What are the treatment options for Basal cell carcinoma (BCC) or Benign Esophageal Ring (BER)?

Treatment Options for Basal Cell Carcinoma (BCC)

For basal cell carcinoma (BCC), surgical treatment is the most effective approach for optimal outcomes in terms of mortality, morbidity, and quality of life. 1

Surgical Treatment Options for BCC

Primary Surgical Approaches

• Mohs Micrographic Surgery (MMS): Preferred for high-risk BCCs or those in cosmetically sensitive areas
• Standard Surgical Excision: Effective for well-defined, low-risk BCCs
• Curettage and Electrodesiccation (C&E): For small, low-risk, superficial BCCs on non-hair-bearing areas

Patient Selection for Surgical Approaches

• MMS is indicated for:

  • Recurrent BCCs
  • Poorly defined tumors
  • Sclerosing/morpheaform BCCs
  • BCCs in areas with high recurrence risk (e.g., face)
  • Large tumors

• C&E considerations:

  • Avoid in terminal hair-bearing areas (scalp, pubic, axillary regions, beard area)
  • Less effective due to potential follicular extension
  • May have longer healing time and inferior cosmetic outcome compared to excision
  • Best for trunk and extremities in low-risk cases 1

Non-Surgical Treatment Options

When surgical therapy is not feasible or preferred, the following options can be considered for low-risk BCCs:

Topical Therapy

• Imiquimod: FDA-approved for superficial BCC

  • Indicated for biopsy-confirmed primary superficial BCC in immunocompetent adults
  • Maximum tumor diameter of 2.0 cm
  • Located on trunk, neck, or extremities (excluding hands, feet, and anogenital skin)
  • Application schedule: 5 times per week for 6 weeks
  • Clinical clearance rates: 75% composite clearance at 12 weeks post-treatment
  • Long-term follow-up shows 79% remained clinically clear at 24 months 2

• 5-Fluorouracil (5-FU): Alternative topical option for superficial BCC 1

Other Non-Surgical Options

• Cryosurgery: Consider only when more effective therapies are contraindicated

  • Recurrence rates range from 6.3% at 1 year to 39% after 2 years 1

• Photodynamic Therapy (PDT):

  • Options include aminolevulinic acid (ALA) or methylaminolevulinate (MAL)
  • Can be considered for low-risk tumors 1

• Radiation Therapy:

  • Traditional radiotherapies and modern superficial radiation therapy
  • Option for patients who cannot undergo surgery 1

Treatment Algorithm for BCC

1. Assess tumor risk factors:

   • Location (high-risk areas: face, especially around eyes, nose, lips)
   • Size (larger tumors have higher risk)
   • Borders (poorly defined borders indicate higher risk)
   • Previous treatment (recurrent tumors have higher risk)
   • Histological subtype (morpheaform, infiltrative, micronodular are higher risk)

2. For low-risk BCC:

   • First choice: Standard excision or C&E
   • If surgery contraindicated: Consider imiquimod (for superficial BCC), cryosurgery, or PDT

3. For high-risk BCC:

   • First choice: Mohs micrographic surgery
   • If MMS unavailable: Wide local excision with margin assessment
   • If surgery contraindicated: Consider radiation therapy

Important Considerations and Pitfalls

• Histologic confirmation: Always obtain biopsy confirmation before treatment, especially for non-surgical approaches
• Follow-up: Regular follow-up is essential, particularly after non-surgical treatments
  • For imiquimod-treated sBCC, regular follow-up is needed to re-evaluate the treatment site 2
• Immunosuppressed patients: Safety and efficacy of non-surgical treatments not established
• Special populations: Efficacy and safety not established for patients with Basal Cell Nevus Syndrome or Xeroderma Pigmentosum 2
• Cosmetic outcomes: Consider location when selecting treatment modality, as some methods may result in inferior cosmetic results
• Treatment limitations: Non-surgical approaches generally have lower cure rates than surgical options 1

Remember that while non-surgical options exist, surgical treatment remains the gold standard for BCC treatment with the highest cure rates and best outcomes for mortality and morbidity.