Treatment.

As stated previously there are many factors that infl uence the treatment of BCC, these include: tumour characteristics; patient characteristics; experience of the clinician; and local facilities. In the case of BCC the factors that infl uence prognosis are shown in Ta le !".# and should e considered when choosing treatment options. The aim of any therapy selected for BCC is to ensure complete removal or destruction of the primary tumour to prevent local recurrence and the need for further therapeutic intervention whilst exposing the patient to the least ris$ of complications and producing an accepta le cosmetic result. The wide range in natural history and iology of the different su types of BCC and the large num er of treatment modalities availa le for the removal and destruction of s$in tumours means it is diffi cult to draw up rigid guidelines for the management of this common cancer. %uccessful management of BCC re&uires a clear understanding of the clinicopathological factors that affect prognosis and a good theoretical and practical $nowledge of the strengths and limitations of the many different treatments availa le. 'rom pu lished series on outcomes it is clear that successful treatment can e achieved y any one of the large range of therapies, su (ect to appropriate matching of the treatment to the tumour characteristics )*+,*,-. In most cases, treatment selection is usually ased on a clinical assessment which considers a num er of factors that are $nown to infl uence tumour prognosis. These factors include tumour si.e, location, clinical su type and defi ned margin. In addition to the tumour characteristics, other factors such as the patient/s age, ade&uacy and success of previous treatments and coexisting medical conditions that infl uence tumour iology or treatment tolera ility need to e considered. 'or reasons that are still unclear, BCCs recurring following radiotherapy are particularly diffi cult to eradicate y conventional surgical excision and this needs to appropriate therapy)*0-. 1estructive therapies used appropriately, mainly for low2ris$ tumours, can offer an effective alternative to surgical excision for small primary tumours at non2critical sites. A num er of studies have shown that curettage and cautery of low2ris$ BCCs can give cure rates of up to 3,4 )*3-. %imilar high cure rates have also een reported for cryotherapy for low2ris$ BCCs )!5,!#-. Tumour si.e has an important effect on prognosis for BCCs and there is good evidence that the recurrence rate following curettage and cautery or cryotherapy increases signifi cantly with increasing si.e )!",!6-. In addition to ris$ of recurrence, it is also important to ear in mind that the mor idity associated with cryotherapy also increases with increasing si.e. eta$en into account when selecting the most

Conventional surgical excision with predetermined margins

ased on the clinical

characteristics of the tumour is regarded y many as the most appropriate therapy for most nodular BCCs and provides a specimen for histological examination and assessment of the lateral and deep margins yielding 7"4 recurrence rate at ! years post surgery )!*,!!-. %tudies of 8ohs surgical specimens have provided useful information a out the pro a ility of achieving complete excision in tumours with predetermined margins in different si.ed BCCs. 'or BCCs less than " cm in diameter with well2defined clinical margins, a 62mm margin will clear the tumour in 0!4 of cases and a *9!2mm margin in 3!4 of cases )!+9!0-. Although it has een estimated that careful inspection of the common nodular and pla&ue forms of the tumour with a loupe allows the margin to e determined to within 5.! mm of the histologically proven order, inaccuracies in the clinical assessment of tumour margins are an important cause of incomplete excision of nodular BCCs. %mall ulcerated nodular BCCs, which present as non2healing erosions, not infre&uently extend several millimetres eyond the clinically defi ned margin. 'or these tumours and others where the margin is less clearly defi ned, curettage prior toexcision is a useful techni&ue for more accurately defi ning the true orders of the BCC )!3,+5-. :ven in experienced hands there is a ris$ that nodular BCCs with apparently well2defi ned clinical margins may have infi ltrated more extensively, leading to incomplete excision with residual tumour. In some cases, strands of cells extend along nerves for a considera le distance eyond the o vious clinical edge of the tumour )+#,+"-. The outloo$ is poor when cartilage, one or the or it have een invaded. %tudies of incompletely excised BCCs have demonstrated that not all incompletely excised tumours will recur ut that etween "# and *#4 will do so over a " to ! year period )+69+,-. Based on information generated over the years on residual tumour in reexcision specimens and recurrence rates of incompletely excised tumours, it may e reasona le in cases where there is incomplete excision of the lateral margin only, not to re2excise if the BCC is a primary tumour on a non2critical site with a non2aggressive histology. 'or all other cases and in those where the surgical defect has een repaired using a s$in graft or local fl aps, immediate reexcision with fro.en section control or using 8ohs micrographic surgery is the treatment of choice )*,-. The management of morphoeic BCC, large BCCs ;more than " cm in diameter<, some smaller nodular BCCs with poorly defined clinical margins and recurrent BCCs needs to ta$e into account the increased li$elihood of su clinical extension. In the a sence of either fro.en section control or 8ohs surgery, these tumours will re&uire large predetermined margins; even a !2mm margin will only give complete excision of 0"4 of morphoeic BCCs )!+-. 8anagement of recurrent BCCs is a diffi

cult pro lem as cure rates areconsistently poorer than those achieved for primary tumour. 8ohs surgery is an important treatment option for the treatment of high2ris$ BCCs as it offers consistent high cure rates for even the most diffi cult BCCs. 'or primary BCCs and recurrent BCCs, treated with 8ohs surgery, !2year cure rates of 30.+4 and 3+4 respectively have een reported )+0-. The proportion of BCCs treated using 8ohs surgery varies considera ly etween different countries as it is a relatively speciali.ed techni&ue and is more resource2 intensive than simple surgical excision. Tumour characteristics that warrant consideration of 8ohs surgery include BCCs at high2ris$ sites ;nasola ial fold, periocular and nose<, BCCs greater than " cm in diameter, morphoeic, infi ltrative or micronodular BCCs and recurrent BCCs )*+,*,-.