Basal cell carcinoma-treatment with cryosurgery

Introduction

Basal cell carcinoma (BCC) is the most common cutaneous malignancy that arises from the germinative epidermal or adnexal cells.

Various therapeutic approaches such as surgical excision, Moh′s micrographic surgery, radiotherapy, electrosurgery and cryosurgery have been employed to treat BCC.[2] Cryosurgery is the therapeutic approach currently being used at many centers especially for small tumors, located in noncritical zones and having well defined clinical margins.[2] We herein describe three patients with BCC treated successfully with cryosurgery, of which two patients had large tumors located at difficult to treat sites.

Case Reports

Case 1

A 65-year-old female presented with a one year history of a non-healing ulcer over the scalp. It was slowly progressive and had failed to respond to various courses of antibiotics prescribed elsewhere. Her general physical and systemic examination were normal. Examination of the scalp revealed an irregular, 8x10c, sized ulcer with well defined and pearly borders and floor covered with granulation tissue. It was non-tender and fixed to the underlying structures. A skin biopsy showed BCC, confirming the clinical diagnosis. She had normal haemogram, serum biochemistry, uninalysis and chest and skull radiographs. Treatment with liquid nitrogen cryosurgery was started with two freeze thaw cycles each of 30 seconds duration delivered by the open spray method after local infiltration anesthesia. Cryosurgery was done over different segments of the ulcer at different sittings spaced two weeks apart over a period of two months. Analgesics for post treatment pain, and topical antibiotics were administered and daily dressing of the wound were carried out till healing. Gradual healing was observed with peripheral scarring and hypopigmentation [Figure - 1]. After six months the lesions had completely healed and the patient is asymptomatic and without recurrences at one year of follow up.

Case 2

An 85-year-old man presented with crusted lesion over the nose of six months′ duration. He had no other medical problems. Examination revealed a weak debilitated patient having a 2x3.5 cm sized nodulo-ulcerative lesion over the tip of the nose. The lesion was well defined with characteristic rolled pearly borders. Histopathology confirmed the diagnosis of a BCC. Treatment with cryosurgery using liquid nitrogen under local anesthesia was planned. After curettage and control of bleeding by pressure, two freeze thaw cycles each of 45 seconds were delivered by open spray technique over two sittings. Analgesics and topical antibiotics were prescribed. At a follow up of six months the lesions had healed with hypopigmentation.

Case 3

A 45-year-old female presented with a non-healing nodular lesion over the nose first noticed six months back. It was a slowly growing lesion with oozing off and on. Her general health was preserved. Examination revealed a 1.5X2 cm sized nodulo-ulcerative plaque with pearly margins over the left aloe nasi. There was no regional lymphadenopathy. Histopathology of the skin biopsy revealed a BBC. Cryosurgery with liquid nitrogen delivered by open spray technique and two freeze thaw cycles was performed after curettage. Lesion healed completely over one month and she is free of the tumor at three months follow up.

Discussion

Basal cell carcinoma is a common cutaneous malignancy mostly in elderly persons. Various factors to be primarily considered while planning treatment for BCC include the histological type, location, size and nature of the lesion (primary or recurrent). Other factors like associated symptoms, age and general condition of the patient and the cost of therapy are also important.[2] Treatment should aim for the removal or destruction of whole of the tumor with conservation of as much healthy tissue as possible, and preservation of function and cosmetic appearance. Moh′s micrographic surgery gives excellent cure rates, however it is expensive and not easily available. Similarly radiotherapy is a costly procedure requiring multiple sessions. Radiotherapy cannot be used for recurrent tumors and it results in poor cosmetic results.[2] Surgical excision may be suitable for lesions at non critical sites where primary closure of the wound is easily possible without extensive reconstructive procedures. Majority of the patients may present at a late stage with large ulcerated tumors and local destruction as the lesions are initially devoid of symptoms. Most of these individuals may be weak, debilitated, and poor and thus unable to tolerate or afford expensive surgical procedures or radiotherapy.

In contrast, cryosurgery is a convenient and easily available therapeutic modality with satisfactory cure rates and hardly any contraindications.[3] It is easily tolerated and can be performed on old people, debilitated or anticoagulated patients or on patients with pace makers. It is of low cost with minimal technical requirements. Contrary to radiotherapy, cryosurgery can be used in recurrent BCC.[4] It may be safely used for tumors located over bony or cartilaginous structures with minimal risk of osteonecrosis or chondronecrosis. In cryosurgery, tissue destruction is caused by freezing leading to sudden loss of heat and subsequent vascular stasis and cell death.[5] In malignancies, rapid freezing and slow thawing help to achieve optimal tissue damage. Cryosurgery gives favorable results as it selectively destroys epithelial components while preserving the mesenchymal ones which help in tissue regeneration. There is minimal sacrifice of healthy tissues with better functional and cosmetic results. Cure rates reported for BCC treated by cryosurgery are usually over 95%.[6],[7] Zacarian reported a cure rate of approximately 97%$ while Jaramillo-Ayerbe has observed a cure rate of 91.8% in treatment of 136 patients, most of whom had a high risk of recurrence.[2]

Various complications observed post treatment are: pain, inflammation, bleeding and gaseous insufflation in the acute stages, and bleeding and infection at a later stage. Delayed complications include neuropathy, dyschromia, milia and abnormal cicatrisation.[4] Recurrence of the tumor may also develop, mostly in large lesions, having an ill-defined margin or those located on the lips.[2]

Two of our three patients were old and the first patient had a large ulcerated BCC over scalp where surgical excision was not possible. In the second patient surgery was not considered as a first option because of his old age and poor general condition. In all the three patients an excellent clinical response with complete healing of the lesions and satisfactory functional and cosmetic results were obtained with cryosurgery. Apart from post treatment pain no other complications were observed in the patients. In first patient cicatricial alopecia and hypopigmentation have resulted and the other two patients have minimal hypopigmentation. Hypopigmentation secondary to cryosurgery is common but it declines in the long term.[2] Thus cryosurgery is an acceptable therapeutic modality for BCC, especially in tumors at difficult to treat sites and old patients, and results in satisfactory cure rates with a good patient tolerance.