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Standard Treatment of BCC

1. Local anaesthetic surgery with predetermined margins – also known as wide local excision (WLE)
2. Mohs micrographic surgery
3. Cryotherapy
4. Imiquimod
5. Curettage and cautery
6. Photodynamic therapy
7. Radiotherapy

Surgical Excision = Wide local excision = WLE

This is highly effective for BCC. For well defined BCC <2cm, excision margins of 4mm will result in a 95% clearance rate. BCC >2 cm may require wider margins to effect clearance. Recurrent BCC require wider excisional surgery or Mohs micrographic surgery.

Excision of a BCC under local anaesthetic with 4mm margins or more is a standard treatment. The procedure takes 30-60 minutes depending on the complexity of the cancer but is usually straightforward. Stitches are usually in place for 5-7 days.

Pre-op

       
BCC   Classic nodular bcc with telangiectases   nBCC ready for excsion with 4mm margin    

Post-op

       
Immediately post-op   Close up post-op   Scar 2-3 months post-op    

Mohs micrographic surgery

Mohs micrographic surgery is the gold standard but is not necessary for the vast majority of BCC. It is a specialised form of surgery usually reserved for cancers that have recurred or where tissue sparing is advantageous or for high risk BCC or where re-excision of an incompletely excised BCC would be a major problem – eg eyelid. It is the treatment of choice for certain rarer cancers such as dermatofibrosarcoma protruberans.

Mohs micrographic surgery (MMS) is a much more precise method of excising a tumour than excisional surgery with a pre-determined margin = wide local excision = WLE. The tumour is excised, divided and stained. Examination of horizontal sections examines 100% of the excised tumour margin. However MMS is time consuming, costly and requires specialist expertise. (see link to SKCIN Trustee Richard Clifford having Mohs micrographic surgery of his cheek BCC)

Curettage and cautery

This technique is best reserved for small, well-defined BCC on low risk sites.

Cryotherapy

This is a quick, easy, inexpensive and effective treatment which can result in excellent cosmesis. In reality cryotherapy is not used much for skin cancers except in selected circumstances. Depending on the patient, lesion and operator experience, high cure rates can be gained.

Radiotherapy

A useful treatment for BCC or patients not suitable for surgery. Radiotherapy is an excellent option for certain skin cancers. In skilled hands, it offers high cure rates with sometimes excellent outcomes

Photodynamic therapy (PDT)

PDT involves the application of a photosensitising prodrug to the skin cancer. After soaking into the cancer for 4-6 hours, this gets converted to a photosensitser. Activated by an appropriate light source produces a local reaction killing off the cancer. Currently PDT for BCC is reserved for BCC unsuitable for treatment by other methods or where the cosmetic outcome may be considered more favourable to surgery. Good cure rates with excellent cosmetic results can be gained for selected BCC.

Imiquimod

(Aldara) is a cream that is licensed for the treatment of superficial BCC. This cream is useful for low-risk BCC in non-critical sites. Applied 5x/week for 6 weeks, it evokes an inflammatory reaction. The inflammatory response destroys the lesion. Considerable soreness can occur. Assessment of response takes place after a further 12 weeks. For selected BCC, this is a good option with good cure rates but long term follow up data is sparse.

 
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