Canad. Med. Ass. .* Mrrci.u. AND HAIWIE: BASAL CELL CARcINoMA 349 Aug. 21, 1965, vol. 93 Treatment of Basal Cell Carcinoma by Curettage and Electrosurgery J. C. MITCHELL, M.D., M.R.C.P.(Lond.), F.R.C.P.[C] and MARGARET HARDIE, M.D., Vancouver, B.C.

ABSTRACT SOMMAIRE One hundred and forty-eight basal cell Cent quarante-huit cas d'.pith6lioma baso- carcinomas were treated by curettage and cellulaire ont 6t. trait.s par curetage et electrosurgery. Twenty-six recurrent carci- 6lectrochirurgie. Sur 26 r6cidives canc&- nomas were treated and 24 did not recur reuses trait6es, 24 n'ont pas eu de r6cidive during a minimum two-year follow-up. pendant une p6riode minimum de deux Seventy-two newly diagnosed carcinomas ann6es de post-observation. Soixante-douze were treated by the same method, and a cas de cancer nouveliement diagnostiqu6s two-year recurrence-free rate of 97.4% was ont 6t6 trait.s par la m.me m6thode et obtained. About 50 new and recurrent n'ont pas eu de r6cidive pendant deux ans lesions were treated in three patients in juqu'.l concurrence de 97.4%. Environ 50 whom extensive cutaneous changes from l6sions de fraiche date ou recidivantes ont actinic atrophy and previous therapy made 6t6 trait6es chez trois malades: des modifica- the distinction between new and recurrent tions cutan6es 6tendues par atrophie d'ori- lesions difficult or impossible. This tech- gine actinique et des traitements ant6rieurs nique has a particular place in the manage- rendaient impossible ou du moms difficile ment of multiple lesions. Patient accept- toute distinction entre de nouvelles l6sions ance is good. Lesions at some sites, e.g. on et des l6sions r6cidivantes. Cette technique the nose, where closure of a wound is diffi- est particuli.rement utile pour traiter des cult, are better managed by this method l6sions multiples. Le malade accepte volon- than by surgical excision. Secondary infec- tiers le traitement. Les l6sions si6geant en tion is rare and the cosmetic results are certains endroits, par exemple au nez excellent. la fermeture d'une plaie est malais6e, peu- vent .tre mieux trait.es par cette m6thode que par excision chirurgicale. L'infection secondaire est rare et les t6sultats sur le plan esth.tique sont excellents. Canad. Med. Ass. 3. 350 MITCHELL AND HABDIE: BASAL CELL CARCINOM Aug. 21, 1965. vol. 93 the results are consistently gratifying. The prefer- follow-up period and two of these were successfully able size of a lesion to be removed by this method retreated by the same method. is considered to be up to 1 cm. in diameter. Knox There was no recurrence of these two lesions et al.7 reported a composite 98% cure rate in the after a further two-year follow-up. treatment of 765 basal and squamous cell car- cinomas and noted that, in general, lesions treated Curettage and electrosurgery was carried out in by this method should be small, that is, up to 2 26 selected cases of recurrent basal cell carcinoma cm. in diameter. Williamson and Jackson,8 discus- (Tables 1-VI). The original lesions, all biopsy- sing the results of therapy and the advantages and proven, were of the following clinical types: nodu- disadvantages of electrodesiccation and curettage, reported a cure rate of 97.4% when these proce- TABLE 1.-RESULTS OF TREATMENT OF RECURRENT LESIONS dures were performed by an operator experienced wITH CURETTAGE AND ELECTROSURGERY (1957-1961) in the technique. As a general rule, lesions up to Recurred afterCured 2.5 cm. in diameter were considered suitable for Number of curettage and (24 months this procedure. In a series of 593 lesions treated lesions Previous treatment electrosurgery or longer) by curettage and electrosurgery, Sweet9 obtained 26 2 '24 a cure rate of 90%. 'Following retreatment of Radium.2 his recurrences by curettage and electrosurgery, X-radiation.19 95.1% were cured. Excision.1 X-radiation and Knox et al.7 noted that in areas where the re- excision.2 currence rate was high, such as the inner canthus Curettage and of the eye, the area adjacent to the external electrosurgery.... 2 auditory canal, the nasolabial fold, and the oral commissure, only the most experienced operator lar, eight cases; ulcero-nodular, five cases; probable would obtain maximum results with this or any multicentric superficial, two cases; unclassified, nine other method. cases. The treatment which had previously been Pillsbury, Shelley and Kligman1 recommended used is listed in Table I. X-racliation had been used that recurrences of basal cell carcinomas should not for 19 of the 26 basal cell carcinomas and other be treated by electrocoagulation but in such methods for seven. Following treatment of the lesions the extent of the tumour invasion should recurrent carcinomas, 24 did not recur during a be defined as precisely as possible 'by adequate minimum length of follow-up of two years. Eleven excision. Knox et al.7 stated that scar tissue made were followed up for over two years, nine for over curetting difficult, if not impossible, and the three years, three for over four years and one for curetting of fibrotic lesions, or lesions which had over five years (Table II). It is evident from recurred following excision or irradiation, increased the risk of further recurrence. According to TABLE II.-LENG¶ru OF FOLLOW-UP. OF PATIENTS WITH 24 Williamson and Jackson,8 small peripheral recur- LESIONS WHICH DID NOT RECUR AFTER CURETTAGE AND rences following plastic surgery can be treated ELECTROSURGERY very satisfactorily by their technique of electro- No. of years 2-3 3-4 4-5 5-6 desiccation and curettage. In the selection of 9 3 1 suitable cases, the size of the lesion and its location No. of cases.11 should be considered. Sweet9 reported that 13 of the lesions that he Table III that a two-year follow-up, to establish a treated were recurrences after other forms of treat- "two-year recurrence-free rate", is by no means ade- by quate in this group of cases. The lapse of time ment. Nine of the 13 recurrences reported between previous treatment and recurrence (Table Knox et al.7 followed curettage and electrosurgery III) shows that only 10 out of the 26 recurrences and were retreated by the same method.

This communication reports the results of treat- TABLE 111.-LAPSE OF TIME BETWEEN PREVIOUS TREATMENT AND ment of 148 basal cell carcinomas and analyses RECURRENCE the results of treatment of 26 recurrent lesions. All Year8 0-1 1-5 5-3 3-4 4-5 5-6 6-7 7-5 15 14 lesions were examined histopathologically. No.ofcases. 4 6 2 1 3 5 2 1 1 1

RESULTS occurred during the first two years after initial During the period 1957-61, 72 newly diagnosed treatment. Recurrences were noted at the treated biopsy-proven basal cell carcinomas were treated sites after a two-year period in 16 of 26 instances, by curettage 'and electrosurgery. They were of the and as long as 14 years after treatment in one nodular and ulcero-nodular types. Morphea-type instance. It seems likely that, in this group of cases, lesions were not treated by this method. There further recurrences can be expected more than two were four recurrences during a minimum two-year years after treatment of recurrent lesions. Canad. Med. Ass. J. Aug. 21,1965, vol. 93 Mitchell and Hardie: Basal Cell Carcinoma 351

The two lesions which recurred following electro- Special Cases of Skin Cancer surgery were on the temple and at the inner With Multiple Lesions canthus and were recognized after six-month These cases are listed separately because it was and four-month follow-up periods, respectively. considered difficult or impossible to list each new Sixteen of the 26 recurrences were at the edge of carcinoma in the new or in the recurrent group. the treatment site and eight were in the treatment The carcinomas were at sites where severe con¬ site (Table IV). In two cases, the exact relationship fluent cutaneous changes from actinic atrophy were indistinguishable from the cutaneous changes from previous radiotherapy. TABLE IV..Site of Recurrence in Relation to Previous Treatment Site Case 1..An 87-year-old white woman was first A. 26 carcinomas In treatment site. 8 observed to have skin cancer in 1936 when 66 years At edge of treatment site. 16 of age. In 1938, 1942, 1944 and 1948, carcinomas Uncertain. 2 were treated by radium therapy and by x-radiation. B. 19 carcinomas pre- In treatment site. 6 During the period 1957-1960, one intraepithelial car¬ viously treated by At edge of treatment site. 11 cinoma and 12 basal cell carcinomas on the face were x-radiation Uncertain. 2 treated by curettage and electrosurgery. Case 2..A white man, 65 years of age, had multi¬ of recurrence to treatment site was difficult to de- centric superficial basal cell carcinomas of the lower termine, but the recurrence was probably at the posterior trunk. There was no history of ingestion of edge. The difficulty in establishing this relationship arsenic. In view of the confluent nature of the disease, it was not possible to identify and list the lesions arose from the fact that radiodermatitis merged basal cell carcinomas with severe actinic It is more difficult to numerically. Many superficial atrophy. and one pre-malignant fibroepithelial polyp at and classify recurrences clinically than is the case with around sites of previous x-radiation and at new sites new basal cell carcinomas. The recurrences were were treated by curettage and electrosurgery. nodular or ulcero-nodular. In some cases, recur¬ rences were probably multicentric. Case 3..A 64-year-old white man, with a long history of skin cancer, developed one squamous cell Recurrence at the edge of the treated sites in carcinoma and 30 basal cell carcinomas on the face 11 of the 19 cases previously treated by x-radiation and neck during the period 1957-1963. These car¬ (Table IV) suggests the possibility of a "geo- cinomas were treated by curettage and electrosurgery. graphic miss"; that is to say, the treatment field based on the estimated size of the lesion was not The same difficulty in assessing results of treat¬ adequate. ment was encountered as has been noted above. These cases are not listed The of the with recurrent car¬ by two-year follow-up majority patients because it was difficult to decide whether car¬ cinomas were in the older age groups. Table V the shows the incidence decade. cinomas, as they appeared during follow-up age by period, were new or recurrent. During the course of the follow-up period, new lesions continued to some recurrences occurred too but TABLE V..Age of Patients Treated appear. Probably (24 patients with 26 recurrent carcinomas) clinically the disease was considered to be con¬ 40-49 50-59 60-69 70-79 80-89 trolled. Discussion Pillsbury, Shelley and Kligman1 used the term The sites of recurrences which were treated "electrocoagulation" to designate their method of by curettage and electrosurgery are listed in bipolar coagulation. The cutting current and Table VI. All were on the face. Three special cautery have been used by others. Since the cases with multiple lesions are considered separ- results described in this cxraimunication were ately. obtained by the unipolar method, using the Birchner Hyfrecator, the broader term, electro¬ has been in this The TABLE VI..Sites of Recurrent Lesions surgery, adopted report. terms "curettage" and <'electrodesiccation,, are used Temple. 6 in an order which is the reverse of that Cheek. 4- employed Williamson and because we believe Tip of nose. 3 by Jackson8 Bridge of nose. 2 that adequate curettage is the primary part of the Ala nasi. 3 treatment, and removes the bulk of the tumour; Nasolabial fold. 3 has a role in the oblitera- Forehead. 2 electrosurgery secondary Upper lip, eyebrow, inner canthus. 1 tion of marginal pockets of tumour and in each hemostasis. 352 MITcHELL AND HAJiDIE: BASAL CELL CARCINOMA Aug.Canad.21,Med.1965,Ass.vol.J.93

When this method is introduced into a Cancer surgery. Many of the lesions were at or adjacent Institute where it has not been employed pre- to sites of radiodermatitis and further x-radiation viously, it may be used as a last resort for the treat- was contraindicated. In these patients it was diffi- ment of difficult recurrences, before embarking on cult to be sure whether new or recurrent lesions mutilating operations involving extensive excision were occurring because of extensive and confluent and grafting, especially in elderly patients. Some cutaneous changes from actinic atrophy or x-ray of the cases in this series fall into this category, therapy. particularly those with recurrences on and around The cosmetic results were excellent. Since con- the nose. Curettage was undertaken on areas of traction of the wound occurs during and after skin extensively affected by actinic atrophy and electrodesiccation, healing usually results in a de- radiodermatitis, and the margins of the tumour fect considerably smaller than the original carci- were practically impossible to delineate through noma. the "feel" of the curette. The recurrence rate in The immediate result of treatment is the inflic- such difficult cases is likely to be high and it is tion of a third-degree burn covered by a sterile probable, as suggested by the data in Table III, eschar. Secondary infection is rare, and in the that a longer follow-up will reveal a higher recur- great majority of cases the sterile eschar remains rence rate. However, 15 of the 24 patients with in place while re-epithelialization proceeds be- recurrent carcinomas were over 70 years of age neath. and seven were over 80 years. In this age group a less radical form of treatment is preferable to Curettage and electrosurgery is an effective extensive surgery and grafting. Some of the pa- method of treating newly diagnosed basal cell tients were undoubtedly saved from amputation of carcinomas; the results described in this communi- the nose and the wearing of a prosthesis. The great cation also demonstrate that the method is effective advantage of curettage and electrosurgery is that in treatment of recurrent basal cell carcinoma and the treated skin is relatively undamaged and has a special place in management of recurrences further recurrences may be successfully managed in elderly patients. All available methods of treat- by the same method while the aged patient lives ment of basal cell carcinoma must be evaluated in out his remaining years. The same advantage also any individual case. pertains in the treatment of new lesions because any subsequent recurrences are surrounded by SUMMARY relatively normal skin. One hundred and forty-eight basal cell carcinomas Nearly all of the patients in this series with were treated by curettage and electrosurgery. Twenty- recurrent disease who had other forms of treat- six recurrent carcinomas were treated ttnd 24 did not ment expressed a desire for curettage and electro- recur during a minimum two-year follow-up. Seventy- ex- two newly diagnosed carcinomas were treated by the surgery if further treatment was required. In same method and a two-year recurrence-free rate of planation of this preference they mentioned such 97.4% wa's obtained. About 50 new and recurrent lesions points as fewer therapy visits required in this treat- were treated in three patients in whom extensive ment regimen, the fact that it involved no hospital- cutaneous changes from actinic atrophy and previous ization, and the fact that it entailed less discomfort therapy made the distinction between new and re- than other methods of treatment. A notable excep- current lesions difficult or impossible; this technique lion to this pattern of patient acceptance was found has a particular place in the management of multiple in an individual with multicentric superficial basal lesions. Patient acceptance of the technique is good cell carcinomas of the trunk in whom healing of because it requires fewer visits than fractionated x-ray some treated sites was not complete for up to two therapy, discomfort at the time of operation and during healing is slight, and admission to hospital is months. rarely required. Healing is usually advanced or com- In newly diagnosed cases the 'method is of par- plete at a time when a radiation reaction would be ticular value at sites where closure of a surgical at its height. Lesions at some sites, e.g. on the nose, wound is difficult, e.g. on and around the nose, and where closure of a wound is difficult, are better man- in areas of severe actinic atrophy. On the face, aged by this method than by surgical excision. healing is advanced or complete at a time when a Secondary infection is rare and the cosmetic results are radiation reaction would be at its height. Treated excellent. sites on the sebaceous areas of the face heal more the REFERENCES quickly than sites on the trunk and dorsa of 1. PILLSBURY, D. M., SHELLEY, W. B. AND KLIGMAN, A. M.: hands. Surgical excision is usually preferable at Dermatology, W. B. Saunders Company, Philadelphia, 1956, p. 1145. the latter sites except in the case of large super- 2. OSBORNE, E. D.: J. A. M. A., 154: 1, 1954. ficial lesions. 3. LAMB, J. H.: Ibid., 153: 1509, 1953. 4. CIPOLLARO, A. C.: Arch. Phys. Med., 34: 621, 1953. The method has a special place in management 5. Idem: In discussion: New York J. Med., 57: 1578, 1956. as those which occurred 6. EPSTEIN, E.: Skin surgery, Lea & Febiger, Philadelphia, of numerous lesions such 1956, p. 157. in the three special cases described above. Approx- 7. KNox, J. M. et al.: A.M.A. Arch. Derm., 82: 197, 1960. in 8. WILLIAMSON, G. S. AND JACKSON, R.: Canad. Med. Ass. imately 50 basal cell carcinomas were removed J., 86:855, 1962. these three patients by curettage and electro- 9. SWEET, R. D.: Brit. ,T. Derm., 75: 137, 1963.