Elsevier

The Lancet

Volume 364, Issue 9447, 13–19 November 2004, Pages 1766-1772
The Lancet

Articles
Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial

https://doi.org/10.1016/S0140-6736(04)17399-6Get rights and content

Summary

Background

Rates of recurrence of facial basal-cell carcinoma are consistently lower after Mohs' micrographic surgery (MMS) than after other treatments, such as surgical excision (SE). However, MMS is more time-consuming and therefore more expensive than SE. We investigated the types of facial basal-cell carcinomas in which MMS was more effective than SE.

Methods

408 primary and 204 recurrent facial carcinomas (374 and 191 patients, respectively) were analysed separately in this prospective randomised study. Patients were assigned SE or MMS (each 204 primary, 102 recurrent), and received treatment at two hospitals in the Netherlands. The primary outcome was recurrence of carcinoma. Analysis was by intention to treat.

Findings

Of the basal-cell carcinomas included in the trial, 397 primary (198 MMS, 199 SE) and 201 recurrent (99, 102) tumours were actually treated. Of patients with primary carcinomas, 21 had both MMS and SE on different tumours. Nine with recurrent carcinomas had both treatments on different skin tumours. 66 primary and 13 recurrent carcinomas were lost to follow-up. Of the primary carcinomas, five (3%) recurred after SE compared with three (2%) after MMS during 30 months of follow-up. Of the recurrent carcinomas, three (3%) recurred after SE and none after MMS during 18 months of follow-up. Four recurrent carcinomas randomly assigned to the SE group were treated with MMS. Although both differences favoured MMS, they were not significant (primary, difference 1% [95% CI –2·5% to 3·7%], p=0·724; recurrent, 3·2% [–2·0% to 5·0%], p=0·119). Total operative costs of MMS were higher than those of SE (primary €405·79 vs €216·86, recurrent €489·06 vs €323·49; both p<0·001).

Interpretation

No definitive conclusion on recurrence rates of primary or recurrent basal-cell carcinomas is yet possible. Although recurrence rates were lower after MMS than after SE, the differences were not significant.

Introduction

Basal-cell carcinoma is the most common cancer in white people and its incidence continues to increase.1, 2 Although such carcinomas rarely metastasise, some (especially large, neglected, or incompletely treated primary and recurrent tumours) cause substantial morbidity and even mortality.3 Tumour removal (prevention of recurrent tumours), preservation of healthy skin, aesthetic outcome, and costs are important in the treatment of this predominantly facial skin tumour. A previous randomised trial showed that surgery is preferable to radiotherapy.4 Most basal-cell carcinomas are treated worldwide by surgical excision (SE).5, 6

Cure rates for these carcinomas with Mohs' micrographic surgery (MMS) have proved better than those with any other treatments (including SE, radiotherapy, and cryosurgery) in non-comparative studies.7, 8 However, the need for MMS has been questioned, because the procedure is more time-consuming and therefore more expensive than SE.9, 10 We report the results of a randomised trial comparing SE with MMS in the treatment of primary and recurrent facial basal-cell carcinomas.

Section snippets

Patients

To be eligible for the primary basal-cell carcinoma group, a patient had to have at least one untreated, histologically confirmed, facial tumour of at least 1 cm in diameter, located in the H zone (figure 1); or an aggressive histopathological subtype (morpheaform, micronodular, basal-cell carcinoma with squamous differentiation, trabecular, infiltrative). To be eligible for the recurrent group, a patient had to have at least one histologically confirmed, facial tumour recurring for the first

Primary basal-cell carcinomas

From October, 1999, to January, 2001, 374 patients with 408 primary basal-cell carcinomas were randomised. 69 patients with 78 primary tumours did not want to participate in the study, mostly because they specifically preferred SE or MMS. 21 patients had both MMS and SE, but on different skin tumours. 11 patients with 11 carcinomas were not given their assigned treatments (figure 2). Empirical data were available for 397 individuals.

Of the patients who were randomised, 342 had one basal-cell

Discussion

We found slightly fewer recurrences after MMS than after SE in the treatment of primary and recurrent facial basal-cell carcinomas, but this difference was not significant. Moreover, the 95% CIs show that the benefit of MMS is unlikely to be more than 3·7% in primary tumours or more than 5·0% in recurrent tumours, which is substantially smaller than the differences postulated in our power analysis. Although a 5-year follow-up period is still needed to determine definite recurrence rates in both

References (30)

  • RJ Motley et al.

    Treatment of basal cell carcinoma by dermatologists in the United Kingdom. British Association of Dermatologists Audit Subcommittee and the British Society for Dermatological Surgery

    Br J Dermatol

    (1995)
  • MR Thissen et al.

    A systematic review of treatment modalities for primary basal cell carcinomas

    Arch Dermatol

    (1999)
  • DE Rowe et al.

    Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma

    J Dermatol Surg Oncol

    (1989)
  • S Shuster

    The case against micrographically controlled skin surgery

    Acta Derm Venereol

    (1999)
  • CM Lawrence

    Mohs' micrographic surgery for basal cell carcinoma

    Clin Exp Dermatol

    (1999)

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