- Email: [email protected]
Treatment of skin cancer
Volume 12 Number 3 March, 1985
7. Golub ES: Connections between~the nervous, hematopoietic and germ cell systems. Nature 299:483, 1982. 8. Holdstock G, Chastenay BF, Krawitt EL: Effects of testosterone, oestradiol and progesterone of immune regulation. Clin Exp Immunol 47:449-456, 1982. 9. Honeyman JF, Eguiguren G, Pinto A, et al: Bullous dermatoses of pregnancy. Arch Derrnatol 117:264-267, 1981. 10. Ahmed AR: Lymphocyte studies in pemphigus. Arch Dermatol Res 271:111-115, 1981. 11. Noguchi S, Nishitani H: Immunologic studies of a case of myasthenia gravis associated with pemphigus vulgaris after thymomectomy. Neurology 26:1075-1080, 1976. 12. Marsden RA, Dawber RPR, Millard PR, Mowat AG: Herpetiform pemphigus induced by penicillamine. Br J Dermatol 97:451-452, 1977.
Treatment of skin cancer To the Editor: There are four C's to consider when a physician chooses a modality for the treatment of any specific basal cell epithelioma. The four C's are easy to remember: (1) cure rate, (2) cosmetic results, (3) convenience to the patient, and (4) cost. For most routine basal cell epitheliomas, the method of curettage followed by electrodesiccation wins on three of four counts. The references cited by Dr. Spiller show that curettage and desiccation (C&D), when properly employed by skilled hands, will cure approximately 98% of appropriately selected tumors. Other authors, some cited by Spiller, have implied (directly and indirectly) that C&D should be abandoned. Let us not belittle or downgrade a technic that has served dermatology and our patients so well. Unfortunately, many who perform Mohs' chemosurgery, including the fresh tissue technic, have become "evangelists." Some go so far as to state that if you agree that chemosurgery is best for large, poorly defined aggressive lesions, then you would have to agree that this procedure would be best for all basal cell tumors in order to assure a maximal cure rate. That type of reasoning is similar to selecting an elephant gun to shoot a rabbit. Granted, the cure rate would be high; however, more tissue would be destroyed than would be optimal. Costs are much higher and aesthetic results are unquestionably poorer. Regarding the convenience factor, the liberal utilization of chemosurgery wastes another person's time; let us not forget that a patient's time is as valuable as our own--and nothing is as precious as time. During this period of ever-increasing emphasis on dermatologic surgery, remember that radiotherapy also has a place in the management of skin cancer. Often residents and younger dermatologists have not been in-
Correspondence
589
structed on the usefulness of, and indications for, choosing radiotherapy. For certain cutaneous malignancies, properly applied radiotherapy is unquestionably superior. Squamous cell carcinomas of the lip and selected basal cell tumors of the nose in elderly patients are good examples. Excision has its place and was underutilized for many years in dermatology. It is gratifying to see the increased emphasis on dermatologic surgery. Our young people are obtaining much better surgical training than was available in the past. The objective of this letter is to emphasize that each and every cutaneous malignancy must be individualized and treated with the four C's kept foremost i n mind. Dermatologists are uniquely qualified to assess and implement appropriate therapy for each and every skin cancer. Again, my compliments to Dr. Spiller for this timely, well-documented presentation.
John M. Knox, M.D. 1810 St. Joseph Medical Place 1 1315 Calhoun, Houston, TX 77002
Reply To the Editor: We thank Dr. Knox for his compliments on our article (J AM ACAD DERMATOL 11:808-814, 1984) and agree with his additional remarks. There are two minor errors we detected in our article that in no way change the sense or substance: on page 812, seventh line from the bottom in the second column, the percent figure of 0.01% should read 0.6%, and also on page 812, tenth line from the top in the first column, the word of should be or in the sentence beginning "Even though some tumor cells remain at the base or margins . . . . " William F. Spiller, M.D., and Rachel F. Spiller, M.D. 3801 Kirby Dr., #300, Houston, TX 77098
Familial Becker's nevus To the Editor: In 1949 Becker first described an acquired localized hypermelanosis and hypertrichosis on the shoulder of two young men.I Subsequent reports of similar cases have termed this distinct clinical entity Becket's nevus, We report the first documented familial occurrence of Becket's nevus in the English literature. Case reports. Case 1. A 24-year-old white man came to us with a solitary pigmented area on his right arm appearing during childhood and slowly increasing in size until 14 years of age. An increase in hair growth in the affected
7. Golub ES: Connections between~the nervous, hematopoietic and germ cell systems. Nature 299:483, 1982. 8. Holdstock G, Chastenay BF, Krawitt EL: Effects of testosterone, oestradiol and progesterone of immune regulation. Clin Exp Immunol 47:449-456, 1982. 9. Honeyman JF, Eguiguren G, Pinto A, et al: Bullous dermatoses of pregnancy. Arch Derrnatol 117:264-267, 1981. 10. Ahmed AR: Lymphocyte studies in pemphigus. Arch Dermatol Res 271:111-115, 1981. 11. Noguchi S, Nishitani H: Immunologic studies of a case of myasthenia gravis associated with pemphigus vulgaris after thymomectomy. Neurology 26:1075-1080, 1976. 12. Marsden RA, Dawber RPR, Millard PR, Mowat AG: Herpetiform pemphigus induced by penicillamine. Br J Dermatol 97:451-452, 1977.
Treatment of skin cancer To the Editor: There are four C's to consider when a physician chooses a modality for the treatment of any specific basal cell epithelioma. The four C's are easy to remember: (1) cure rate, (2) cosmetic results, (3) convenience to the patient, and (4) cost. For most routine basal cell epitheliomas, the method of curettage followed by electrodesiccation wins on three of four counts. The references cited by Dr. Spiller show that curettage and desiccation (C&D), when properly employed by skilled hands, will cure approximately 98% of appropriately selected tumors. Other authors, some cited by Spiller, have implied (directly and indirectly) that C&D should be abandoned. Let us not belittle or downgrade a technic that has served dermatology and our patients so well. Unfortunately, many who perform Mohs' chemosurgery, including the fresh tissue technic, have become "evangelists." Some go so far as to state that if you agree that chemosurgery is best for large, poorly defined aggressive lesions, then you would have to agree that this procedure would be best for all basal cell tumors in order to assure a maximal cure rate. That type of reasoning is similar to selecting an elephant gun to shoot a rabbit. Granted, the cure rate would be high; however, more tissue would be destroyed than would be optimal. Costs are much higher and aesthetic results are unquestionably poorer. Regarding the convenience factor, the liberal utilization of chemosurgery wastes another person's time; let us not forget that a patient's time is as valuable as our own--and nothing is as precious as time. During this period of ever-increasing emphasis on dermatologic surgery, remember that radiotherapy also has a place in the management of skin cancer. Often residents and younger dermatologists have not been in-
Correspondence
589
structed on the usefulness of, and indications for, choosing radiotherapy. For certain cutaneous malignancies, properly applied radiotherapy is unquestionably superior. Squamous cell carcinomas of the lip and selected basal cell tumors of the nose in elderly patients are good examples. Excision has its place and was underutilized for many years in dermatology. It is gratifying to see the increased emphasis on dermatologic surgery. Our young people are obtaining much better surgical training than was available in the past. The objective of this letter is to emphasize that each and every cutaneous malignancy must be individualized and treated with the four C's kept foremost i n mind. Dermatologists are uniquely qualified to assess and implement appropriate therapy for each and every skin cancer. Again, my compliments to Dr. Spiller for this timely, well-documented presentation.
John M. Knox, M.D. 1810 St. Joseph Medical Place 1 1315 Calhoun, Houston, TX 77002
Reply To the Editor: We thank Dr. Knox for his compliments on our article (J AM ACAD DERMATOL 11:808-814, 1984) and agree with his additional remarks. There are two minor errors we detected in our article that in no way change the sense or substance: on page 812, seventh line from the bottom in the second column, the percent figure of 0.01% should read 0.6%, and also on page 812, tenth line from the top in the first column, the word of should be or in the sentence beginning "Even though some tumor cells remain at the base or margins . . . . " William F. Spiller, M.D., and Rachel F. Spiller, M.D. 3801 Kirby Dr., #300, Houston, TX 77098
Familial Becker's nevus To the Editor: In 1949 Becker first described an acquired localized hypermelanosis and hypertrichosis on the shoulder of two young men.I Subsequent reports of similar cases have termed this distinct clinical entity Becket's nevus, We report the first documented familial occurrence of Becket's nevus in the English literature. Case reports. Case 1. A 24-year-old white man came to us with a solitary pigmented area on his right arm appearing during childhood and slowly increasing in size until 14 years of age. An increase in hair growth in the affected