Original Research

Optimal Cosmetic Outcomes for Basal Cell Carcinoma: A Retrospective Study of Nonablative Laser Management

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Results

Patient and Lesion Characteristics
Sixty-eight patients with 93 BCCs (77 facial; 16 nonfacial) were included. The median age of patients was 70 years (range, 31–91 years). All 93 BCCs demonstrated residual tumor on OCT after diagnostic biopsy. Four BCCs had been treated earlier with MMS and were biopsy-proven recurrences. Most BCCs were of the nodular subtype; however, sclerosing, superficial, pigmented, morpheaform, and infiltrative subtypes also were included (eTable 1). Eight BCCs were obtained at outside institutions with no subtype provided. Facial BCCs had a mean (SD) clinical and dermoscopic diameter of 6.75 (4.71) mm (range, 2–24 mm). Patients were followed for 2.53 months to 6.03 years (mean follow-up, 2.43 years) and assessed for clinical and subclinical recurrence.

Tumor Clearance
Most lesions were effectively treated, with 89 of 93 BCCs (95.70%) demonstrating complete tumor clearance. Complete tumor clearance following laser therapy was reported in 74 of 77 facial BCCs (96.10%) and 15 of 16 nonfacial BCCs (93.75%)(eTable 2). Successfully treated BCCs underwent an average of 2.88 laser treatments over a mean duration of 3.54 months (range, 1 week to 1.92 years). Four incomplete responders underwent an average of 3.25 laser treatments over a mean duration of 3.44 months (range, 1.13–6.87 months). Of the 4 lesions that did not clear, 2 were nodular, 1 was pigmented, and 1 was sclerosing.

Number of Treatments
When the clearance rate is divided into lesions that received 3 or fewer laser treatments and those that received more than 3 laser treatments, the following results were determined:

• Lesions receiving 3 or fewer treatments had a clearance rate of 96.05% (73/76) for all BCCs, 96.72% (59/61) for facial BCCs, and 93.33% (14/15) for nonfacial BCCs.

• Lesions receiving more than 3 laser treatments had a clearance rate of 94.12% (16/17) for all BCCs, 93.75% (15/16) for facial BCCs, and 100% (1/1) for nonfacial BCCs.

The relationship between facial BCC tumor diameter and number of treatments required for clearance had a positive correlation coefficient (Pearson r=0.319), indicating that larger BCCs required more laser treatments (eTable 3).

Tumor Recurrence
Four of 89 BCCs (4.49%)(4 of 74 facial BCCs [5.41%]) showed tumor recurrence following laser treatment, as assessed by OCT and dermoscopy. Of them, all were nodular BCCs. Prior to laser treatment, there were 4 additional patients each diagnosed with a recurrence from prior treatment with MMS; all were successfully treated with laser therapy without recurrence post–laser treatment (eFigure 1). Most of the recurrences from prior MMS required more than 3 laser treatments before clearing: 1 required 3 treatments, 2 required 4 treatments, and 1 required 6 treatments.

eFigure 1. A, A recurrent basal cell carcinoma (BCC) following Mohs micrographic surgery (MMS) without clinical evidence of recurrence. This lesion, as well as 3 other recurrent BCCs post-MMS in different patients, was detected early within the scar using noninvasive imaging with dermoscopy, optical coherence tomography (OCT), and reflectance confocal microscopy. B, A BCC recurrence after 3 nonablative laser treatments. Although there was no clinical and/or dermoscopy evidence for BCC, BCC recurrence was detected with OCT and confirmed with RCM post–laser treatment at a 3-year follow-up.

Of 93 lesions included in this study, 2 BCCs were deemed not clear on histologic analysis, which corresponded with residual tumor seen on OCT. Two additional lesions were determined to be not clear on OCT but were not confirmed as such on biopsy; both lesions were confirmed not clear, however, by histologic analysis on the first layer of MMS

Follow-up
All cleared lesions (89/93) showed complete clinical response to laser treatment for 6 months or more (median follow-up, 2–3 years; mode, 1–2 years; mean, 2.66 years)(eTable 4). Although 45% of patients (40/89) have been followed clinically and/or dermoscopically (as is done for MMS follow-ups) for 3 years to more than 5 years, only 20% of patients (18/89) were followed up with OCT in combination with clinical and/or dermoscopic examination between 3 years and more than 5 years. Follow-up took on a bimodal distribution, with a peak follow-up period at 1 to 2 years and again at 3 to 4 years. Half of the lesions (45/89) were followed up with OCT in combination with clinical and dermoscopic examination at 1 to 6 months (eTable 5). Of the 2 patients with 1-month OCT follow-up, 1 died from other medical causes and the other was unable to return for further follow-up scans.

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