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Document Sample
Presented by
Robert S. Stern, M.D.
at the
September 10, 2003
meeting of the
Dermatologic and Ophthalmic
Drugs Advisory Committee
Recurrence Rates in Primary
Basal Cell Carcinoma According to
Treatment Modality
Jean C. Lee, Harvard Medical Student
Treatment Modalities for
Basal Cell Carcinoma
• Surgical Excision Usually reserved for
small (<2cm), well-
Reserved for high risk tumors,
defined tumors on low
• Cryosurgery Usually
including: reserved for
risk areas, 1 cm on
tumors < performed of
Size 5-10mm in H zone
with 4-5 mm margins
cosmetically less of face,
face, >10 mm on restsensitive
• Curettage and areas
or > 20 mm lowbody
Usually for on risk
Electrodesiccation lesions on trunk distinct
Tumors with no or
margins
extremities
High risk histology
• Mohs' Micrographic (morpheaform or infiltrative
Surgery BCC)
Persistently recurrent tumors
Predictors of BCC Recurrence
• Size of tumor
• Clinically indistinct margins
• Location (embryonic fusion planes provide little
resistance to tumor growth)
• Histologic type (morpheaform, micronodular,
sclerosing, or mixed type)
• Perineural invasion
• Recurrent tumor
• Previously irradiated tumor
• Skill of the operator
Defining Recurrence Rates
• Raw recurrence rate: total number of recurrences
divided by the total number of tumors treated
• Strict recurrence rate: total number of patients
with recurrence divided by number of treated
patients observed for at least 5 years
• Life table cumulative 5 year recurrence rate:
Adjusts recurrence rates for the number of patients
lost to follow-up each year
BCC recurrence rates for
Mohs’ Surgery
Study Comments No of Patients Cumm Recurr Cumm Recurr
Rate (%) < 5 yr Rate (%) 5yr
Julian and Bowers, 1981-1995 145 0.7- 0.8
1997
Mohs, et al, 1988 Ear 1032 1.3- 1.7
Mohs, 1986 Eyelid 1483 0.5- 0.6
Lindgren, et al 2000 Eyelid, medial 64 5*
canthus
Mean f/u 49 mos
Roenigk et al, 1986 F/u 2-4 yrs 367** 1.4*
Robins, 1981 1483** 1.8*
Mohs, 1978 6187** 0.7*
Data from Thissen M et al. “A Systematic Review of Treatment Modalities for Primary Basal Cell
Carcinomas”, Archives of Dermatology 1999;135(10):1177-1183.”
* Represents raw recurrence rate
**Represents total number of tumors, not number of patients
BCC recurrence rates for
Surgical Excision
Study Comments No of Cumm Recurr Cumm Recurr
Patients Rate (%) < 5 yr Rate (%) 5yr
Baur et al, 1977 443 8.0
Germann et al, 1992 272 3.2
Silverman et al, 1992 1955-1982 588 4.8
Werlinger et al, 2002 Private practice 90** 1.7
Van der Meer, 2001 Frozen section analysis 108 1.9*
Mean f/u 59 mos
Spraul et al, 2000 Periocular 141** 11.8* pos margins
Mean f/u 31.3 mos 2.3* neg margins
Rowe et al, 1989 Metanalysis (27) 5560** 2.8*
Rowe et al, 1989 Metanalysis (10) 2606** 10.1*
*Represents raw recurrence rate
**Represents total number of tumors, not number of patients
BCC recurrence rates for
Cryosurgery
Study Comments No of Cumm Rate (%) Cumm Rate (%)
Patients < 5 yr 5yr
Nordin et al, 1997 Nose, >10mm 61 1.6-2.0
Lindgren and Larko, Eyelid 214 0
1997
Anders et al 1995 Eyelid 254 3.5
Fraunfelder et al, 1984 Eyelid (<=10mm) 181 4.7
Eyelid (> 10mm) 88 16.5
Kuflik and Gage, 1991 Single provider 628* 1.0
Rowe et al, 1989 Metanalysis (13) 2462** 3.7*
Rowe et al, 1989 Metanalysis (1) 269** 7.5*
* Represents raw recurrence rate
**Represents total number of tumors, not number of patients
BCC recurrence rates for
Curettage and Electrodesiccation
Study Comments No of Cumm Recurr Cumm Recurr
Patients Rate (%) < 5 yr Rate (%) 5yr
Kopf et al, 1977 1958-1962, trainees 597 18.8
1970 91 9.6
1962-1973, certified 210 5.7
Launis, 1993 356 6.2*
McDaniel, 1983 Curettage only 88 4.3- 8.5
Welinger et al, 2002 Private practice 102** 3.7
Nordin, 1999 Curettage-Cryosurg 39** 2.6
External ear
Nordin et al, 1997 Curettage-Cryosurg 50 2.0
Nose
Silverman et al, 1991 1955-1982, includes 2258** 8.6 (low risk)
lesions > 10 mm 12.9 (med risk)
17.5 (high risk)
Rowe et al, 1989 Metanalysis (12) 3664** 4.7*
Rowe et al, 1989 Metanalysis (10) 3573** 7.7*
Dubin and Kopf, 1983 Trainees 758** 26.0
Summary
• The range of recurrence rates appear to be similar
for most physical modalities, including surgical
excision, cryosurgery, curettage and
electrodesiccation, curettage and cryosurgery, and
curettage alone.
• For follow-up period of 3-4 years, this rate falls
between 3 to 5%
• For a follow-up period of 5 years or more, this rate
is about double, approximately 5 to 12%
• Recurrence rates for tumors treated by Moh’s
Micrographic Surgery appear to be lower at all
points in time and averages between 1-2%.
Conclusions
• The key predictors of tumor recurrence are size
and site of the lesion, histology of tumor, and skill
of the operator
• All of the non-Mohs' modalities have roughly
equal and excellent cure rates for BCC without
high-risk prognostic factors
• There is an increased risk of BCC recurrence
regardless of treatment modality with increasing
time. This underscores the importance of long
term follow-up for evaluating the effectiveness of
a therapy.
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