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Have We Forgotten the Curette? Conflicts of Interest Howard Steinman, M.D. None U.S. Dermatology Partners Grapevine, Texas

Duplicate Haveor We Forgotten the Curette? For treating:

Reverse Conflicts of Interest • Superifical BCC’s (sBCC’s) I have lost lots of income by following the ideas put forth in this lecture • SCC in-situ’s (SCCis)

Distribute Main Points of Talk sBCC

• Mohs Surgery Appropriate Use Criteria (MAUC) • are over-broad and excessively permissive • justify MMSNot for very indolent tumors – sBCC and SCCis • We should stop using MMS as primary treatment for: • sBCC & SCCis

• Dermatology must develop algorithmic guidelines of Docare for NMSC

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Superficial Basal Cell Carcinoma sBCC

• sBCC’s are discontiguous tumors

• Tumors must be contiguous for Mohs surgery

Mina MA, et al. Superficial Basal Cell Carcinomas of the Head and Neck. Dermatol Surg 2013;39:1003–1008 http://www.dovemed.com/diseases-conditions/superficial-basal-cell-carcinoma-skin/ Shriner DL, et al.: Mohs micrographic surgery. J Am Acad Dermatol 1998;39:79-97

Duplicate sBCC sBCC or • Comprise 17% of all BCCs • Risk of progression is very low at all anatomic sites • Can evolve into nodular BCC • Risk of recurrence is very low with conservative • No evidence they evolves into more aggressive variants surgical treatments • sBCC is perhaps the most indolent of all skin cancers. • Despite foci of other BCC subtypes being found in: • >20% of serially sectioned punch biopsy specimens • >50% excisional specimens

Distribute sBCC Tumor Thickness & Adnexal Extention sBCC – Anatomic Location Risk • 336 sBCC’s evaluated • Central face (Area H) is considered a risk factor for • Tumor thickness = 0.2 – 1.0 mm (median 0.35 mm) BCC invasion and recurrence. • Adnexal extension was present in 13% • Paucity of studies comparing the biologic behavior of • “Tumor thicknessNot and adnexal extension of sBCC sBCC with other lower-risk BCC subtypes are NOT limitations for noninvasive therapy.” • There are NO studies suggesting that sBCC in Area H or M are at higher risk for invasion or recurrence

Roozeboom MH et al J Am Acad Dermatol Do2015;73:93-98

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sBCC – Size Risk sBCC – Patient Co-Morbidities Risks

• BCCs of any size in MAUC Area H, >1.0 cm in Area M • Hematologic malignancies, organ transplantation, and >2.0 cm in Area L are considered high risk factor HIV, immunosuppression and some genodermatoses for recurrence result in higher risk of developing more aggressive BCC and SCC • There are NO studies of sBCC suggesng ↑ size has ↑ recurrence risk • Studies show no ↑ risk for sBCC in these patients sub-groups

Duplicate sBCC - Patient Co-Morbidities Curettageor and Electrodessication for BCC • Lott et al & Harwood et al both found that: NYU BCC Curettage and Electrodessication Data • BCCs in organ transplant patients do not behave more aggressively. BCC 5 year recurrence rates for fully trained dermatologists: • Barlow et al found that BCCs in immunosuppressed patients treated with curettage alone had no increased rates of Curettage & electrodessication 5.7% recurrence. Surgical Excision 5.3% Lott DG, et al. Aggressive behavior of nonmelanotic skin cancers in solid organ transplant recipients. Transplantation. 2010;90(6):683-687. Harwood CA, et al. Clinicopathologic features of skin cancer in organ transplant recipients: a retrospective case- Macrene, AA, et al: The appropriateness of curettage and electrodessication for the control series. J Am Acad Dermatol. 2006;54(2):290-300. treatment of Basal Cell Carcinoma. Arch Dermatol 2000;136:800 Barlow et al. Treatment of basal cell carcinoma with curettage alone. J Am Acad Dermatol. 2006;54(6):1039-1045

Distribute Curettage Alone for BCC

Retrospective, single center, single investigator study of 302 BCC’s with >5 year follow-up. Remembering the Curette Not Discrete nodular or superficial BCC’s not involving the mucosa or eyelids.

The 5-year recurrence rate = 3.97%)

Barlow JO, Zalla MJ, Kyle A, et al: Treatment of basal cell carcinoma with curettage alone. Do J Am Acad Dermatol 2006;54:1039-45

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sBCC – Non-Excisional Surgical Treatment sBCC – Non-Excisional Surgical Treatment

• Peikert prospectively evaluated 94 sBCC on the neck, trunk • and extremities treated with curettage and cryosurgery Lindemalm-Lundstam treated 73 sBCC of the face & scalp with C&C • 5-year recurrence rate = 1.1%. • mean follow-up = 42 months • no recurrences.

Peikert JM. Int J Dermatol. 2011;50(9):1135-1138. Lindemalm-Lundstam B. Br J Dermatol. 2009;161(3):568-576.

Duplicate

Curettage Then Imiquimod 5% Cream • Tillman & Carroll or • 90 patients (101 tumors) - including infiltrating BCC’s • Curettage then Imiquimod 5 days/week for six week • 96% clearance rate at an average of 36 month follow-up Mohs Surgery for sBCC • Rigel et al • 57 nodular and superficial BCC’s • Curettage followed by Imiquimod 5 days/week for six week • 0% recurrence after one year

Tillman DK and Carroll MT: J Drugs Dermatol 2008;7(1) Suppl 8-14 Rigel DS, et al: J Drugs Dermatol 2008;7(1) Suppl 15-16

Distribute Mohs Surgery for sBCC Mohs Surgery for sBCC

• Mina evaluated 158 sBCCs treated with MS. • Orengo retrospectively evaluated 342 BCCs treated • 122 (77%) were primary sBCC with MMS • Average stages to clear = 2.6 stages (range 2.2 – 2.9) • 54% of sBCCs required 3 or more stages • PostoperativeNot wounds were 2.5 - 38.5 times larger than • Only 18% of nBCCs and 37% of micronodular, infiltrative, preoperative tumor sizes (except on scalp and ears.) and morpheaform BCCs required 3 or more stages.

Mina MA, et al. Dermatol Surg. 2013;39(7):1003-1008. Do Orengo IF, et al. J Am Aced Dermatoi. 1997;37(3.pt 1).395-397.

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Stages to Clearance for sBCC Mohs Surgery for sBCC

• Mina = average of 2.6 • Requires more stages to clear margins • Orengo: 54% required ≥ 3 average stages to clearance • Often leaves significantly larger defects

• The average number of stages for clearance for all nonmelanoma skin cancers has been reported to be 1.2 to 1.9.

Duplicate Ratings orCategory Summary

Connolly SM, et al: AAD/ACMS/ASDSA/ASMS 2012 Appropriate Use Criteria for Mohs Micrographic Surgery: Am Acad Dermatol 2012;67:531-50 J Am Acad Dermatol 2012;67:531-50

Distribute Ratings Category Summary This is where we have Not “Forgotten the Curette”

Do J Am Acad Dermatol 2012;67:531-50

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sBCC MAUC Score = 7

Duplicate orAAD Guidelines for BCC •Last published in 1992 •Do not compare treatment options What Do Published Guidelines Say? •Do not prioritize options for various subtypes of Other than MAUC BCC

Drake LA, et al: Guidelines of care for basal cell carcinoma. J Am Acad Dermatol 1992;26:117-120

Distribute NCCN BCC Guidelines 2016 Not

NCCN Basal Cell Carcinoma Version 1.2016: Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2016;14:574-597 Do J Natl Compr Canc Netw 2016;14:574-597

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Canadian Guidelines for BCC European Guidelines - BCC

Zloty D. Non-melanoma Skin Cancer in Canada Chapter 4: Management of Basal Cell Carcinoma Trakatelli M, Morton C, Nagore E, et al: Update of the European guidelines for basal J Cutan Med Surg 2015,19(3):239–248 cell carcinoma management. Eur J Dermatol 2014, 24(3):312-29

Duplicate or SCCis Non-Mucosal

Distribute SCCis SCCis

• Intraepidermal • Low risk • 3-5% risk of progression to SCC • DespiteNot foci of invasive SCC being found in 9.8% to 31%19 of SCCis biopsies • Negligible risk of metastasis Do http://emedicine.medscape.com/article/1960631-overview#a8 Accessed 11/8/2016

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SCCis - Follicular Penetration SCCis - Anatomic Location Risk

• Maximum average thickness – 0.8 mm • Ear & temple are risk factors for SCC recurrence & metastasis. • Many involve the superficial follicle • No studies separately evaluate SCCis • No evidence that ear & temple SCCis are at a higher risk. • 12.5% penetrate to the isthmus and lower follicle • Chuang studied serial sections of first-stage MMS SCCis specimens and found no statistically significant correlation between the presence of SCC and anatomic site.

Christensen SR. J Am Acad Dermatol. 2016;74(2):356-362. Morton CA. Br J Dermatol. 2014;170(2):245-260. NCCN clinical practice guidelines in oncology: squamous cell skin cancer version 1.2016. 2016. Chuang GS, Lu LK, Cummins DL, et al. Incidence of invasive squamous cell carcinomas in biopsy-proven squamous cell carcinomas in situ sent for Mohs micrographic surgery. Dermatol Surg. 2012;38(9):1456-1460.

Duplicate SCCis – Patient Comorbidities or SCCis • NO studies separately evaluate SCCis in patients with skin cancer comorbidities

• Yet, MAUC grade SCCis at any anatomic site in patients with genodermatoses and nearly all lesions in Areas H and M in immunosuppressed patients “appropriate” for MMS.

Distribute Curettage and Electrodessication

• Reports of C&D for SCCis found recurrence rates of 1.9 to 9.6%, with one outlier study reporting 18.8%. TreatmentNot Results for SCCis

Shimizu I, Cruz A, Chang KH, Dufresne RG. Treatment of squamous cell carcinoma in situ: a review. Dermatol Surg. 2011;37(10):1394-1411. Bell HK, Rhodes LE. Bowen's disease--a retrospective review of clinical management. Clin Exp Dermatol. 1999;24(4):338-339. Honeycutt WM, Jansen GT. Treatment of squamous cell carcinoma of the skin. Arch Dermatol. Do 1973;108(5):670-672.

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Curettage and Cryosurgery Curettage and Imiquimod

• Lindemalm-Lundstam and Nordin boh found no 5-year • MacFarlane and Tal treated 31 SCCis with cryosurgery recurrences following treatment of SCCis with C&C. followed by imiquimod with an average follow-up of 43.5 months and found no recurrences.

Lindemalm-Lundstam B, Dalenbäck J. Prospective follow-up after curettage-cryosurgery for scalp and face skin MacFarlane DF, El Tal AK. Cryoimmunotherapy: superficial basal cell cancer and squamous cell carcinoma in situ cancers. Br J Dermatol. 2009;161(3):568-576. treated with liquid nitrogen followed by imiquimod. Arch Dermatol. 2011;147(11):1326-1327.

Nordin P, Stenquist B. Five-year results of curettage-cryosurgery for 100 consecutive auricular non-melanoma skin cancers. J Laryngol Otol. 2002;116(11):893-898.

Duplicate

Mohs Surgery for SCCis Hansen et al • or 4-year retrospective study at one university center • Leibovitch retrospectively evaluated 270 SCCis treated with MMS. • average stages to clearance was 2.0 • 406 SCCis patients (50.7% recurrent tumors) • 5- year recurrence rates were 2.5% for primary and 9.1% for recurrent tumors • Estimated 5-year recurrence rate: • Cryotherapy 13.4% • Hansen and Drake noted a recurrence rate of 6.3% in 83 SCCis treated • 5-FU 9.0 % with MMS, with a mean follow-up of 26.3 months. • Shave excision 9.0 % • MMS 6.5% • Malhotra et al noted an 8.3% recurrence rate in 36 periocular SCCis • C&D 6.3% treated with MMS with a 77.4 months follow-up. • Elliptical excision 5.5%

Hansen JP, et al.: Bowen’s Disease: A Four-Year Retrospective Review of Epidemiology and Treatment at a University Center. Dermatol Surg 2008;34:878–883

Distribute

NotGuidelines for SCC Do

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British Guidelines for Bowen's Disease 2014 Summary

• American, Canadian, British, and "European" guidelines: • MMS is NOT a first line treatment for any low risk head & neck NMSC.

• The MAUC: • MMS is "appropriate" for any low risk head & neck NMSC.

Duplicate or

Distribute Ratings Category Summary Not

Connolly SM, et al: AAD/ACMS/ASDSA/ASMS 2012 Appropriate Use Criteria for Mohs DoMicrographic Surgery: Am Acad Dermatol 2012;67:531-50 J Am Acad Dermatol 2012;67:531-50

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Ratings Category Summary MAUC

• Mohs surgery is “appropriate” for: • ANY SCCis of any size in Areas H and M

J Am Acad Dermatol 2012;67:531-50

Duplicate How Do I Treat SCCis SCCisor Treated with Liquid Nitrogen 1. Ask referring provider if I can treat with C&C, C&D +/- Imiquimod or 5-FU 2. Otherwise - perform “razor blade” Mohs surgery

6-Weeks Post-Op

Distribute Not Do

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Razor Blade Technique

• If SCCis is in follicles – I take a second and subsequent layer

• If margins are clear – heal by secondary intention

Post-Op 6-Weeks Post-Op

Duplicate Indolentor Lesions of Epithelial Origin (IDLE) • The National Cancer Institute recommends that there is a need to address the over-diagnosis and over-treatment of cancers and their precursors which have negligible propensity to invade, disfigure, metastasize or kill. • Each specialty was requested to designate IDLEs • sBCC and SCCis are dermatology’s IDLEs

4-Weeks Post-Op Esserman L et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol. 2014 May; 15(6): e234–e242.

Distribute Conclusions

1. MAUC are NOT guidelines of care of skin cancers. 2. MAUC are permission to use MMS on nearly any Area H or M skin cancer 3. MAUC areNot inappropriate justification to treat IDLEs 4. We must stop using MMS as a primary treatment for: • Most primary superficial BCC (sBCC) • Most primary squamous cell carinoma in-situ (SCCis) Do5. Should adopt algorithmic guidelines of care

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