Treatment

Primary aim of treatment is complete removal or destruction of the BCC lesion to result in cure and minimise the risk of recurrence:

• BCCs are usually slow-growing tumours that only very rarely metastasize (spread) to other distant parts of the body (0.0028% to 0.55% of advanced BCCs metastasize (1)
• should also be balanced against the patient's requirement for a good/acceptable cosmetic result (2)
• choice of intervention is determined by tumour factors such as the histological/clinical subtype of BCC, site, size, whether primary or recurrent tumour, as well as patient factors (e.g. comorbidities, importance of cosmesis) and other factors such as available resources
• interventions are split into surgical and non-surgical interventions include:
  • generally, surgical interventions are used as firstline treatments for both high-risk and low-risk BCC subtypes and non-surgical interventions are usually reserved for low-risk BCC subtypes where histological margins are less important (2)
    
    
  • radiotherapy and electrochemotherapy are the exceptions - tend to be used for high-risk BCCs not amenable to surgical intervention
    
    
  • surgical interventions:
    
    • surgical excision (with predetermined margins)
    • surgical excision (with frozen section margin control)
    • Mohs micrographic surgery (MMS - takes serial horizontal frozen sections intraoperatively to examine histologically the entire surgical margin to confirm complete tumour clearance)
    • curettage and cautery
    • cryosurgery (synonymous for cryotherapy, delivered by a variety of methods)
    • laser therapy (ablative lasers, pulsed dye laser)
  • non-surgical (medical) interventions
    • radiotherapy
    • topical imiquimod
    • topical 5-fluorouracil
    • photodynamic therapy
    • ingenol mebutate
    • intralesional interferon, fluorouracil
    • electrochemotherapy
    • others (solasodine glycosides, sinecatechins, diclofenac, calcitriol)

A systematic review concluded (3):

• Surgical interventions have the lowest recurrence rates, and there may be slightly fewer recurrences with MMS over SE for high-risk facial primary BCC (low-certainty evidence). Non-surgical treatments, when used for low-risk BCC, are less effective than surgical treatments, but recurrence rates are acceptable and cosmetic outcomes are probably superior. Of the non-surgical treatments, imiquimod has the bestevidence to support its efficacy.

Reference:

• Ting PT et al. Metastatic basal cell carcinoma: report of two cases and literature review. Journal of Cutaneous Medicine and Surgery 2005;9(1):10-5.
• Madan V, Lear JT. Basal cell carcinoma. In: Rook's Textbook of Dermatology, Ninth Edition. John Wiley & Sons, Ltd, 2016.
• Thomson J et al. Interventions for basal cell carcinoma of the skin. Cochrane Database of Systematic Reviews 2020, Issue 11. Art. No.: CD003412. DOI: 10.1002/14651858.CD003412.pub3.