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Curettage and shave excision
Curettage and shave excision A tissue-saving technic for primary cutaneous carcinoma worthy of inclusion in graduate training programs Norman A. Brooks, M.D. Los Angeles, CA Curettage and electrodesiccation, the customary treatment for primary basal and squamous cell carcinomas, lacks histologic control and standardization. A review of the literature cites these factors as potential causes for undesirable recurrence rates, especially in cosmetically sensitive areas. Curettage and shave excision offers histologic control, yet with no more sacrifice of normal tissue than curettage and electrodesiccation. An experimenta/study with 100 patients is described in which curettage and shave excision was used, instead of curettage and electrodesiccation, to treat primary carcinomas 1.0 cm or less. It is suggested that curettage and shave excision, while simple in concept, requires formal training and warrants consideration for inclusion into graduate training programs as an alternative effective treatment for primary carcinomas. (J AM ACADDERMATOL10:279-284, 1984.)
The most common treatment for primary skin cancers is curettage and electrodesiccation. 1-6 The method has been used successfully by most dermatologists for many years. Examination of the pertinent literature suggests that curettage and electrodesiccation may not always b e as effective as many think. There is a body of evidence indicative of less-than-expected cure rates, especially in cosmetically sensitive facial areas. 6-n An alternative method, I suggest, is curettage and shave excision. The purpose of this paper is to define the technic, examine its benefits, and recommend that it be added to the roster of fundamental dermatology treatments taught in graduate training programs. The procedure eliminates electrodesiccation and replaces it with shave biopsy. There is no more
From the Department of Dermatologic Surgery, University of California at Los Angeles. Reprint requests to: Dr. Norman A. Brooks, 16311 Ventura Blvd., Suite 690, Encino, CA 91436.
sacrifice of tissue than with electrodesiccation. However, the tissue that is removed is utilized for histologic examination, enhancing the accuracy of the procedure (Figs. 1-5). The inspiration for this technic is Mohs' surgery, a specialized treatment primarily reserved for large, recurrent, difficult or sclerosing carcinomas that have irregular shapes and often extensive roots spreading along nerves, blood vessels, periosteum, perichondrium, and facial or embryologic fusion planes. 1~-17 A key element of the Mohs' procedure is the removal of tumors in thin, saucer-shaped layers, with progressive shave excisions. 18 In Mohs' surgery, the physician is not only the surgeon but also the pathologist, simultaneously examining frozen sections of excised tissue? 8 The dual role is necessary because of the complex nature of the carcinomas involved. To avoid serious errors, exact histologic localization is required. This is accomplished through multiple serial excisions and detailed excision maps. Frequently, extensive cases are encountered requiring sophisti-
279
Journal of the 280
American Academy of Dermatology
Brooks
A.
A
B.
3.
Ca
.~~~"~"" Fig. 1. Illustration of thin shave excision of basal cell carcinoma. When the thin specimen is histologically examined horizontally along the entire undersurface and sides, as is done in the Mohs method, A will show no evidence of tumor, B will show a deep central root, and C will show a lateral superficial extension. No portion of the wound margin is left unexamined.
cated surgical skills and a most thorough knowledge of both microscopic and gross anatomy. The technic is effective but clearly a demanding one. The learning of additional skills is requisite. Mohs' surgical method, however, requires a full year of training and is taught to but a limited number of postgraduate students each year. The curettage and shave excision procedure discussed in this paper borrows some elements from the Mohs' technic and applies them to lesions similar to those typically treated with curettage and electrodesiccation. An experimental study was conducted to examine the feasibility and effectiveness of the curettage and shave excision procedure. Large, recurrent tumors, or sclerosing carcinomas, with their irregular shapes and frequent extensive roots are the domain of the Mohs' surgeon. These lesions
Fig. 2. Standard transverse vertical sectioning of thick specimen obtained by surgieal excision. A and B demonstrate how a small silent outgrowth can be easily missed by the pathologist in sectioning such a specimen for histologic analysis.
were not included in this study. Consideration was limited to primary cutaneous carcinomas, approximately 1.0 cm or less.
PROCEDURE Following vigorous curettage, a thin shave excision was performed conforming to the sides and base of the curetted defect. The sides and undersurface of the specimens were stained for orientation purposes. In order to obtain maximum objectivity in the study, specimens were prepared by permanent section and jointly read with an outside pathologist. The thin specimens were sectioned horizon-
Volume 10 Number 2, Part 1 February, 1984
Curettage and shave excision
281
tally along the undersurface, as is done in the Mohs' process.
surgical technic. There were only two reported recurrences. 12
RESULTS
DISCUSSION
One hundred cases of primary carcinomas 1 .O cm or less were treated in the experimental study. There were eighty-eight basal cell carcinomas and twelve squamous cell carcinomas. Eighty-three cases involved the face, scalp, or ears and seventeen cases involved the neck, trunk, or extremities. In sixty cases, a single shave excision was sufficient to eliminate the tumor. There was no evidence of residual carcinoma. No further surgery was required. In twenty-one patients there was definite extensive or focal residual carcinoma. In these patients a single repeat shave excision was performed in the area o f positive tumor, resulting in elimination of carcinomatous tissue. In the remaining nineteen cases a definite diagnosis was not possible on the part of the pathologist. Atypical loci interpreted as suspicious but not diagnostic for residual carcinoma were found. It called for a co-reading between the pathologist and the dermatologist. The special training of the dermatologist in the pathologic interpretation of specimens cut in the horizontal plane and the intimate knowledge of the patient's tumor led to a subsequent precise reading of these questionable slides. Some of the patients required further shave excision; others did not. The uncertainty of the pathologist underscores the importance of dermatologists' receiving training not only in general dermatopathology, which is provided in the standard curriculum, but also in the specific dermatopathology relating to horizontal section interpretation of skin cancers encountered in shave excision procedures. The experimental study was conducted over 5 years. The most recent cases are approximately 1 year old. All cases were seen for follow-up at least at monthly, 3-month, 6-month, and yearly intervals, To date there have been no recurrent lesions. These results are in line with Dr. Fred Mohs' published series of 4,034 cases of basal cell carcinoma, 1.0 cm or less, over a 5-year period. A 99.9% cure rate was achieved using the Mohs'
Medical textbooks describe cure rates as " g o o d " or "high" for primary carcinomas using the curettage and electrodesiccation method. 1~-21 Cure rates of up to 96% have been reported by Knox and associates. 2~ A review of the literature yields evidence that the cure rate may not always be as high and in fact suggests there is room for improvement, especially in cosmetically sensitive areas. Kopf et aP discovered an appreciable variation in the 5-year recurrence rate of basal cell carcinoma treated by residents at the New York University Hospital in a clinic setting as opposed to treatment rendered by more experienced private physicians. In a computerized survey of 3,531 cases from 1955 to 1969, there was a 19.8% recurrence rate for curettage-electrodesiccation and an 8.9% recurrence rate for surgical excision. The unexpected high recurrence rate for curettageelectrodesiccation was ascribed to the fact that the procedure was done by residents with only limited faculty supervision. In another report, Kopf noted a three times greater recurrence rate with the procedure done by residents (18.8%) than with it done by private physicians (5.7%). Following improved training and supervision of residents, a second comparison still revealed a nearly twofold difference (9.6% vs 5.7%). The authors concluded that although the principles of curettage and electrodesiccation are well established, there was considerable variation in technic. They stated that "fiature studies should attempt to identify those elements of the curettage and electro-desiccation technic that result in the highest cure rates, fewest complications, and best cosmetic results." They further stated that "possibly, a more standardized technic of curettage and electro-desiccation for the treatment of basal cell carcinomas of the skin could be defined and taught in graduate training programs. ' ' 6 In a survey of 1,170 patients, Robins and A1bom 1~ discovered a much higher recurrence rate of basal cell carcinoma in young women 21 to 40 years of age than in their male peers. This discrepancy was attributed to overly conservative and in-
Journal of the
282
Brooks
adequate initial therapy in young women due to cosmetic consideration. Rakofsky, 11 an ophthalmic surgeon, found a 50% incidence of histologically inadequate surgical excisions on the eyelids of ninety-five patients. Not only were female patients determined to suffer a higher incidence of basal cell carcinoma of the eyelid than male patients, but also there was a higher incidence of inadequate surgery among female patients. Thirty of fifty-three pathologic specimens from female patients were reported as being incompletely excised (57%) as compared to seventeen of forty-two for male patients (40%). Rakofsky, 1~ like Robins and Albom, indicates the consequences of cosmetic conservatism in treating female patients. Rakofsky's findings furthermore raise questions about the technical difficulty and effectiveness of standard treatments in removing basal cell carcinomas from the eyelid. Rakofsky H makes the following conclusion: It is my recommendation that upon a preoperative diagnosis of basal cell carcinoma, arrangements should be made for a pathologic assistant. The surgeon should make his excision based upon his immediate clinical impression. The excised mass should then be examined by a pathologist to determine the adequacy of the surgical excision before any plastic repair is attempted. Further excisions should be conducted upon the pathologist's recommendation. Finally, the edges of the excised mass should be labeled in the event further surgery is required. Furthermore, in a carefully controlled study by Salasche, 23 curettage and electrodesiccation procedures were performed on one hundred patients with primary basal cell carcinomas of the face, after which the lesion sites were histologically examined. Residual carcinoma was found in 30% of cases from the midfacial region. This led Salasche to conclude that "C and D may not be the preferred method o f therapy for lesions located on the nose and nasolabial f o l d . " Salasche further noted that "several authors have cautioned against the use of C and D on and around the nose, and our findings of a 30% incidence of residual tumor in this area, despite seemingly adequate C and D treatment, support this contention."6'23-27
American Academy of Dermatology
This review clearly indicates the importance of histologic control. The technic of curettage and electrodesiccation does not allow for this essential control. Marginal tissue is desiccated, and, as the recurrence rate shows, the presence of extensive or focal residual carcinoma can be missed. The curettage and shave excision technic has the built-in feature of histologic examination. This enables the physician to effectively identify and remove all diseased tissue. The sacrifice of surrounding healthy tissue is minimized, accommodating the cosmetic concerns particularly when dealing with facial carcinoma, while at the same time maximizing the precise removal of unhealthy tissue. I have found this technic highly advantageous in cosmetically sensitive areas prone to high recurrence in which tissue conservation is essential. Outside of training in the Mohs' surgical method, instruction in the curettage and shave excision approach for primary skin tumors is not available. B y integrating this technic into the dermatology curriculum, medical schools will be serving the best interests of progress and the healing art. Skin cancer is the most common form of malignancy. No stone should be left unturned that can make our work more effective. It could be argued that formal training really is not necessary. Dermatologists routinely excise moles with shave biopsy. Why should they not apply that technic to small, primary carcinomas? Why the need for formal training? 1. The technic, while simple in concept, is much more difficult to perform. 2. The proper technic of removing the thin, saucershaped layers and the mapping and orienting of the tissue all require detailed instruction and intensive close-up observation of the method in actual practice. 3. The correct pathologic interpretation of the slide specimens is absolutely pivotal to the success of this procedure. Specimens are cut on a horizontal plane as opposed to the customary vertical plane. However, dermatologists do not receive specific training in the interpretation of horizontal planes. Not only can hair follicles or adnexal structures cut on edge give the appearance of carcinoma, but also the surgery itself or the process of fixation can frequently result in a shrinkage
Volume 10 Number 2, Part 1 February, 1984
Curettage and shave excision
283
Fig. 3. Pigmented basal cell carcinoma of right lower eyelid. Fig. 4. Wound after shave excisions. Fig. 5. Wound after natural healing. or distortion of cells that renders them atypical in appearance. The presence of inflammation can also result in varying degrees of atypia. Formal training in the interpretation of the pathologic specimens cut on the horizontal plane is a must. 4. A lesion may look small at the outset but in reality can be extensive. An improperly trained physician attempting to treat such a lesion invites complications and even possible legal difficulties. 5. Unless properly taught, the procedure contains the seeds for serious error. When properly taught, it promises optimal effectiveness. Voices have been raised suggesting that graduate training programs offer a standardized curettage and electrodesiccation technic for the sake of reducing carcinoma recurrence rates. I would suggest as well to offer training in curettage and shave
excision for primary carcinomas, an alternative technic promising maximum results. CONCLUSION A review of the literature indicates the potential for undesirable recurrence rates of primary skin cancers treated with curettage and electrodesiccation. It has been suggested that the procedure be standardized and to it be added some dimension of histologic control. The experimental study conducted and reported here utilized the curettage and shave excision technic instead of curettage and eleetrodesiccation for primary carcinomas 1.0 cm or less. The benefits of this method were explained, namely, that it combines histologic control with the least pos-
284
Brooks
sible removal of normal tissue. The procedure is especially effective for treatment of cosmetically sensitive facial carcinomas prone to high recurrence. Extremely high cure rates are achieved. These factors contribute to an excellent patient response. Although simple in concept, curettage and shave excision requires proper training in order to avoid serious errors. It is suggested that this procedure be added to the treatment modalities taught in graduate training programs. REFERENCES 1. Atbright SD III: Treatment of skin cancer using multiple modalities. J AM ACAD DERMATOL 7'- 143-165, 1982. 2. Jansen GT, Westbrook KC: Cancer of the skin, in Suen JY, Myers EN: Cancer of the head and neck. New York, 1981, Churchill Livingstone Inc., pp. 212-241. 3. Chemosky ME: Treatment for early squamous basal cell carcinoma. Reprinted from Neoplasms of the skin and malignant melanoma. Chicago, 1976, Year Book Medical Publishers Inc., pp. 129-154. 4. Knox JM, Freeman RG, Heaton CL: Curettage and electrodesiccation in the treatment of skin cancer. South Med J 55:1212-1215, 1962. 5. Knox JM, Lyles TW, Shapiro EM, Martin RD: Curettage and electrodesiccation in the treatment of skin cancer. Arch Dermatol 82:197-204, 1960. 6. Kopf AW, Bart RS, Shrager D, et al: Curettage-electrodesiccation treatment of basal cell carcinomas. Arch Dermatol 113:439-443, 1977. 7. Menn H, Robins P, Kopf AW, et al: The recurrent basal cell epithelioma: A study of 100 cases of recurrent, retreated basal cell epitheliomas. Arch Dermatol 103: 628-631, 1971. 8. Koplin L, Zarem HA: Recurrent basal cell carcinoma: A review concerning the incidence, behavior, and management of recurrent basal cell carcinoma with emphasis on the incompletely excised lesion. Plast Reconstr Surg 65:656-664, 1980. 9. Kopf AW: Computer analysis of 3531 basal cell carcinomas of the skin. J Dermatot Surg Oncol 6:267-282, 1979.
Journal of the American Academy o f Dermatology
10. Robins P, Albom MJ: Recurrent basal cell carcinomas in young women. J Dermatol Surg 1:49-51, 1975. 11, Rakofsky SI: The adequacy of the surgical excision of basal cell carcinoma. Ann Ophthalmol 5:596-600, 1973. 12. Mohs FE: Chemosurgery: Microscopically controlled surgery for skin cancer. Springfield, IL, 1978, Charles C Thomas, Publisher, pp. 154, 256-273. 13, Mohs FE: Chemosurgery: A microscopically controlled method of cancer excision. Arch Surg 42:279-295, 1941. 14. Tromovitch TA, Stegman SJ: Microscopic-controlled excision of cutaneous tumors: Chemosurgery, fresh tissue technique. Cancer 41:653-658, 1978. 15. Tromovitch TA, Stegman S J: Microscopically controlled excision of skin tumors: Chemosurgery (Mohs), fresh tissue technique. Arch Dermatol 110:231-232, 1974. 16, Robins P, Albom MJ: Mobs' surgery: Fresh tissue technique. J Dermatol Surg 1:37-41, 1975. 17. Robins P: Chemosurgery: My 15 years of experience. J Dermatol Surg Oncol 7:779-789, 1981. 18. Swanson NA, Taylor WB" The evolution of Mohs' surgery. J Derrnatol Surg Oncol 8:651-654, 1982. 19. Rook A, Wilkinson DS, Ebling FJG: Basal cell tumors, in Textbook of dermatology. Oxford, 1972, Blackwell Scientific Publications, vol. 2, pp. 1949-1951. 20. Fitzpatrick TB, et al: Dermatology in general medicine. New York, 1971, McGraw-Hill Book Co.,pp. 466-488. 21. Domonkos AN: Andrews' Diseases of the skin, ed. 6, Philadelphia, 197l, W. B. Saunders Co., p. 766. 22. Knox JM, et al: Curettage and electrodesiecation in the treatment of skin cancer. Arch Dermatol 82:197-204, 1960. 23. Salasche SJ: Curettage and electrodesiccation in the treatment of midfacial basal cell epithelioma. J AM ACAD DERr~ATOL 8:496-503, 1983. 24. Popkin GL, Bart RS: Excision versus curettage and electrodesiccation as derrnatologie office procedures for the treatment of basal-cell carcinomas. J Dermatol Surg Oncol 1:33-35, 1975. 25. Sweet RD: The treatment of basal cell carcinomas b y curettage. Br J Dermatol 75:137-148, 1963. 26. Knox JM, Lyles TW, Shapiro EM, Martin RD: Curettage and electrodesiccation in the treatment of skin cancer. Arch Dernaatol 82:197-204, 1960. 27. Robins P, Bennett RG: Current concepts in the management of skin cancer. New York, 1979, Clinicom, Inc., pp. 54-56.
The most common treatment for primary skin cancers is curettage and electrodesiccation. 1-6 The method has been used successfully by most dermatologists for many years. Examination of the pertinent literature suggests that curettage and electrodesiccation may not always b e as effective as many think. There is a body of evidence indicative of less-than-expected cure rates, especially in cosmetically sensitive facial areas. 6-n An alternative method, I suggest, is curettage and shave excision. The purpose of this paper is to define the technic, examine its benefits, and recommend that it be added to the roster of fundamental dermatology treatments taught in graduate training programs. The procedure eliminates electrodesiccation and replaces it with shave biopsy. There is no more
From the Department of Dermatologic Surgery, University of California at Los Angeles. Reprint requests to: Dr. Norman A. Brooks, 16311 Ventura Blvd., Suite 690, Encino, CA 91436.
sacrifice of tissue than with electrodesiccation. However, the tissue that is removed is utilized for histologic examination, enhancing the accuracy of the procedure (Figs. 1-5). The inspiration for this technic is Mohs' surgery, a specialized treatment primarily reserved for large, recurrent, difficult or sclerosing carcinomas that have irregular shapes and often extensive roots spreading along nerves, blood vessels, periosteum, perichondrium, and facial or embryologic fusion planes. 1~-17 A key element of the Mohs' procedure is the removal of tumors in thin, saucer-shaped layers, with progressive shave excisions. 18 In Mohs' surgery, the physician is not only the surgeon but also the pathologist, simultaneously examining frozen sections of excised tissue? 8 The dual role is necessary because of the complex nature of the carcinomas involved. To avoid serious errors, exact histologic localization is required. This is accomplished through multiple serial excisions and detailed excision maps. Frequently, extensive cases are encountered requiring sophisti-
279
Journal of the 280
American Academy of Dermatology
Brooks
A.
A
B.
3.
Ca
.~~~"~"" Fig. 1. Illustration of thin shave excision of basal cell carcinoma. When the thin specimen is histologically examined horizontally along the entire undersurface and sides, as is done in the Mohs method, A will show no evidence of tumor, B will show a deep central root, and C will show a lateral superficial extension. No portion of the wound margin is left unexamined.
cated surgical skills and a most thorough knowledge of both microscopic and gross anatomy. The technic is effective but clearly a demanding one. The learning of additional skills is requisite. Mohs' surgical method, however, requires a full year of training and is taught to but a limited number of postgraduate students each year. The curettage and shave excision procedure discussed in this paper borrows some elements from the Mohs' technic and applies them to lesions similar to those typically treated with curettage and electrodesiccation. An experimental study was conducted to examine the feasibility and effectiveness of the curettage and shave excision procedure. Large, recurrent tumors, or sclerosing carcinomas, with their irregular shapes and frequent extensive roots are the domain of the Mohs' surgeon. These lesions
Fig. 2. Standard transverse vertical sectioning of thick specimen obtained by surgieal excision. A and B demonstrate how a small silent outgrowth can be easily missed by the pathologist in sectioning such a specimen for histologic analysis.
were not included in this study. Consideration was limited to primary cutaneous carcinomas, approximately 1.0 cm or less.
PROCEDURE Following vigorous curettage, a thin shave excision was performed conforming to the sides and base of the curetted defect. The sides and undersurface of the specimens were stained for orientation purposes. In order to obtain maximum objectivity in the study, specimens were prepared by permanent section and jointly read with an outside pathologist. The thin specimens were sectioned horizon-
Volume 10 Number 2, Part 1 February, 1984
Curettage and shave excision
281
tally along the undersurface, as is done in the Mohs' process.
surgical technic. There were only two reported recurrences. 12
RESULTS
DISCUSSION
One hundred cases of primary carcinomas 1 .O cm or less were treated in the experimental study. There were eighty-eight basal cell carcinomas and twelve squamous cell carcinomas. Eighty-three cases involved the face, scalp, or ears and seventeen cases involved the neck, trunk, or extremities. In sixty cases, a single shave excision was sufficient to eliminate the tumor. There was no evidence of residual carcinoma. No further surgery was required. In twenty-one patients there was definite extensive or focal residual carcinoma. In these patients a single repeat shave excision was performed in the area o f positive tumor, resulting in elimination of carcinomatous tissue. In the remaining nineteen cases a definite diagnosis was not possible on the part of the pathologist. Atypical loci interpreted as suspicious but not diagnostic for residual carcinoma were found. It called for a co-reading between the pathologist and the dermatologist. The special training of the dermatologist in the pathologic interpretation of specimens cut in the horizontal plane and the intimate knowledge of the patient's tumor led to a subsequent precise reading of these questionable slides. Some of the patients required further shave excision; others did not. The uncertainty of the pathologist underscores the importance of dermatologists' receiving training not only in general dermatopathology, which is provided in the standard curriculum, but also in the specific dermatopathology relating to horizontal section interpretation of skin cancers encountered in shave excision procedures. The experimental study was conducted over 5 years. The most recent cases are approximately 1 year old. All cases were seen for follow-up at least at monthly, 3-month, 6-month, and yearly intervals, To date there have been no recurrent lesions. These results are in line with Dr. Fred Mohs' published series of 4,034 cases of basal cell carcinoma, 1.0 cm or less, over a 5-year period. A 99.9% cure rate was achieved using the Mohs'
Medical textbooks describe cure rates as " g o o d " or "high" for primary carcinomas using the curettage and electrodesiccation method. 1~-21 Cure rates of up to 96% have been reported by Knox and associates. 2~ A review of the literature yields evidence that the cure rate may not always be as high and in fact suggests there is room for improvement, especially in cosmetically sensitive areas. Kopf et aP discovered an appreciable variation in the 5-year recurrence rate of basal cell carcinoma treated by residents at the New York University Hospital in a clinic setting as opposed to treatment rendered by more experienced private physicians. In a computerized survey of 3,531 cases from 1955 to 1969, there was a 19.8% recurrence rate for curettage-electrodesiccation and an 8.9% recurrence rate for surgical excision. The unexpected high recurrence rate for curettageelectrodesiccation was ascribed to the fact that the procedure was done by residents with only limited faculty supervision. In another report, Kopf noted a three times greater recurrence rate with the procedure done by residents (18.8%) than with it done by private physicians (5.7%). Following improved training and supervision of residents, a second comparison still revealed a nearly twofold difference (9.6% vs 5.7%). The authors concluded that although the principles of curettage and electrodesiccation are well established, there was considerable variation in technic. They stated that "fiature studies should attempt to identify those elements of the curettage and electro-desiccation technic that result in the highest cure rates, fewest complications, and best cosmetic results." They further stated that "possibly, a more standardized technic of curettage and electro-desiccation for the treatment of basal cell carcinomas of the skin could be defined and taught in graduate training programs. ' ' 6 In a survey of 1,170 patients, Robins and A1bom 1~ discovered a much higher recurrence rate of basal cell carcinoma in young women 21 to 40 years of age than in their male peers. This discrepancy was attributed to overly conservative and in-
Journal of the
282
Brooks
adequate initial therapy in young women due to cosmetic consideration. Rakofsky, 11 an ophthalmic surgeon, found a 50% incidence of histologically inadequate surgical excisions on the eyelids of ninety-five patients. Not only were female patients determined to suffer a higher incidence of basal cell carcinoma of the eyelid than male patients, but also there was a higher incidence of inadequate surgery among female patients. Thirty of fifty-three pathologic specimens from female patients were reported as being incompletely excised (57%) as compared to seventeen of forty-two for male patients (40%). Rakofsky, 1~ like Robins and Albom, indicates the consequences of cosmetic conservatism in treating female patients. Rakofsky's findings furthermore raise questions about the technical difficulty and effectiveness of standard treatments in removing basal cell carcinomas from the eyelid. Rakofsky H makes the following conclusion: It is my recommendation that upon a preoperative diagnosis of basal cell carcinoma, arrangements should be made for a pathologic assistant. The surgeon should make his excision based upon his immediate clinical impression. The excised mass should then be examined by a pathologist to determine the adequacy of the surgical excision before any plastic repair is attempted. Further excisions should be conducted upon the pathologist's recommendation. Finally, the edges of the excised mass should be labeled in the event further surgery is required. Furthermore, in a carefully controlled study by Salasche, 23 curettage and electrodesiccation procedures were performed on one hundred patients with primary basal cell carcinomas of the face, after which the lesion sites were histologically examined. Residual carcinoma was found in 30% of cases from the midfacial region. This led Salasche to conclude that "C and D may not be the preferred method o f therapy for lesions located on the nose and nasolabial f o l d . " Salasche further noted that "several authors have cautioned against the use of C and D on and around the nose, and our findings of a 30% incidence of residual tumor in this area, despite seemingly adequate C and D treatment, support this contention."6'23-27
American Academy of Dermatology
This review clearly indicates the importance of histologic control. The technic of curettage and electrodesiccation does not allow for this essential control. Marginal tissue is desiccated, and, as the recurrence rate shows, the presence of extensive or focal residual carcinoma can be missed. The curettage and shave excision technic has the built-in feature of histologic examination. This enables the physician to effectively identify and remove all diseased tissue. The sacrifice of surrounding healthy tissue is minimized, accommodating the cosmetic concerns particularly when dealing with facial carcinoma, while at the same time maximizing the precise removal of unhealthy tissue. I have found this technic highly advantageous in cosmetically sensitive areas prone to high recurrence in which tissue conservation is essential. Outside of training in the Mohs' surgical method, instruction in the curettage and shave excision approach for primary skin tumors is not available. B y integrating this technic into the dermatology curriculum, medical schools will be serving the best interests of progress and the healing art. Skin cancer is the most common form of malignancy. No stone should be left unturned that can make our work more effective. It could be argued that formal training really is not necessary. Dermatologists routinely excise moles with shave biopsy. Why should they not apply that technic to small, primary carcinomas? Why the need for formal training? 1. The technic, while simple in concept, is much more difficult to perform. 2. The proper technic of removing the thin, saucershaped layers and the mapping and orienting of the tissue all require detailed instruction and intensive close-up observation of the method in actual practice. 3. The correct pathologic interpretation of the slide specimens is absolutely pivotal to the success of this procedure. Specimens are cut on a horizontal plane as opposed to the customary vertical plane. However, dermatologists do not receive specific training in the interpretation of horizontal planes. Not only can hair follicles or adnexal structures cut on edge give the appearance of carcinoma, but also the surgery itself or the process of fixation can frequently result in a shrinkage
Volume 10 Number 2, Part 1 February, 1984
Curettage and shave excision
283
Fig. 3. Pigmented basal cell carcinoma of right lower eyelid. Fig. 4. Wound after shave excisions. Fig. 5. Wound after natural healing. or distortion of cells that renders them atypical in appearance. The presence of inflammation can also result in varying degrees of atypia. Formal training in the interpretation of the pathologic specimens cut on the horizontal plane is a must. 4. A lesion may look small at the outset but in reality can be extensive. An improperly trained physician attempting to treat such a lesion invites complications and even possible legal difficulties. 5. Unless properly taught, the procedure contains the seeds for serious error. When properly taught, it promises optimal effectiveness. Voices have been raised suggesting that graduate training programs offer a standardized curettage and electrodesiccation technic for the sake of reducing carcinoma recurrence rates. I would suggest as well to offer training in curettage and shave
excision for primary carcinomas, an alternative technic promising maximum results. CONCLUSION A review of the literature indicates the potential for undesirable recurrence rates of primary skin cancers treated with curettage and electrodesiccation. It has been suggested that the procedure be standardized and to it be added some dimension of histologic control. The experimental study conducted and reported here utilized the curettage and shave excision technic instead of curettage and eleetrodesiccation for primary carcinomas 1.0 cm or less. The benefits of this method were explained, namely, that it combines histologic control with the least pos-
284
Brooks
sible removal of normal tissue. The procedure is especially effective for treatment of cosmetically sensitive facial carcinomas prone to high recurrence. Extremely high cure rates are achieved. These factors contribute to an excellent patient response. Although simple in concept, curettage and shave excision requires proper training in order to avoid serious errors. It is suggested that this procedure be added to the treatment modalities taught in graduate training programs. REFERENCES 1. Atbright SD III: Treatment of skin cancer using multiple modalities. J AM ACAD DERMATOL 7'- 143-165, 1982. 2. Jansen GT, Westbrook KC: Cancer of the skin, in Suen JY, Myers EN: Cancer of the head and neck. New York, 1981, Churchill Livingstone Inc., pp. 212-241. 3. Chemosky ME: Treatment for early squamous basal cell carcinoma. Reprinted from Neoplasms of the skin and malignant melanoma. Chicago, 1976, Year Book Medical Publishers Inc., pp. 129-154. 4. Knox JM, Freeman RG, Heaton CL: Curettage and electrodesiccation in the treatment of skin cancer. South Med J 55:1212-1215, 1962. 5. Knox JM, Lyles TW, Shapiro EM, Martin RD: Curettage and electrodesiccation in the treatment of skin cancer. Arch Dermatol 82:197-204, 1960. 6. Kopf AW, Bart RS, Shrager D, et al: Curettage-electrodesiccation treatment of basal cell carcinomas. Arch Dermatol 113:439-443, 1977. 7. Menn H, Robins P, Kopf AW, et al: The recurrent basal cell epithelioma: A study of 100 cases of recurrent, retreated basal cell epitheliomas. Arch Dermatol 103: 628-631, 1971. 8. Koplin L, Zarem HA: Recurrent basal cell carcinoma: A review concerning the incidence, behavior, and management of recurrent basal cell carcinoma with emphasis on the incompletely excised lesion. Plast Reconstr Surg 65:656-664, 1980. 9. Kopf AW: Computer analysis of 3531 basal cell carcinomas of the skin. J Dermatot Surg Oncol 6:267-282, 1979.
Journal of the American Academy o f Dermatology
10. Robins P, Albom MJ: Recurrent basal cell carcinomas in young women. J Dermatol Surg 1:49-51, 1975. 11, Rakofsky SI: The adequacy of the surgical excision of basal cell carcinoma. Ann Ophthalmol 5:596-600, 1973. 12. Mohs FE: Chemosurgery: Microscopically controlled surgery for skin cancer. Springfield, IL, 1978, Charles C Thomas, Publisher, pp. 154, 256-273. 13, Mohs FE: Chemosurgery: A microscopically controlled method of cancer excision. Arch Surg 42:279-295, 1941. 14. Tromovitch TA, Stegman SJ: Microscopic-controlled excision of cutaneous tumors: Chemosurgery, fresh tissue technique. Cancer 41:653-658, 1978. 15. Tromovitch TA, Stegman S J: Microscopically controlled excision of skin tumors: Chemosurgery (Mohs), fresh tissue technique. Arch Dermatol 110:231-232, 1974. 16, Robins P, Albom MJ: Mobs' surgery: Fresh tissue technique. J Dermatol Surg 1:37-41, 1975. 17. Robins P: Chemosurgery: My 15 years of experience. J Dermatol Surg Oncol 7:779-789, 1981. 18. Swanson NA, Taylor WB" The evolution of Mohs' surgery. J Derrnatol Surg Oncol 8:651-654, 1982. 19. Rook A, Wilkinson DS, Ebling FJG: Basal cell tumors, in Textbook of dermatology. Oxford, 1972, Blackwell Scientific Publications, vol. 2, pp. 1949-1951. 20. Fitzpatrick TB, et al: Dermatology in general medicine. New York, 1971, McGraw-Hill Book Co.,pp. 466-488. 21. Domonkos AN: Andrews' Diseases of the skin, ed. 6, Philadelphia, 197l, W. B. Saunders Co., p. 766. 22. Knox JM, et al: Curettage and electrodesiecation in the treatment of skin cancer. Arch Dermatol 82:197-204, 1960. 23. Salasche SJ: Curettage and electrodesiccation in the treatment of midfacial basal cell epithelioma. J AM ACAD DERr~ATOL 8:496-503, 1983. 24. Popkin GL, Bart RS: Excision versus curettage and electrodesiccation as derrnatologie office procedures for the treatment of basal-cell carcinomas. J Dermatol Surg Oncol 1:33-35, 1975. 25. Sweet RD: The treatment of basal cell carcinomas b y curettage. Br J Dermatol 75:137-148, 1963. 26. Knox JM, Lyles TW, Shapiro EM, Martin RD: Curettage and electrodesiccation in the treatment of skin cancer. Arch Dernaatol 82:197-204, 1960. 27. Robins P, Bennett RG: Current concepts in the management of skin cancer. New York, 1979, Clinicom, Inc., pp. 54-56.