Curettage, electrosurgery and skin cancer

An Institutional Experience of a Tertiary Referral Center in Surgically Managing Patients With Gorlin Syndrome

BACKGROUND

The lifetime risk for basal carcinoma (BCC) is 90% in patients with Gorlin syndrome, also known as basal cell nevus syndrome. Compared with non-Gorlin patients, Gorlin patients often develop BCCs at a younger age and in greater numbers up to 500 BCCs in a lifetime.

OBJECTIVE

To review the options available for Gorlin patients and highlight existing knowledge gaps where future studies are indicated to optimize the care of this unique population.

METHODS

We review the current literature on managing patients with Gorlin syndrome from the lens of a dermatologic surgeon.

RESULTS

Although Mohs surgery is still the gold standard for large and aggressive BCCs, other less-invasive approaches may be considered for smaller, more numerous lesions. As dermatologic surgeons, we must be open to the full spectrum of surgical and nonsurgical options to individualize treatment and optimize patients' quality of life. Without maintaining a balance between optimal cure rate and volume management, Gorlin patients become at risk for surgical burn out and loss to follow-up.

CONCLUSION

Gorlin patients undergo numerous surgeries especially on the central face which can lead to disfigurement and reduce the quality of life. Identifying gaps in the current literature, continuing ongoing research, and eventually establishing appropriate guidelines that help to guide the formation of an individualized treatment plan is crucial in developing a balance between conservative and complex treatments for this population.

Medical gas plasma technology: Roadmap on cancer treatment and immunotherapy

Despite continuous therapeutic progress, cancer remains an often fatal disease. In the early 2010s, first evidence in rodent models suggested promising antitumor action of gas plasma technology. Medical gas plasma is a partially ionized gas depositing multiple physico-chemical effectors onto tissues, especially reactive oxygen and nitrogen species (ROS/RNS). Today, an evergrowing body of experimental evidence suggests multifaceted roles of medical gas plasma-derived therapeutic ROS/RNS in targeting cancer alone or in combination with oncological treatment schemes such as ionizing radiation, chemotherapy, and immunotherapy. Intriguingly, gas plasma technology was recently unraveled to have an immunological dimension by inducing immunogenic cell death, which could ultimately promote existing cancer immunotherapies via in situ or autologous tumor vaccine schemes. Together with first clinical evidence reporting beneficial effects in cancer patients following gas plasma therapy, it is time to summarize the main concepts along with the chances and limitations of medical gas plasma onco-therapy from a biological, immunological, clinical, and technological point of view.

Curettage and electrodessication combined with photodynamic therapy in the treatment of large squamous cell carcinomas in unfit and frail patients

A Caucasian female patient in her 90s was referred to the department of plastic and reconstructive surgery for surgical removal of a large invasive squamous cell carcinoma on the anterior chest wall. A skin biopsy prior to the referral indicated that the tumour was moderately differentiated. The patient suffered from severe congestive heart failure with a mechanical valve prosthesis and atrial fibrillation, and was therefore treated with anticoagulants. Hence, a surgical procedure would be hazardous. Therefore, other treatment options were considered. The principal aim was to reduce the amount of tumour tissue to an appropriate size suitable for later excision with primary wound closure. After interdisciplinary discussions, curettage and electrodessication combined with photodynamic therapy was judged the best alternative treatment in this case. At the 1.5 years follow-up after the intervention there was no indication for further surgery. The patient was at that stage content with the treatment and its outcome.

Management of keratinocyte carcinoma - Special considerations in the elderly

Keratinocyte carcinomas (KCs) are now an epidemic in The United States of America, especially in elderly patients. KCs, including basal cell carcinoma and squamous cell carcinoma, can lead to disfigurement and occasionally death. However, the lower mortality rate associated with KC compared with melanoma allows for increased flexibility in the selection of treatment. Flexibility in treatment is particularly important in the elderly given that this patient population often has medical comorbidities that should be considered. These patients may have multiple KCs, higher risk tolerance to recurrence, and different concerns about cosmetic outcomes compared with their younger counterparts. We review treatment options for KCs and how the selection of each option may affect the elderly patient.

Electrochemotherapy and Ablative Therapies in Non-melanoma Skin Cancer

Although surgery and radiotherapy remain the most commonly used treatments for non-melanoma skin cancer, there are a variety of alternatives. Here we discuss the use of electrochemotherapy and ablative treatments and examine the evidence for their effectiveness against a number of non-melanoma skin cancers.

Presurgical Curettage Improves Accuracy for Nonmelanoma Skin Cancer Excision

BACKGROUND

Presurgical curettage before nonmelanoma skin cancer surgery may help delineate tumor subclinical extensions.

OBJECTIVE

To determine histologically whether presurgical curettage appropriately or inappropriately changes excision specimen size.

MATERIALS AND METHODS

One hundred fifty consecutive nonmelanoma skin cancers treated with Mohs micrographic surgery. The clinical margin (CM) was marked. Presurgical curettage was then performed and the resultant presurgical curettage margin (PCM) marked. Frozen section analysis of the CM and PCM revealed whether the curettage-induced margin change was appropriate or unnecessary.

RESULTS

Presurgical curettage appropriately increased the surgical margin in 9.3% of cases, reducing the number of Mohs stages from 2 to 1. It appropriately decreased the surgical margin in 17.3% thereby conserving normal skin. In 19.4% of cases the curettage increased the margin in situations where the CM had underestimated the size of the tumor; however, in these cases, the curettage did not increase the margin sufficiently to clear the tumor. In 44.0% of cases the PCM did not change the size of the stage I specimen compared to the CM and confirmed the CM. In 10.0% of cases, preoperative curettage reduced margin accuracy by removing healthy tissue (8.0%) or underestimating tumor (2.0%). These errors were associated with eyelid location, severe background photodamage, and morpheiform/infiltrating/sclerosing basal cell carcinomas.

CONCLUSION

Presurgical curettage can improve tumor excision accuracy and efficiency. Careful tumor selection is important to optimize curette utility.

Applications of SNAP-tag technology in skin cancer therapy

BACKGROUND

Cancer treatment in the 21st century has seen immense advances in optical imaging and immunotherapy. Significant progress has been made in the bioengineering and production of immunoconjugates to achieve the goal of specifically targeting tumors.

DISCUSSION

In the 21st century, antibody drug conjugates (ADCs) have been the focus of immunotherapeutic strategies in cancer. ADCs combine the unique targeting of monoclonal antibodies (mAbs) with the cancer killing ability of cytotoxic drugs. However, due to random conjugation methods of drug to antibody, ADCs are associated with poor antigen specificity and low cytotoxicity, resulting in a drug to antibody ratio (DAR) >1. This means that the cytotoxic drugs in ADCs are conjugated randomly to antibodies, by cysteine or lysine residues. This generates heterogeneous ADC populations with 0 to 8 drugs per an antibody, each with distinct pharmacokinetic, efficacy, and toxicity properties. Additionally, heterogeneity is created not only by different antibody to ligand ratios but also by different sites of conjugation. Hence, much effort has been made to find and establish antibody conjugation strategies that enable us to better control stoichiometry and site-specificity. This includes utilizing protein self-labeling tags as fusion partners to the original protein. Site-specific conjugation is a significant characteristic of these engineered proteins. SNAP-tag is one such engineered self-labeling protein tag shown to have promising potential in cancer treatment. The SNAP-tag is fused to an antibody of choice and covalently reacts specifically in a 1:1 ratio with benzylguanine (BG) substrates, eg, fluorophores or photosensitizers, to target skin cancer. This makes SNAP-tag a versatile technique in optical imaging and photoimmunotherapy of skin cancer.

CONCLUSION

SNAP-tag technology has the potential to contribute greatly to a broad range of molecular oncological applications because it combines efficacious tumor targeting, minimized local and systemic toxicity, and noninvasive assessment of diagnostic/prognostic molecular biomarkers of cancer.

Neurofibromatosis Type 1: Review of Cutaneous and Subcutaneous Tumor Treatment on Quality of Life

Background:

Neurofibromatosis Type 1 (NF1) is the most common type of neurogenetic disorder with a worldwide incidence of between 1 in 2,600 and 1 in 3,000. NF1 has a wide range of manifestations; as a result, NF1 has no “public persona.” Beginning at puberty and continuing thereafter patients may grow cutaneous and subcutaneous tumors (neurofibromas) in large numbers, which cause severe problems with appearance, which are similar in severity to those of psoriasis. Appearance concerns due to tumors affect NF1 patients’ Quality of Life (QoL). NF1 patients are at increased risk for depression and treatment for depression and significantly enhance QoL. Improving appearance and QoL by decreasing the number of tumors is the NF1 patient’s greatest concern. Improving QoL is an end in itself.

Methods:

There are no currently available medical or pharmacological treatments for cutaneous and subcutaneous tumors of NF1. Surgery is the only treatment option for cutaneous and subcutaneous tumors. High Quantity (HQ) surgical removal by several methods has been used.

Results:

HQ electrosurgical (ES) allows removal of large numbers of tumors, hundreds per surgical session, appears to be highly effective, and most patients are happy with their results. Other surgical techniques, such as scalpellic surgery, are not effective. Inadequate insurance payments, few plastic surgeons performing HQ tumor removal, lack of support from nonsurgeon physicians, few if any NF clinics providing HQ tumor removal, pediatric orientation, focus on basic research, and a dismissive attitude toward NF1 patients are all components in the unavailability of HQ NF tumor removal. Such surgery is not cosmetic but restoration of normal appearance from disfigurement due to a congenital, neoplastic disease.

Conclusions:

National legislation is required to mandate insurance companies to provide coverage for HQ tumor removal. Payments by health insurance companies to plastic surgeons must be reasonable and comparable with other procedures. Effort by neurologists and other nonsurgeons is needed to gain support of plastic surgeons. Strong pressure is needed by support groups of NF for providing NF1 HQ surgery at institutions with NF clinics and for proper payments for surgeons and others.

Dosimetry of indigenously developed 177Lu patch source for surface brachytherapy-Experimental and Monte Carlo methods

This paper describes the evaluation of dosimetry characteristics of an in-house developed ¹⁷⁷Lu skin patch source for treatment of non-melanoma skin cancer. A ¹⁷⁷Lu skin patch source based on Nafion-115 membrane backbone containing 3.46 ± 0.01 mCi of activity was used. Activity measurement of the patch source was based on gamma ray spectrometry using a HPGe detector. The efficiencies of the HPGe detector were fitted using an orthogonal polynomial function. The absorbed dose rate to water at 5 μm depth in water was determined using an extrapolation chamber, EBT3 Gafchromic film and compared with Monte Carlo methods. The correction factors such as Bragg-Gray stopping power ratio of water-to-air and chamber wall material being different from water, needed to be applied on measurements for establishing the dose rate at 5 μm depth, were calculated using the Monte Carlo method. Absorbed dose rate at 5 μm depth in water (surface dose rate) measured using an extrapolation chamber and EBT3 Gafchromic film were 9.9 ± 0.7 and 8.2 ± 0.1 Gy h^-1 mCi^-1 respectively for the source activity of 3.46 ± 0.01 mCi. The surface dose rate calculated using the Monte Carlo method was 8.7 ± 0.2 Gy h^-1 mCi^-1, which agrees reasonably well with measurement. The measured dose rate per mCi offers scope for ascertaining treatment time required to deliver the dose for propitious therapeutic outcome. Additionally, on-axis depth dose and lateral dose profiles at 5 μm and 1 mm depth in water phantom were also calculated using the Monte Carlo method.

On the application of Nafion membrane for the preparation of (90)Y skin patches, quality control, and biological evaluation for treatment of superficial tumors

This article describes the preparation, quality control, and biological evaluation of (90)Y-skin patches based on Nafion(®) membrane as a viable treatment modality for superficial skin tumors such as melanoma. To arrive at the conditions for optimum uptake of (90)Y on the membrane, influence of various experimental parameters, such as pH of the feed solution, inactive yttrium carrier concentration, reaction volume, contact time, and temperature, was systematically investigated. Under the optimized conditions, >95% of the (90)Y activity (37-185 MBq) could be incorporated in the Nafion membranes to prepare (90)Y-skin patches. Quality control tests were carried out to ensure nonleachability, uniform distribution of activity, and stability of the (90)Y-patches. Mice bearing transplanted melanoma tumors that were treated with two doses of 74 MBq (90)Y-Nafion membrane sources showed complete tumor regression. Histopathological examination of the treated area showed absence of tumor. The results of the study indicate the potential of (90)Y-Nafion membrane sources for treatment of superficial skin tumors.

Electrosurgery: part I. Basics and principles

The term electrosurgery (also called radiofrequency surgery) refers to the passage of high-frequency alternating electrical current through the tissue in order to achieve a specific surgical effect. Although the mechanism behind electrosurgery is not completely understood, heat production and thermal tissue damage is responsible for at least the majority--if not all--of the tissue effects in electrosurgery. Adjacent to the active electrode, tissue resistance to the passage of current converts electrical energy to heat. The only variable that determines the final tissue effects of a current is the depth and the rate at which heat is produced. Electrocoagulation occurs when tissue is heated below the boiling point and undergoes thermal denaturation. An additional slow increase in temperature leads to vaporization of the water content in the coagulated tissue and tissue drying, a process called desiccation. A sudden increase in tissue temperature above the boiling point causes rapid explosive vaporization of the water content in the tissue adjacent to the electrode, which leads to tissue fragmentation and cutting.

Electrosurgery: part II. Technology, applications, and safety of electrosurgical devices

Electrosurgical currents can be delivered to tissue in monopolar or bipolar and monoterminal or biterminal modes, with the primary difference between these modes being their safety profiles. A monopolar electrosurgical circuit includes an active electrode and a dispersive (return) electrode, while there are 2 active electrodes in bipolar mode. In monoterminal mode, there is an active electrode, but there is no dispersive electrode connected to the patient's body and instead the earth acts as the return electrode. Biterminal mode uses a dispersive electrode connected to the patient's body, has a higher maximum power, and can be safer than monoterminal mode in certain situations. Electrosurgical units have different technologies for controlling the output power and for providing safety. A thorough understanding of these technologies helps with a better selection of the appropriate surgical generator and modes.

Curettage and diathermy: a treatment for feline nasal planum actinic dysplasia and superficial squamous cell carcinoma

OBJECTIVE

To evaluate curettage and diathermy as a treatment for actinic dysplasia and superficial squamous cell carcinoma of the feline nasal planum.

METHODS

Thirty-four cats clinically assessed to have actinic dysplasia and superficial squamous cell carcinoma involving less than 50% of the nasal planum were treated with a three-cycle curettage and diathermy procedure. Degree of dysplasia, response to treatment, adverse effects, owner perceptions, time to recurrence and proportion disease free at 1 year were evaluated.

RESULTS

Lesions ranged from actinic keratoses to invasive squamous cell carcinoma. A complete response to treatment was obtained in all cats. The median follow-up time was 18 · 2 (IQR: 12 · 0-22 · 8) months. Two cats had a clinical recurrence of lesions at 161 and 192 days after treatment. The probability of remaining disease free after 12 months was 0 · 94 (95% CI: 0 · 85-1 · 0). Median time to recurrence was not reached. The procedure was well tolerated with a good cosmetic outcome and no significant post-operative complications.

CLINICAL SIGNIFICANCE

This study suggests that curettage and diathermy is an effective treatment for feline actinic dysplasia and for superficial squamous cell carcinoma involving less than 50% of the nasal planum. Curettage and diathermy is an easily mastered technique, requiring minimal equipment.

Nonmelanoma skin cancer

Nonmelanoma skin cancer (NMSC) represents the most common form of cancer in Caucasians, with continuing increase in incidence worldwide. Basal cell carcinoma (BCC) accounts for 75% of cases of NMSC, and squamous cell carcinoma (SCC) accounts for the remaining majority of NMSC cases. Whilst metastasis from BCC is extremely rare, metastasis from high-risk SCC may be fatal. In this article, we review the aetiology, diagnosis and management of NMSC.

Nonsurgical treatment of nonmelanoma skin cancer

The ever-increasing incidence of primary cutaneous malignancies has heralded the need for multiple treatment options. Surgical modalities remain the mainstay of treatment of nonmelanoma skin cancer. However, it is important for the dermatologic surgeon to have an understanding of all treatment options to assist the patient in making the most informed decision possible, ultimately leading to the most favorable outcome. This article explores the available nonsurgical treatment options, their indications, and their efficacy.

[Intralesional infusion of methotrexate as neoadjuvant therapy improves the cosmetic and functional results of surgery to treat keratoacanthoma: results of a randomized trial]

BACKGROUND

Keratoacanthoma is currently considered to be an in situ squamous cell carcinoma that mainly affects patients over 70 years of age. The tumor has a good prognosis and, in some cases, can resolve spontaneously. Treatment involves simple excision. However, since the tumors generally occur on the face or extremities and display rapid growth, aggressive surgery may be required and the cosmetic results may be poor.

OBJECTIVE

The primary study objective was assessment of the efficacy of presurgical intralesional methotrexate infiltration to reduce the size of the tumor and the corresponding surgical defect.

MATERIAL AND METHODS

A prospective, randomized study was undertaken in patients with a diagnosis of keratoacanthoma of at least 1.5 cm who were seen in our service between January 2009 and January 2010. Two groups were established: one receiving a single infiltration of methotrexate prior to surgery and another that did not receive methotrexate.

RESULTS

Of the 25 patients included in the study, 10 received neoadjuvant intralesional methotrexate (group A) and 15 underwent surgery without prior infiltration of methotrexate (group B). The patients in group A displayed a reduction of between 50% and 80% in the size of the lesion prior to surgery. No complications were observed either in relation to methotrexate infusion or surgery. In group B, only 1 patient had a slight reduction in the dimensions of the lesion prior to surgery. In the remaining cases, the lesions remained similar (4 cases, 26%) or had increased in size (10 cases, 66%) at the time of surgery. Five patients in this group required hospital admission following surgery.

CONCLUSIONS

Neoadjuvant intralesional methotrexate is well tolerated and reduces the need for aggressive surgery in elderly patients with keratoacanthoma measuring more than 1.5 cm on the face or extremities.

Non-surgical treatments of primary, non-melanoma eyelid malignancies: a review

The diagnosis and management of periocular cutaneous malignancies are essential components of an ophthalmologist's practice. Skin cancers comprise nearly one-third of newly diagnosed malignancies. Furthermore, the incidence of skin cancer appears to be increasing. Multiple treatment modalities exist for periocular cutaneous malignancy. Surgical extirpation, often with the combined expertise of a Mohs micrographic surgeon, is typically the first line therapy and is often curative in the periocular region, depending on a variety of factors, including tumour histology, specific location, depth of invasion and surgical technique. However, there are instances where a less invasive, non-surgical treatment option is warranted, including patients who are poor surgical risks or those with diffuse disease. The purpose of this article is to review the literature and describe the non-surgical treatment options, indications and efficacies for non-melanoma primary eyelid malignancies.

Guidelines for the management of basal cell carcinoma

This article represents a planned regular updating of the previous British Association of Dermatologists guidelines for the management of basal cell carcinoma. These guidelines present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

Management of nonmelanoma skin cancer in 2007

As the incidence of nonmelanoma skin cancer (NMSC) increases, so does the number of modalities used to treat this condition. Surgery is the most frequent approach used to treat NMSC, and clinicians usually perform Mohs micrographic surgery, conventional excision, electrodesiccation and curettage or cryosurgery. The 'gold standard' for treatment continues to be Mohs micrographic surgery, but owing to the time and expense involved with this procedure, it is indicated only in patients with aggressive tumors or those where disfigurement or functional impairment is a risk. Although radiation therapy is effective, its use is limited because of the side effects induced; radiation therapy can be used in certain patients who are not surgical candidates. Newer noninvasive options for NMSC include topical chemotherapeutics, biological-immune-response modifiers, retinoids, and photodynamic therapy, which can be used particularly in patients with superficial tumors. Treatments should be tailored to tumor type, location, size, and histological pattern, and although surgical methods remain the most frequently used, newer noninvasive treatments can be used in select tumors and may reduce morbidity.

Intralesional methotrexate treatment for keratoacanthoma tumors: a retrospective study and review of the literature

BACKGROUND

Intralesional methotrexate (MTX) is an effective treatment for keratoacanthoma (KA).

OBJECTIVE

We sought to systematically examine response rates and adverse events in KA treated with intralesional MTX.

METHODS

All cases of KA treated with intralesional MTX at our institution from 1991 to 2006 were identified. A MEDLINE and PubMed search of cases of KA treated with intralesional MTX was also performed.

RESULTS

In all, 38 cases of KA treated with intralesional MTX were identified: 18 from our institution and 20 from the literature. Intralesional MTX achieved resolution in 92%, requiring an average of 2.1 injections an average of 18 days apart. Adverse events were rare, with two reports of pancytopenia in patients with chronic renal failure.

LIMITATIONS

Use of single case reports, small series, and retrospective analysis are limitations.

CONCLUSION

Intralesional MTX is a useful nonsurgical therapy for the treatment of KA. Histologic diagnosis before initiation of treatment is preferred. A complete blood cell count at baseline and during treatment should be considered to monitor for potential cytopenia.

Recurrence rates of primary basal cell carcinoma in facial risk areas treated with curettage and electrodesiccation

BACKGROUND

The incidence of basal cell carcinoma (BCC) is increasing. Curettage and electrodesiccation (CE) are not recommended for BCC treatment at medium- and high-risk facial sites. Surgical excision has been proposed as the treatment of choice.

OBJECTIVE

We sought to evaluate the cumulative recurrence rate (RR) of primary BCC in facial areas of medium and high risk after CE.

METHODS

This nonrandomized, clinical trial enrolled 257 patients with primary BCC located in medium- and high-risk facial areas, and treated with 4 or 5 cycles of CE by a single operator from a section specializing in BCC CE in a tertiary teaching hospital in Oviedo, Spain. Exclusion criteria for study entry included: recurrent BCC, fibrosing BCC, ill-defined BCC, and BCC larger than 10 mm in diameter (high-risk facial sites) or larger than 15 mm in diameter (medium-risk sites); BCC smaller than 4 mm; and nonbiopsy-proven BCC. BCCs included in the study were from the nose, and paranasal and nasal-labial fold (n = 105); eyelids and canthi (n = 48); perioral areas (n = 12); ears (n = 11); forehead and temples (n = 48); periauricular areas (n = 14); and malar areas and cheeks (n = 19). The primary outcome was recurrence of carcinoma, which was clinically evaluated by at least two observers in consensus. Data were analyzed using both a life table method and Kaplan-Meier analysis. The statistical analysis included best- and worst-case scenarios (which means that all cases lost to follow-up were considered as recurrences).

RESULTS

The 5-year cumulative non-RR in the best-case scenario was 98.80% (SE 0.70, 95% confidence interval 97.40%-100%); thus, a 5-year cumulative RR of 1.20% was found after CE in our medium- and high-risk BCCs of the face (best case). The 5-year cumulative non-RR in the worst-case scenario was 79.40% (95% confidence interval 78.90%-79.90%); thus, a 5-year cumulative RR of 20.60%.

LIMITATIONS

Retrospective design with a relatively small number of patients lost to follow-up is a study limitation.

CONCLUSION

High 5-year cure rates can be obtained after CE of primary, nonfibrosing BCCs of medium- and high-risk areas of the face performed in a specialized section.

Therapeutic options for Bowen's disease

Multiple therapeutic options are available for treatment of Bowen's disease. The choice of therapy depends on clinical circumstance and medical practitioner experience. Newer therapies have more extensive support from the literature, but more established therapies may be preferred because of accessibility, cost and efficacy. An overview of the current therapeutic options for Bowen's disease is presented.

Comparison of cryotherapy and curettage for the treatment of pyogenic granuloma: a randomized trial

BACKGROUND

Pyogenic granuloma is a benign vascular lesion of the skin and mucous membranes. Many different treatments have been used, with variable success rates.

OBJECTIVES

To evaluate and compare the effects of cryotherapy and curettage in the treatment of pyogenic granuloma.

METHODS

Eighty-nine patients with pyogenic granuloma were randomized to receive cryotherapy with liquid nitrogen or curettage and electrodesiccation. Forty patients in the cryotherapy group and 36 patients in the curettage group completed the study period.

RESULTS

Among the patients who completed the study, treatment resulted in complete resolution of all lesions after one to three sessions (mean 1.42) in the cryotherapy group and after one to two sessions (mean 1.03) in the curettage group. The difference between the two groups was statistically significant (P < 0.001). Twenty-three patients (57.5%) in the cryotherapy group and 25 patients (69%) in the curettage group had no scar or pigmentation abnormality. Except for cosmetic problems, no other side-effect or complication was recorded in the study.

CONCLUSIONS

This study showed that both cryotherapy and curettage are safe and effective. Curettage had the advantage of fewer treatment sessions required to achieve resolution and better cosmetic results. We suggest that curettage could be the first-line treatment for pyogenic granuloma.

The occurrence of residual or recurrent squamous cell carcinomas in organ transplant recipients after curettage and electrodesiccation

BACKGROUND

Organ transplant recipients frequently develop multiple squamous cell carcinomas (SCCs). Surgical excision and Mohs micrographic surgery are frequently used treatments for these carcinomas; however, curettage and electrodesiccation are a useful alternative in these patients.

OBJECTIVES

To evaluate the efficacy of curettage and electrodesiccation for the treatment of appropriately selected low-risk SCCs in organ transplant recipients at different sites.

METHODS

Between April 1989 and December 2004, 211 SCCs in 48 organ transplant recipients were treated by curettage and electrodesiccation. Only histologically confirmed SCCs were considered in this study. The charts of these patients were retrospectively reviewed and checked for the rate of residual or recurrent SCCs. The occurrence of residual or recurrent SCCs at different locations after treatment of SCCs with curettage and electrodesiccation was estimated with Kaplan-Meier survival analysis.

RESULTS

The mean follow-up time after curettage and electrodesiccation of the individual SCCs was 50 months (median 41; range 3-186). In total, 13 residual or recurrent SCCs were observed in 10 patients. The overall rate of residual or recurrent SCCs was 6%, with 7% for SCCs on the dorsum of the hands or fingers, 11% for SCCs on the head and neck, 0% for the forearms, and 5% for the remaining nonsun-exposed areas (shoulder, legs). No major clinical or cosmetic adverse events were registered after treatment.

CONCLUSIONS

In organ transplant recipients with many SCCs curettage and electrodesiccation can be a safe therapy for appropriately selected low-risk SCCs, with an acceptable cure rate.

Therapieoptionen bei epithelialen Hauttumoren

There has been worldwide a significant rise in the incidence of epithelial skin tumors and their precursors in the past years with an increased number of younger patients affected. The risk factors are identified. The choice of the appropriate treatment for each individual is crucial. Major consideration include high cure rate, low long-term recurrence rate and few side effects. In the following article different therapeutic approaches for actinic keratoses, Bowen's disease, basal cell carcinoma and squamous cell carcinoma are presented and analysed.

Periocular keratoacanthoma: clinical features, pathology, and management

PURPOSE

To review the clinical features and results of surgical treatment of keratoacanthoma of the eyelids.

DESIGN

Retrospective, interventional case series.

PARTICIPANTS

Ten patients.

METHODS

Chart review of all eyelid keratoacanthomas treated between 1992 and 2001.

MAIN OUTCOME MEASURES

Adequate excision, recurrence rate, and complications.

RESULTS

Patient ages ranged from 27 to 78 years, with a mean age of 59 years. Six patients were male and four were female. The lesion was found on the lower lid in five patients, upper lid in two, medial canthus in two, and lateral canthus in one. The maximum diameter of the lesion varied from 2 to 25 mm, with a mean of 7.2 mm. All lesions were treated by surgical excision, with frozen-section control of margins in five cases. All lesions were excised completely with clear resection margins, and there were no cases of recurrence. The only complication was a minor wound infection in one patient. Mean follow-up was 34.5 months.

CONCLUSIONS

Because of the aggressive nature and uncertain relationship to squamous cell carcinoma, we recommend excision of periocular keratoacanthoma. Surgical excision of eyelid keratoacanthoma provides good results and a very low risk of recurrence. Frozen-section control of margins should be used in selected cases to ensure complete excision.

The current status of curettage and electrodesiccation

Curettage and electrodesiccation (CE) is a technique widely used in the destruction of benign and selected malignant cutaneous neoplasms. CE is used mainly by dermatologists and family practice physicians, whereas plastic surgeons and other surgeons excise most benign and malignant lesions. The use of CE for the treatment of skin cancer has been widely extolled and also fervently criticized. Some practitioners treat most non-melanoma skin cancers (NMSC) with CE, and others have called for abandoning the technique in the treatment of such lesions. A thorough review of the literature reveals that CE has both virtues and flaws. In taking a rational approach to the treatment of benign and malignant cutaneous lesions it is essential to learn the basis for CE, the likely cure rates for given lesions, the proper technique, and the expected level of cosmesis. As the surgical treatment of skin cancer has become firmly entrenched in the field of dermatology, it is valuable to examine this technique in depth and to come to some thoughtful conclusions about its use for patients with skin cancer and assorted benign skin lesions. Last year a remarkably complete and exhaustive favorable review of curettage, electrosurgery, and skin cancer was published by Sheridan and Dawber. This article is a must read for anyone performing curettage; however, the author is writing with a slightly different perspective, that of a dermatologic surgeon. Although the author believes that CE has value and he uses this technique frequently, he disagrees with some of the truisms expressed in the literature about CE and attempts to define carefully what he believes are the strengths and limitations of this technique.

Nonmelanoma skin cancer

Therapy for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) does not end with treatment of the initial lesion because almost 50% of patients with one nonmelanoma skin cancer (NMSC) develop another NMSC in the next 5 years. An integrated program of skin cancer awareness, sun protection, and prophylactic approaches is critical. The risk profile of the tumor influences which therapies and specialties will be involved. Most NMSCs may be treated with outpatient methods. Primary care physicians may treat low-risk tumors, but dermatologists specially trained in cutaneous oncology and a multidisciplinary team should manage high-risk lesions. Superficial BCC and SCC may be treated adequately with superficial modalities such as electrodesiccation and curettage (EDC) and cryotherapy. Topical 5-fluorouracil is effective for small in situ lesions. Invasive but low-risk lesions may be treated with EDC and cryotherapy provided that the tumor is limited to the papillary dermis, is not recurrent, and does not have high-risk features. High-risk tumors are best treated with excision and histologic examination or Mohs micrographic surgery (MMS). MMS is the therapeutic gold standard for all NMSCs in terms of cure rates, margin control, and tissue conservation. Because of its higher cost and specialized process, MMS is best reserved for specific indications.