skin_biopsy_habif.jpg (15603 bytes) Read the review articles on treatment of basal cell cancer here and squamous cell cancer here. In general the results with surgery or radiation are the same, but for recurrent skin cancers, more aggressive or complete surgery (like Mohs') may be best (go here). For superficial cancers, topical creams like Aldara may be an option (go here).

Also see the radiation section and discussion of the NCCN guidelines:
The NCCN published guidelines on the treatment of skin cancers. They describe a high risk area of the face, other basal cell risk factors, guidelines for treating low risk, for treating high risk and recommended doses of radiation. They limit the use of radiation to people aged 55 or older. They also define risk groups for squamous, and guidelines for treatment of low risk and treatment of high risk patients.)
 
 Treatment Basal Cell Carcinoma     Habif: Clinical Dermatology, 3rd ed.1996.  The following section outlines various treatment modalities.

Electrodesiccation and curettage. (see section on EDC)

This treatment is most beneficial for nodular BCCs less than 6 mm in diameter, regardless of anatomic site; selected larger BCCs, depending on their anatomic site; and superficial BCCs.It is not appropriate for morpheaform BCCs because margins cannot be clinically defined. Lesions on the nose and nasolabial folds may be treated if they are well defined and very small; otherwise these high-risk areas should be treated by Mohs' micrographic surgery. However, the treatment is particularly useful for ear lesions, where mobilization of skin for closure after excision is difficult.

Curettage requires firm dermis on all sides and below the tumor to enable the curette to distinguish between dermis and soft tumor. If the tumor encroaches on the fat, the curette cannot distinguish between fat and soft tumor, and an alternate procedure must be used. Curettage should be avoided for lesions on the back and shoulders, where the dermis is thick, unless the BCCs are superficial and small. Proper technique requires vigorous curettage, usually two to three times; therefore, lesions on the eyelid or lip area are treated by other methods. It is especially useful for lower extremity tumors, where tissue mobilization for excision may be difficult. Wounds created by electrosurgery ooze serum and accumulate crust during a 2- to 6-week healing period.

Excision surgery.

Excision surgery is preferred for large tumors with well-defined borders on the cheeks, forehead, trunk, and legs. The cosmetic result is good and healing time is less than that required for electrosurgery. Excision with primary closure is technically difficult on the ears and nose. The advantage of feeling the tumor with a curette is lost and adequate margins must be taken. A 98% cure rate was achieved in one study when BCCs less than 2 cm were excised with excisional margins of 4 mm around the tumor.  One large series revealed 5-year recurrence rates of BCCs excised from various anatomic sites: 0.7% on the neck, trunk, and extremities; 3.2% on the head if lesions were less than 6 mm in diameter; 5.2% on the head if lesions were 6 to 9 mm in diameter; and 9.0% on the head if lesions were 10 mm or more in diameter.

INCOMPLETELY RESECTED BCC.

Adequate excision, peripherally and in depth, is the key to surgical control, and the demonstration of tumor cells at the margins of excision is associated with recurrence rates of more than 30%. Data support the policy of immediate re-excision for all patients with incompletely excised basal cell carcinomas rather than a "wait-and-see" policy after incomplete excision. Re-excision may not be necessary if the patient's life span is limited or if treatment of a possible recurrence would not be difficult.

Cryosurgery.

Cryosurgery with liquid nitrogen delivered with a spray apparatus or a cryoprobe is appropriate for small-to-large BCCs of the nodular and superficial types with clearly definable margins (laterally and in depth). [40] It is not indicated for tumors deeper than 3 mm unless thermocouples are used to measure depth of freeze. A biopsy is performed as a separate operation before the cryosurgical procedure to determine cell type and extent of the tumor or just before the cryosurgery if there is no doubt about the diagnosis. Postoperative pain is moderate to severe. The appearance of a wound a few days after treatment is sometimes alarming to patients.

Mohs' micrographic surgery. (see section on Mohs')

Mohs' surgery is a microscopically controlled technique that may be used for all types and sizes of BCCs. The procedure is unnecessarily destructive for smaller lesions or for lesions with well-defined clinical margins, such as nodular or superficial multicentric BCCs.

Mohs' surgery is the treatment of choice for most sclerosing BCCs and other BCCs with poorly defined clinical margins; for tumors in areas of potentially high recurrence, such as the nose or eyelid; for very large primary tumors; and for large recurrent BCCs.

Radiation. (see radiation section)

Radiation is useful for elderly patients who cannot tolerate minor surgical procedures. For areas in which preservation of normal surrounding tissue is of prime consideration (e.g., around the eyelids and lips), radiation therapy may produce the best cosmetic result.

The overall 5-year recurrence rate is 7.4%. BCCs less than 10 mm in diameter on the head have a 5-year recurrence rate of 4.4%, [42] whereas those 10 mm or greater in diameter have a rate of 9.5%. The proportion of recurrence-free treatment sites with a good or excellent long-term cosmetic outcome after x-ray therapy (63%) is lower than that of curettage-electrodesiccation (91%) and of surgical excision (84%). [43] Radiation therapy is an effective method of treating recurrent BCCs that are smaller than 1 cm.   Therefore, if the long-term cosmetic outcome after treatment is not an overriding concern, x-ray therapy is an effective modality for many primary and recurrent BCCs. The treatment requires a number of outpatient visits that may be difficult for debilitated patients.

5-fluorouracil.

5-fluorouracil (5-FU) should not be used for the treatment of any BCCs, with the exception of some that occur in the rare basal cell nevus syndrome.  5-FU can destroy the surface tumor without affecting deeper cells.