. Macomber WB, Wank MKH, Sullivan IG. Cutaneous epithelioma. Plast Reconstr Surg 1959;24:545-62. 17. Albright SD. Treatment of skin cancer using multiple modalities. J AM ACAD DERMATOL1982;7:143-71. 18. Salasche S J, Amonette RA. Morpheaform basal cell epitheliomas. J Dermatol Surg Oncol 1981;7:387-94. 19. Gooding CA, White F, Yatsuhash M. Significance of marginal extension in excised basal cell carcinoma. N Engl J Med 1965;273:923-4. 20. Shanoff LB, Spira M, Hardy SB. Basal cell carcinoma: a statistical approach to rational management. Plast Reconstr Surg 1967;39:619-24. 21. Pascal RR, Hobby LW, Lattes R, et al. Prognosis of incompletely excised vs completely excised basal cell carcinoma. Plast Reconstr Surg 1968;41:328-32. 22. Lauritzen RE, Johnson RE, Spratt JS. Pattern of recurrence in basal cell carcinoma. Surgery 1965;57:813-6. 23. McDaniel WE. Surgical therapy for basal cell epitheliomas by curettage only. Arch Dermol 1978;114:1491-2. 24. Siegle R J, MacMillan J, Pollack SV. Infiltrative basal cell carcinoma: a nonsclerosing subtype. J Dermatol Surg Oncol 1986;12:830-6. 25. LangPG, MaizeJC. Histologicevolutionofrecurrent basal cell carcinoma and treatment implications. J AM ACAD DERMATOL 1986;14:186-96. 26. Burg G, Hirsch RD, Konz B, et al. Histographic surgery: accuracy of visual assessment of the margins of basal cell epithelioma. J Dermatol Surg Oncol 1975;1:21-4. 27. Swanson NA, Grekin RC. Mohs surgery: techniques, indications, and applications in head and neck surgery. Head Neck Surg 1983;6:683-92. 28. Salasche SJ. Curettage and electrode.~iccation in the treatment of midfaclal basal cell epithelioma. J AM ACADDERMA'rOL 1983;8:496-503.