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Analysis of treatment of basal cell carcinoma: curettage vs curettage and electrodesiccation

<p><span id="docs-internal-guid-33aff1ad-88ae-18e9-5115-25a88a34d259"> </span></p> <p><span><strong>Abstract</strong></span></p> <p><span>Background</span></p> <p><span>Destructive techniques for basal cell carcinoma most frequently include curettage and electrodesiccation, but curettage alone has been studied as well. Curettage alone has the potential advantage of less scarring and therefore better cosmesis, no smoke plume, and less time required to treat.</span></p> <p><span>Objective</span></p> <p><span>Comparison</span><span> </span><span>of</span><span> </span><span>outcome of curettage versus curettage and electrodesiccation for treatment of</span><span> </span><span>basal</span><span> </span><span>cell</span><span> </span><span>carcinoma</span><span>.</span></p> <p><span>Methods</span></p> <p><span>A retrospective review and statistical analysis was performed of studies of patients treated with curettage alone or curettage and electrodesiccation with 5 year follow up.</span></p> <p><span>Result</span><span> </span></p> <p><span>Cure rates for basal cell carcinoma amenable to destructive techniques showed no statistically significant difference for curettage versus curettage and electrodesiccation.</span></p> <p><span>Conclusion</span></p> <p><span>Curettage has similar cure rates to curettage and electrodesiccation for basal cell carcinoma.</span></p> <div></div> <div></div> <div><span><i>*See note at end of the article regarding peer review.</i></span></div>

Abstract

Background

Destructive techniques for basal cell carcinoma most frequently include curettage and electrodesiccation, but curettage alone has been studied as well. Curettage alone has the potential advantage of less scarring and therefore better cosmesis, no smoke plume, and less time required to treat.

Objective

Comparison of outcome of curettage versus curettage and electrodesiccation for treatment of basal cell carcinoma.

Methods

A retrospective review and statistical analysis was performed of studies of patients treated with curettage alone or curettage and electrodesiccation with 5 year follow up.

Result

Cure rates for basal cell carcinoma amenable to destructive techniques showed no statistically significant difference for curettage versus curettage and electrodesiccation.

Conclusion

Curettage has similar cure rates to curettage and electrodesiccation for basal cell carcinoma.

*See note at end of the article regarding peer review.

 

 

Introduction

Basal cell carcinoma (BCC) is the most common skin cancer, and the most common cancer overall. Treatment modalities include curettage (Barlow, McDaniel), curettage and electrodessication (FIlho, Spiller), curettage and another modality (cryosurgery (Piekert), photodynamic therapy (Berrota), immune modulator cream (Zeichner, Rigel, Neville)), excision, Mohs micrographic surgery, and other less common interventions such as cryosurgery alone (Torre).

Standard treatment of uncomplicated basal cell carcinoma in many areas is the destructive technique curettage and electrodesiccation. In general, criteria for clinically suitable BCC skin cancers amenable to destructive modalities include primary tumor, nodular or superficial subtypes, well-demarcated borders, and size less than 6 millimeters in high-risk areas and less than 2 centimeters elsewhere.(Barlow)

As criteria for use of Mohs micrographic surgery is observed (AVC), alternatives such as curettage and excision may be increasingly utilized. Curettage alone versus curettage and electrodessication is an alternative that is 1) less time-consuming 2) cost-effective 3) potentially cosmetically superior due to less scarring 4) does not emit a potentially hazardous smoke plume and 5) has a high cure rate.

Curettage and electrodesiccation (C&E) was first proposed and promoted in the early to mid 1960’s as an effective treatment for small to modest sized skin cancers (keratinocyte carcinomas) in non-critical, appropriately selected cases (Knox, Tromovitch, Sweet). The authors, without evidence, decided that 3 passes would be the standard technique; curettage followed by electrodessication 3 times (hence ED&C x 3). However, there has never been a randomized controlled trial examining the efficacy of C&E versus curettage alone. There have, however, been multiple published studies on recurrence rate following C&E (Table I) (Kopf, Sweet, Tromovitch, Knox, Crissey, Whiting Spiller, Silverman, Reodriguez-Vigil, Chren 1) and curettage alone (Table II) (McDaniel, Reymann, Barlow). Cure rates for each are similar (Table I and II).

Use of electrodessication during the procedure has some disadvantages. Adding electrodesiccation takes additional time compared to curettage alone, since the typical technique involves curettage followed by electrodesiccation three separate times. Electrodesiccation is associated with hypertrophic scarring (Crissey), which can be disfiguring and potentially painful for patients. Electrodessicated wounds tend to hypopigment. (McDaniel)

Smoke plumes from electrodessication are potentially carcinogenic due to the particulate matter and chemicals in the plume. (Lewin) Additionally, there is the potential to be a vector for infectious agents such as human papillomavirus (HPV), which is especially concerning in many cases of squamous cell carcinoma. Standard surgical masks are not protective against fine particulate matter and chemicals in smoke plumes. Smoke evacuators typically do not capture all of the emitted plume, are expensive, and can be cumbersome to operate. (Asgari, Lewin)

There is less cost involved with curettage alone due to lack of need for smoke evacuators, electrosurgical instruments, cautery tips, and a protective instrument sheath.

Curettage alone simply involves thorough curettage until the tumor appears to be clinically eradicated, as described later in the article.

 

Materials and Methods

Study selection

Medical literature from 1962 through 2014 was searched for English language studies of treatment for basal cell carcinoma. Studies that involved destructive methods (curettage or C&E) were reviewed from MEDLINE, PubMed, and Ovid databases. Keywords used alone or in combination include basal cell carcinoma, BCC, curettage, and curettage and electrodessication. The studies were selected according to the following inclusion criteria; histopathologic diagnosis of basal cell carcinoma amenable to destructive modality, sample size greater than 50 cases, and at least 5 year follow up of recurrence rate. The studies were evaluated critically by the author. 13 studies met the above criteria and were included in the meta-analysis.

 

 

Table I. Basal cell carcinoma recurrence rates; curettage and electrodessication

 

Reference

No. of patients

5 year recurrence

% recurrence

Kopf et al

Residents (1955-63)

Residents (1962-73)

Faculty (1962-73)


597

91

210


112

9

12


18.8

9.9

5.7

Sweet (1963)

244

30

12.3

Tromovitch (1965)

75

3

4.0

Knox et al (1967)

315

4

1.3

Crissey (1971)

1400

104

7.4

Whiting (1978)

767

27

3.5

Spiller and Spiller (1984)

233

7

3.0

Silverman et al (1991)

2314

305

13.2

Rodriguez-Vigil et al (2007)

257

3

1.2%

Chren et al (2013)     Univ.

VA

185

113

12

3

6.5

2.7

Total

6801

631

9.3%

Total without residents

6113

490

8.3%

 

 

Table II. Basal cell carcinoma recurrence rates; curettage

Reference

No. of patients

5 year recurrence

% recurrence

McDaniel (1983)

328

28

8.5

Reymann (1985)

397

40

10.1

Barlow et al (2006)

302

12

4.0

Total

1027

80

7.8%

 

Study design

Evidence

Levels of evidence based on grading recommendations assessment, development and evaluation (GRADE) B Moderate; further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Centre for Evidence Based Medicine, Oxford; therapy/prevention/etiology/harm 2b: individual cohort study or low quality randomized controlled trials. Diagnosis; 3a: systematic review (with homogeneity) of 3b and better studies (non-consecutive study; or without consistently applied reference standards). Prognosis; 2b: retrospective cohort study or follow-up of untreated control patients in a randomized controlled trial; or derivation of a clinical decision rule or validated on split-sample only.

 

Statistical analysis

Statistical analysis of C&E versus curettage alone were evaluated by means of the Fisher exact test. 2 by 2 contingency tables were constructed.

 

Results

p-values show no statistically significant difference in recurrence between the two modalities elucidated. (Table III and IV.)

 

Table III. with residents


Recurrence

No recurrence

Total cases

C + E

631

6170

6801

curettage

80

947

1027

Yates chi squared value 0.23

 

Table IV. without residents


Recurrence

No recurrence

Total cases

C + E

510

5603

6113

curettage

80

947

1027

Yates chi squared value 0.86

 

Discussion

As opposed to electrodessication, curettage appears to be the critical portion of the destructive technique for basal cell carcinomas, as evinced by studies that involve only curettage and others that have investigated curettage plus cryosurgery (Peikert), curettage plus immune modulating creams (Neville, Zeichner), and curettage plus photodynamic therapy (Berretta). In all of these studies, curettage is performed, and not electrodesiccation.

As with any manual technique, proper training is essential. Technique of curettage alone involves initial shave biopsy after local anesthesia for histopathologic analysis and subsequent curettage of the base of the wound using a sharp sterilized or disposable 4 to 6 millimeter curette. Curettage is typically performed in different directions to treat the base thoroughly and includes a peripheral margin of 2 millimeters or more. The softer tumor should be curetted away entirely, and a firm collagenous base reached uniformly. The base is visually examined for uniform appearance of the collagen without visible residual tumor. Smaller sized curette may be used if there appear to be foci of BCC interspersed within the normal collagen. The edge of the defect can be feathered, avoiding a sharp drop-off to the resulting dell for improved healing and a better cosmetic result. Subsequent to curettage, 20% aluminum chloride can be used for hemostasis (as opposed to electrodesiccation). Standard wound dressings can be subsequently applied.

A potential advantage of use of electrocautery is that it may increase inflammation in the treated site, which may lead to increased chance of tumor eradication.(Spencer, Nouri) However, this has not been proven, nor does it explain the lack of difference in cure rates between curettage and C&E.  It also does not explain the success of curettage plus another modality other than electrodessication. Another potential reason for maintaining the standard technique of using C&E is that electrodessication is thought to potentially give a margin for error in the case of operator inexperience, such as dermatology residents. However, proper training in through and effective curettage is just as possible as any other surgical technique and should be encouraged.

Comparison of studies of treatment of basal cell carcinoma clinically amenable to curettage alone versus C&E are difficult because many studies have lacked clinical or pathologic correlation. Most authors of prior studies did not specify subtypes or clinical characteristics of the BCC’s treated or simply made brief mention such as  "lesions are not of the morphea type." (McDaniel)

While most of these previous studies did not delineate specific subtypes of basal cell carcinoma, lesions most amenable to the destructive modalities of either curettage or C&E were selected by the authors. In general, criteria for clinically suitable BCC skin cancers amenable to destructive modalities include primary tumor, nodular or superficial subtypes, well-demarcated borders, size less than 6 millimeters in high-risk areas and size less than 2 centimeters elsewhere. Tumors are generally excluded that are recurrent, involve mucous membranes or eyelids, or have morpheaform, micronodular, or infiltrative features. Recurrence rates of aggressive histologic subtypes of basal cell carcinoma following electrodesiccation and curettage may be as high as 27%. (Blixt)

With regression to the mean, across the large number of lesions in these studies, the basal cell carcinomas that were studied are likely similar in each group. Lesions that were amenable to destructive modality were likely treated as such, and included in these studies. Clinically more apparently aggressive or concerning tumors were likely relegated to excision or Mohs micrographic surgery. Further, one study found that while 75 percent of BCC tumors consisted of more than one subtype, subtype analysis of BCC did not predict risk of recurrence. (Barlow) The highest predictor of recurrence was positive deep margin, with greater than 50% deep margin involvement predictive of recurrence. They did not find tumor location, size, or histologic subtype to be predictive of recurrence, which may reflect a small sample size and selection of smaller and less aggressive tumors in high risk areas.

 

Limitations

As noted earlier, there has been no previous prospective randomized controlled trials of curettage alone vs C&E. However, given the large numbers of basal cell carcinomas in the previous studies, a trend towards the mean could be expected and selection for lesions most amenable to destructive modalities by the investigators could be assumed. A limitation of this study is that the subtypes and locations of basal cell carcinoma in previous studies were not rigorously delineated, and therefore direct comparison between studies is imperfect. Ideally, a prospective randomized clinical trial of C&E vs curettage alone will be performed.

 

Conclusion

Curettage alone is an elegant, simple, viable technique for treatment of uncomplicated basal cell carcinomas. Similar cure rates with less disadvantages of electrodesiccation should prompt consideration for treatment using this worthwhile modality.

 

Note regarding peer review.

This article was peer reviewed both by a traditional dermatology journal and by an online dermatology journal. It was rejected!

All constructive comments made by the reviewers were incorporated into this revised article. The main criticism of the article was that a prospective randomized trial of curettage vs. curettage and electrodessication of basal cell carcinomas should be performed. However, until the time that this is done, the above article uses the best available evidence on this subject.

 

References

 

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

McDaniel WE. Therapy for basal cell epitheliomas by curettage only: further study. Arch Dermatol 1983; 119:901-3.

Filho LLL et al. Histological and immunohistochemical evaluation of basal cell carcinoma following curettage and electrodesiccation. Int J Dermatol 2008;47:610-4.

Spiller WF, Spiller RF. Treatment of basal cell epithelioma by curettage and electrodesiccation. J Am Acad Dermatol 1984;11:808-14.

Peikert JM. Prospective trial of curettage and cryosurgery in the management of non- facial, superficial, and minimally invasive basal and squamous cell carcinoma. Int J Dermatol 2011 Sep;50(9):1135-8.

Berroeta L et al. A randomized study of minimal curettage followed by topical photodynamic therapy compared with surgical excision for low-risk nodular basal cell carcinoma. (Letter) British Journal of Dermatology 2007;157:401-2.

Zeichner JA, Patel RV, Birge MB. Treatment of basal cell carcinoma with curettage followed by imiquimod 3.75% cream. J Clinic Aesthet Dermatol 2011 May;4(5):39-43.

Rigel DS, Torres AM, Ely H. Imiquimod 5% cream following curettage without electrodesiccation for basal cell carcinoma: preliminary report. J Drugs Dermatol 2008 Jan;7(1 Suppl1):s15-6.

Neville JA, Williford PM, Jorizzo JL. Pilot study using topical imiquimod 5% cream in the treatment of nodular basal cell carcinoma after initial treatment with curettage. J Drugs Dermatol 2007 Sep;6(9):910-4.

Torre D. Cryosurgery of basal cell carcinoma. J Amer Acad Derm Nov 1986:15(5);917-29.

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Asgari MM et al. Patient satisfaction after treatment of non-melanoma skin cancer. Dermatol Surgery 2009;35:1041-9.

Kopf AW, Bart RS, Schrager D, et al. Curettage-electrodesiccation treatment of basal cell carcinomas. Arch Dermatol 1977;113:439-43.

Sweet RD. The treatment of basal cell carcinoma by curettage. Br J Dermatol 1963; 75:137-48.

Chren MM Linos E, Torres JS et al. Tumor recurrence 5 years after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma. J Invest Dermatol 2013;133;1188-96.

Chen MM et al.  Patient-reported outcomes of electrodessication and curettage for treatment of non-melanoma skin cancer (Letter).  J Am Acad Dermatol 2014; 71(5):1026-7.

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Knox JM, Freeman RG, Duncan WC et al. Treatment of skin cancer. South Med J 1967;60;241-6.

Crissey JT. Curettage and electrodesiccation as a method of treatment for epitheliomas of the skin. J Surg Oncol 1971;3:287-90.

Whiting DA. Skin tumors in white South Africans, part IV: influence of occupation, sun sensitivity, coloring, and associated skin tumors on the incidence of skin tumors. S Afr Med J 1978;53:162-6.

Silverman MK, Kopf AW, Grin CM, Bart RS, Levenstein MJ. Recurrence rates of treated basal cell carcinomas, part 2:curettage-electrodessication. J Am Acad Dermatol 1984;11:808-14.

Rodriguez-Vigil T et al. Recurrence rates of primary basal cell carcinoma in facial risk areas treated with curettage and electrodesiccation. J Am Acad Dermatol 2007;56:91-5.

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