From the Guidelines
Surgical excision is the preferred treatment for basal cell carcinoma (BCC) due to its lower recurrence rates and ability to provide histological confirmation of complete tumor removal, especially for higher-risk lesions. Excision involves surgically removing the tumor with a margin of healthy tissue (typically 3-4 mm for well-defined primary BCCs), followed by histological examination to confirm complete removal 1. This approach offers several advantages, including lower recurrence rates (typically 2-8%) and the ability to confirm complete tumor removal. In contrast, cryotherapy, which involves freezing the tumor with liquid nitrogen using a double freeze-thaw cycle, may be appropriate for select low-risk, superficial, or small nodular BCCs in non-critical anatomical sites, particularly in elderly or frail patients. However, cryotherapy has higher recurrence rates (up to 39% after 2 years of follow-up) and doesn't provide histological confirmation of complete removal 1.
Some key considerations when choosing between excision and cryotherapy for BCC include:
- Tumor characteristics (size, location, subtype)
- Patient factors (age, comorbidities)
- Cosmetic outcomes
- Provider expertise For high-risk BCCs (large size, aggressive histology, recurrent tumors, or those in high-risk locations like the face), Mohs micrographic surgery, which offers the highest cure rates with maximal tissue preservation, is often the preferred approach 1.
The guidelines of care for the management of basal cell carcinoma recommend a treatment plan that considers recurrence rate, preservation of function, patient expectations, and potential adverse effects 1. Surgical excision with 4-mm clinical margins and histologic margin assessment is recommended for low-risk primary BCC, and Mohs micrographic surgery is recommended for high-risk BCC 1. Cryosurgery should be considered only under select clinical circumstances, and when more effective therapies are contraindicated or impractical 1.
From the Research
Excision vs Cryotherapy for Basal Cell Carcinoma
- Excision and cryotherapy are two common treatment modalities for basal cell carcinoma (BCC) [(2,3)].
- Surgical excision remains the standard of treatment, with Mohs micrographic surgery typically utilized for high-risk lesions [(2,4)].
- Cryotherapy, on the other hand, is a suitable alternate treatment option for appropriately selected primary low-risk lesions [(2,3)].
Efficacy Comparison
- A randomized controlled trial comparing curettage plus cryosurgery (C&C) and surgical excision (SE) found that recurrences occurred 9 times after C&C (17.6%) and 4 times after SE (8.2%) 3.
- The overall 5-year recurrence probability was 19.6% for C&C and 8.4% for SE, indicating a putative advantage of SE 3.
- Another study suggested that surgical margins of 4mm seem to be suitable for small, primary, well-defined basal cell carcinomas [(4,5)].
Factors Influencing Treatment Choice
- Tumor-specific factors, including histopathologic subtype, as well as postoperative outcome, should be considered in treatment planning [(6,5)].
- The site and size of the lesion, previous treatment, and histological subtype should also be taken into account when choosing a treatment modality [(6,5)].
- For high-risk and recurrent tumors, margins of 5-6 mm or margin control of the surgical excision is required [(4,5)].