Results
Patient Characteristics
A total of 16 patients (6 female, 10 male) with 17 BCCs were included in this study. Mean age was 68 years (median, 71.5 years; range; 48–89 years). Mean lesion size was 7.1 mm (median, 6 mm; range, 3–15 mm). Eight lesions were on the face; 9 were on extrafacial sites. Two lesions had a history of laser treatment with the PI’s PDL with fractional laser treatment protocol and had locally recurred. Subtypes of lesions were not elicited by RCM.
Outcomes
Fourteen lesions (14/17 [82.4%]) required 1 treatment to achieve clearance, as confirmed clinically, dermoscopically, and by OCT scanning. One lesion on the back (1/17 [5.8%]) required 2 treatments (70 days between treatments). Two lesions (2/17 [11.8%]) required 3 treatments (time between treatments: 49 and 61 days [lesion 1]; 62 and 64 days [lesion 2]). Lesion 1 was on the face; lesion 2 was on the back. Mean time between last treatment and OCT clearance scan was 103 days (median, 64 days; range, 48–371 days).
Comment
Our study supports the notion that the 1064-nm Nd:YAG laser is a viable option for treating BCC. All (100%) lesions cleared, most (82.4%) with a single treatment. Of course, for patients who required more than 1 treatment (17.6%), we cannot make an argument for fewer patient visits because those patients had to return for multiple laser treatments, but they were able to avoid surgery, as they had wanted. Overall, our diagnostic approach utilizing RCM as opposed to traditional tissue biopsy meant that patients’ skin cancers were diagnosed and treated the same day.
A one-stop shop for diagnosis and treatment model has been reported by Kadouch et al32 as part of a randomized controlled trial in which patients were randomly assigned to receive standard care for BCC—biopsy followed by surgical excision—or RCM diagnosis followed by surgical excision. Their outcome was tumor-free margins after surgical treatment; the RCM approach was found to be noninferior to standard care.32 Our retrospective study differs, of course, in its laser treatment approach; however, both studies investigated a potentially more efficient pathway to BCC management, which becomes increasingly relevant given the rising incidence of NMSC.
A real-time, image-based diagnostic approach combined with laser treatment delivers patient-driven care, offering choice and convenience. It might be optimal for patients who have an extensive history of BCC, are poor surgical candidates, have difficulty with the logistics of the multiple visits required for surgical management, cannot (for practical reasons) spend multiple hours in office between Mohs stages, and do not want potentially disfiguring scars, making a minimally invasive treatment preferable.
As we found in our sample, not all patients are amenable to undergoing what is regarded now as the most definitive treatment—namely, surgical options. This subset of patients, whose lesions require more definitive treatment but who do not desire invasive management, need alternative approaches to BCC treatment. The present study proposes a model of patient-driven care that requires collaboration between physician and patient, offering more customized care that takes into account patient choice.
In our study, most patients had lesions that were detected early in their evolution; these lesions might be particularly amenable to laser management. The 2 resistant lesions in our set—requiring 3 treatments—appeared more aggressive clinically at initial evaluation but still had posttreatment outcomes with mild dyschromia similar to the lesions only treated once (Figure, A–D). Of those 2 lesions, the 9-mm lesion on the back (Figure, C and D) might have been larger than clinically apparent; in hindsight, it might have responded to a single treatment had it been premarginated. (An additional factor to have considered is the patient’s immunosuppressed status, which might have led to a more resistant lesion. Larger trials would help elucidate whether an immunosuppressed patient requires a different treatment approach, broader treatment area, OCT premargination regardless of anatomic location, or a greater number of treatments.) Nevertheless, the 2 aforementioned patients were offered treatment with the 1064-nm Nd:YAG laser because they refused surgery, radiation, and other more aggressive modalities. The patients were given advanced warning of an increased possibility of recurrence or nonclearance.
A, Basal cell carcinoma on the face that was clinically more advanced, ulcerated, and bleeding. B, After 3 treatments with the 1064-nm Nd:YAG laser. C, Basal cell carcinoma on the back that was clinically more advanced, ulcerated, and bleeding. D, After 3 treatments with the 1064-nm Nd:YAG laser. E, Basal cell carcinoma on the back that was on the larger side of an immunosuppressed patient (1.5 cm in diameter). F, After 2 treatments with the 1064-nm Nd:YAG laser.
The lesion that required 2 treatments did not appear to be an aggressive subtype; however, it was considerably larger than most other treated lesions (1.5 cm)(Figure, E and F). In this patient, as with the others, we utilized milder (700–1000 J) fluence settings than those used in the Moskalik et al24 study; however, we were optimizing for patient comfort, overall downtime, and cosmetic outcomes.
Clearance in this study was assessed by OCT scanning. Scans were obtained 2 months after the last treatment to avoid detecting inflammation and early scar tissue. We opted not to perform biopsies to determine clearance, as done in prior studies, because we were investigating a fully nonsurgical protocol and wanted to enable patients to avoid surgical intervention, as they had requested. Clinical and dermoscopic examinations by a world expert in dermoscopy and OCT (O.M.) provided additional reassurance of lesion clearance.
Limitations
The retrospective study design with a limited sample size was a main limitation of our study. Our limited data suggest that there is value in further investigation and prospective trials of minimally invasive skin cancer management with the pulsed 1064-nm Nd:YAG laser.
Limitations or disadvantages of this nonablative laser treatment include dyschromia and minimal scarring. Furthermore, at fluence settings utilized, treatment can be painful. Without use of a local anesthetic, treatment is limited to what patients can tolerate.
The percentage of BCCs located on the body (53%) was higher in our study than in the general population, estimated in a study to be approximately 20%.33 This percentage might have been an effect of the larger Vivascope 1500 RCM probe, which made certain areas of the face difficult to access, therefore excluding certain facial lesions encountered in our practice from the initial noninvasive diagnosis.
Most lesions in our study have not been followed long-term; median noninvasive OCT follow-up was 64 days; however, the longest follow-up from our data set is longer than 1 year posttreatment (371 days). We have used OCT to establish clearance, which also will allow us to continue using imaging to monitor for changes that might indicate recurrence. Although OCT is not approved by the US Food and Drug Administration as a validated means of diagnosing and detecting BCC, numerous studies have suggested that this modality has high sensitivity (95.7%) and specificity (75.3%) for features of BCC as well as the more critical high negative predictive value (92.1%) for noninvasive management.22-24
Furthermore, setting up the lesions to be monitored long-term using OCT is likely to be more sensitive than monitoring lesions by clinical examination alone, as they have been followed in studies to date. In fact, an earlier study of 115 lesions by the PI found that utilizing OCT significantly improved sensitivity and specificity for detecting BCC (P<.01); improved diagnostic certainty by a factor of 4 compared to clinical examination alone; and improved overall diagnostic accuracy by 50% compared to clinical and dermoscopic examinations.19
Conclusion
Traditional approaches to BCC management usually involve multiple visits: the initial encounter, which might or might not include biopsy, and a return visit for more definitive management. Reflectance confocal microscopy enables live diagnosis and facilitates targeted same-day treatment of BCC. Our pilot study has contributed data to support the further investigation and use of the Nd:YAG laser to treat BCC in combination with early detection with noninvasive diagnosis for a more patient-driven approach. For some patients as well as for dermatologists, the potential for increased efficiency of same-day diagnosis and treatment might provide a clear advantage.