Basal Cell Carcinoma. Treatment with Carbon Dioxide Laser Vaporization

Introduction

Basal cell carcinoma (BCC) is the most common malignant epidermal tumour of the skin that’s derived from the basal layer of the epidermis. The tumour infiltrates tissues in a three-dimensional fashion (Braun et al 2005) usually with a slow growing, and metastases are extremely rare (Lo et al 1991). Tumor-related morbidity results from local tissue invasion and destruction that might be very important in some areas such as the face. 

BCCs vary greatly in appearance and several clinical types had been described including nodular, cystic, superficial, sclerosing, keratotic, and pigmented.

Dermatologists usually perform clinical diagnosis of BCC. Diagnostic accuracy is enhanced by dermoscopy (Felder et al 2006) and confirmed by histopathological examination. Biopsy is also indicated when clinical doubt exists or when the histological subtype of BCC may influence treatment selection and prognosis (Telfer et al 2008).

Histological subtypes are mainly three: nodular, expansive and infiltrative. The most important form is the infiltrative pattern that usually corresponds to a sclerosing clinical pattern because it has the worst prognosis.

An important histopathological characteristic of BCC, like in other tumours, is the neoangiogenesis process, crucial requirement for tumour nutrition and growth, manifested as an increased in the number of blood vessels in the tumour. BCC contains a basket-like capillary plexus interwoven throughout the tumour bed, with many abnormal blood vessels with luminal diameters of 20 m and more (Van der Geer et al 2009). This vascular component is used as a target in the treatment of BCC with some specific vascular lasers.

Several treatment options for basal cell carcinoma have been described including surgical excision (Walker et al 2006), curettage (Barlow et al 2006) and cautery (Spiller et al 1984), cryotherapy (Mallon et al 1996, Kokoszka 2003), radiotherapy (Al-Othman 2001), photodynamic therapy (Star et al 2006, Chapas et al 2006, Brathen et al 2007), micrographic surgery (Bieley et al 1992, Rowe et al 1989)), ablative laser (Goldman and Wilson 1964, MacGuff 1966, Goldman et al 1968, Adams and Price 1979, Wheeland et al 1987, Fairhurst et al 1992, Grobbelaar et al 1997, Krunic et al 1998, Humpreys et al 1998, Horlock et al 2000, Nouri et al 2002, Campolmi et al 2002, Robinson et al 2003, and Smuckler et al 2008), other laser systems (El-Tonsy et al 2004, Moskalik et al 2009, Allison et al 2003, Campolmi et al 2008, Shah et al 2009, Konnikov et al 2011, Ibrahimi et al 2011), topical treatment with 5-fluorouracil and immunomodulators, such as imiquimod (Kagy and Amonette 2000, Schulze et al 2005) and intralesional agents as interferon (Greenway et al 1986).

The selection of treatment in each patient depends on several factors, such as some definable prognostic factors (Telfer et al 2008), that classify these tumours with low or high risk:

1. Tumour size (increasing size confers higher risk of recurrence)

2. Tumour site (lesions on the central face, especially around the eyes, nose, lips and ears, are at higher risk of recurrence)

3. Definition of clinical margins (poorly defined lesions are at higher risk of recurrence)

4. Histological subtype (certain subtypes confer higher risk of recurrence)

5. Histological features of aggression (perineural and ⁄ or perivascular involvement confers higher risk of recurrence)

6. Failure of previous treatment (recurrent lesions are at higher risk of further recurrence)

7. Immunosuppression (possibly confers increased risk of recurrence)

Surgery and radiotherapy (RT) remains the treatments of choice for the majority of high-risk lesions, nevertheless, with the recent development of more effective topical and nonsurgical therapies, the treatment options for many low-risk lesions are extended (Bath-Hextall et al 2007).

Patient specific factors, like general fitness, coexisting serious medical conditions, and the use of antiplatelet or anticoagulant medication may also influence the choice of treatment. A conservative approach to asymptomatic, low-risk lesions will prevent treatment causing more problems than the lesion itself. Even when dealing with high-risk BCC, aggressive management may be inappropriate for certain patients, especially the very elderly or those in poor general health, when a palliative rather than a curative treatment regimen may be in the best interests of the patient (Telfer et al 2008).

Finally, factors including patient choice, local availability of specialized services, together with the experience and preferences of the involved specialist may influence treatment selection.

In this manner, there are some instances when an easy destructive modality as carbon dioxide laser vaporization may be preferred:

1. In patients with numerous tumours or basal cell carcinomas of large size,

2. In locations with difficult surgical solution, such as inferior lower lip,

3. In patients with basal cell nevus syndrome or immunosuppression who may develop literally dozens to hundreds of tumours,

4. In elderly patients with multiple comorbidities, who take multiple medications which sometimes include anticoagulants, may not be ideal surgical candidates.

Therefore, we present the carbon dioxide laser vaporization as a good alternative treatment of BCC in selected cases and instances.

Method of Treatment

The treatment of BCC with carbon dioxide laser was performed under local anaesthesia of 2% mepivacaine without epinephrine. An adequate informed consent signed by the patient is obtained before performing the treatment. Usually several laser passes were necessary in order to eliminate all tumoral tissues. The number of passes of laser required depends on the type of BCC and the time of evolution.

The superpulsed mode of carbon dioxide laser emits high fluence (energy density) with short pulse time of exposition, providing a good degree of vaporization with minimal surrounding thermal tissue damage.

It was not difficult to delimitate the lesion by experienced doctors. The researchers carried out another pass after the tumoral tissue has been completely removed with a security margin of 5 mm around the suspected tissue. All the cellular detritus might be retired in order to achieve a good healing and if possible, a good cosmetic result. A cure with topical antibiotic ointment until the total resolution of the lesion was prescribed.

In the first pass, the researchers used superpulsed and focused mode (beam diameter 1 mm), with a power density of 5 to 10 W/cm2, to eliminate the superficial layer. They used a focused mode in the first pass because with this mode, the deep penetration of the carbon dioxide laser is higher, the elimination of the tumoral tissue is more effective, and the possibility of recurrence is reduced. After this pass, the partially desiccated tissue was manually removed with a saline-soaked gauze. When the necrotic debris was eliminated, a flaming red surface appears with central bleeding surrounded by a pink peripheral area that corresponds to unaffected skin appears. In the next passes, this area must disappear because it represents tissue infiltrated by tumour, according to the neoangiogenic induction produced by BCC. The flaming red surface is the guide to the surgeon. The decision of number of passes required to eliminate the tumour was made on the histologic type and the time of evolution of the lesion. When a superficial basal cell carcinoma was treated, usually only two of three passes were necessary, except in lesions with several years of evolution. When the treatment was performed in nodular BCC, five or six passes were considered to be necessary, so a residual scar after healing was expected.

After laser treatment, topical antibiotic ointment was applied to the wound, and covered with a dressing. A daily wound cleaning of the treated area with mild soap and water, followed by application of antibiotic ointment for a period of 2 weeks, was indicated. A new physician evaluation was made after 6 weeks of treatment.

Results

This paper presents some cases of BCC treated with CO2 laser vaporization in order to illustrate this treatment modality.