Original Research

Patient-Driven Management Using Same-Day Noninvasive Diagnosis and Complete Laser Treatment of Basal Cell Carcinomas: A Pilot Study

Author and Disclosure Information

The increasing incidence of nonmelanoma skin cancer (NMSC) poses a serious public health concern. Standard care for basal cell carcinoma (BCC) requires patients to attend multiple visits for diagnosis and treatment. This pilot study describes a model of care that aims to alleviate some of the demand placed both on the specialty and on patients by utilizing a novel same-day approach to BCC management with noninvasive diagnosis, same-day treatment, and noninvasive imaging follow-up. This study evaluates the efficacy of the 1064-nm Nd:YAG laser for treating BCC while leveraging noninvasive imaging technology for diagnosis and confirmation of clearance.

Practice Points

  • Novel imaging modalities such as reflectance confocal microscopy and optical coherence tomography can be used to diagnose, monitor treatment response, and confirm clearance of basal cell carcinoma.
  • Leveraging new imaging technologies can enable a streamlined patient experience, with same-day diagnosis and management of skin cancer.
  • For patients who do not desire surgical management of nonmelanoma skin cancer, laser treatment with Nd:YAG is a promising emerging therapeutic option.


 

References

The increasing incidence of nonmelanoma skin cancer (NMSC) is a serious public health concern.1 Lesions often are identified on routine total-body examination, and there is a considerate burden on dermatologists to diagnose these lesions, which is both costly and results in a long wait time to see a specialist. Furthermore, standard care requires patients to attend multiple visits for the diagnosis and treatment of NMSC.

In recent decades, diagnosing basal cell carcinoma (BCC) has been facilitated by the handheld dermatoscope. The advent of dermoscopy has led to increased sensitivity and specificity of the NMSC diagnosis (estimated at 95%–99%) and has helped facilitate earlier diagnosis of BCC and reduce unnecessary biopsy of benign lesions.2-5 Dermoscopy also can be useful in monitoring response to treatment.5 Lesions that are detected early tend to be easier and less expensive to treat, a strong argument for the use of early detection techniques.6-8

More recently, in vivo reflectance confocal microscopy (RCM)(Vivascope 1500 [Caliber I.D.]) has become an acceptable means for confirming a BCC diagnosis, offering an alternative to tissue biopsy. Reflectance confocal microscopy can be reimbursed under Category I Current Procedural Terminology codes 96931 to 96936.9 Reflectance confocal microscopy is a noninvasive diagnostic technique that uses an 830-nm diode laser to enable visualization of a 0.5×0.5-mm patch of skin to a depth of 200 to 300 μm, which corresponds roughly to the papillary dermis. Reflectance confocal microscopy has the advantage of providing real-time diagnosis, enabling same-day treatment of BCC, and providing an efficient alternative to biopsy. Ultimately, these advantages are beneficial and time-saving for patients because biopsies can be painful; create a delay in diagnosis; and require further follow-up visits for treatment, which may be of importance to patients who have trouble attending multiple appointments.

Optical coherence tomography (OCT) is another noninvasive imaging device that is useful in BCC management. It uses an infrared broadband light source to visualize skin architecture to 2-mm deep with a 6×6-mm field of view.10 Although OCT does not offer the same cellular clarity as RCM, it allows visualization of a greater depth of skin and a wider field of view, making it a useful tool both in marginating NMSCs prior to treatment and monitoring response to treatment over time.11-16 Optical coherence tomography has demonstrated a high negative predictive value (92.1%) for BCC, which makes it useful for ruling out residual tumor in lesions undergoing management.17-19

With all available options, BCC management benefits from care that is tailored to the individual and the lesion, taking into account size and subtype because not every available treatment is appropriate. Lasers, including solid state, diode, dye, and gas types, are emerging as promising minimally invasive treatment modalities.20,21

Nonablative laser therapy with a pulsed dye laser (PDL) and fractional laser is an example; the principal investigator (PI) of this study (O.M.) recently reported a 95.70% clearance rate utilizing a PDL and fractional laser protocol.22 The 1064-nm Nd:YAG laser also has been used with PDL and as a stand-alone treatment. Jalian et al23 used PDL and the Nd:YAG laser on 13 BCC lesions, with a 58% (7/12) clearance rate after 4 treatments; all nonresponders were taking an anticoagulant, which inhibited the laser’s mechanism of action, according to the researchers.

Moskalik et al24 published a report of 3346 facial BCC lesions treated with pulsed Nd and pulsed Nd:YAG lasers, and included follow-up for as long as 5 years, with a 3.7% recurrence rate. Another report by Moskalik et al25 recorded a recurrence rate of 2.2% to 3.1% for BCCs that were followed for at least 5 years.

Ortiz et al26 reported use of the long-pulsed 1064-nm Nd:YAG laser to treat 13 lesions with biopsy-confirmed BCC on the trunk and extremities, with a 92% (12/13) clearance rate based on histologic analysis 1 month after laser treatment. In an expanded study of 31 patients by Ortiz et al,27 the histologic clearance rate was 90.3% (28/31)—also obtained after 1 month—after 1 Nd:YAG laser treatment, also treating lesions on the trunk and extremities. A further retrospective review of Nd:YAG laser treatment of BCC revealed a 100% clearance rate for 16 lesions (including lesions on the face) that were monitored for at least 6 months (mean duration, 9 months; range, 6–15 months).28 Optical coherence tomography imaging was used for one of the review’s lesions before and after treatment and suggested that the Nd:YAG laser works by selectively destroying the vasculature supplying BCC tumors while preserving surrounding healthy tissue.28

Apart from Moskalik et al,24,25 these studies are limited by a relatively short follow-up time to confirm tumor clearance. Prior studies utilizing the Nd:YAG laser to treat BCC are summarized in the eTable.

This pilot study describes a model of care that aims to alleviate some of the demand placed both on the specialty and on patients by utilizing a novel same-day approach to BCC management. We sought to evaluate management using noninvasive diagnosis with RCM; same-day laser treatment; and follow-up examination with clinical, dermoscopic, and noninvasive imaging using OCT. This method focuses on patient-driven health care from various perspectives. Patients are given real-time information about their diagnosis using RCM, leading to an increased level of information flow and immediate transparency regarding their diagnosis and management options. Patients also are receiving tailored care by incorporating noninvasive imaging and same-day laser treatment, allowing collaboration between patient and physician. Patients have more choices—to undergo surgical care; other at-home topical regimens; or laser management with potentially fewer visits, immediate results, a clearance rate similar to surgery, and improved cosmetic outcome.

Our study attempts to further evaluate the efficacy of the 1064-nm Nd:YAG laser in treating BCC while leveraging noninvasive imaging technology. The objective was to perform a retrospective review of medical records of a subgroup of patients with BCC diagnosed by RCM who were treated with the 1064-nm Nd:YAG laser and monitored for clearance using OCT imaging, in addition to clinical and dermoscopic examination. Similar to prior long-term Nd:YAG laser follow-up studies, we aimed to demonstrate the possibility of a minimally invasive BCC management approach—in our protocol, utilizing imaging instead of biopsy to facilitate long-term follow-up and by offering a model for patient-driven care.

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