Introduction
The aging of society leads to an increase in the occurrence of basal cell carcinoma (BCC). BCC includes both superficial and nodular lesions with a good prognosis as well as foci that are difficult to treat and require a multidisciplinary approach. There are two basic methods of treating BCC, surgery to remove the tumor and cryosurgery. The paper presents a case of an 82-year-old female patient suffering from BCC in a non-advanced stage of the disease with the presentation of subsequent stages of treatment.Aim of the studyAn attempt was made to confront an alternative method of BCC treatment by cryosurgery with the first-choice procedure - surgical excision of the tumor with a margin of healthy tissues.Description of the caseAn individual clinical case study including the patient's medical records.ConclusionsThe work emphasizes the importance of comprehensive care for a patient diagnosed with BCC.Individualization of the diagnostic and therapeutic process is the basis for dealing with the elderly patient

Grabowska, Ewa

Kapłon, Kamil

Kojder, Dominika

Możdżyńska, Agnieszka

Musiał, Lena

Pawlak, Weronika

Pawłocik, Weronika

Rymarz, Anna

Szymańska, Julia

Wojtala, Laura

English

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43KAPŁON, Kamil, WOJTALA, Laura, PAWLAK, Weronika, PAWŁOCIK, Weronika, MUSIAŁ, Lena,MOŻDŻYŃSKA, Agnieszka, SZYMAŃSKA, Julia, GRABOWSKA, Ewa, RYMARZ, Anna & KOJDER, Dominika. Basal cellcarcinoma in the elderly Cryosurgery or surgery – a case study with reference to the literature. Journal of Education, Health andSport. 2023;14(1):43-49. eISSN 2391-8306. DOI http://dx.doi.org/10.12775/JEHS.2023.14.01.005https://apcz.umk.pl/JEHS/article/view/42929https://zenodo.org/record/7736428The journal has had 40 points in Ministry of Education and Science of Poland parametric evaluation. Annex to the announcement of the Minister of Education and Science of December 21, 2021. No. 32343.Has a Journal's Unique Identifier: 201159. Scientific disciplines assigned: Physical Culture Sciences (Field of Medical sciences and health sciences); Health Sciences (Field of Medical Sciences and Health Sciences).Punkty Ministerialne z 2019 - aktualny rok 40 punktów. Załącznik do komunikatu Ministra Edukacji i Nauki z dnia 21 grudnia 2021 r. Lp. 32343. Posiada Unikatowy Identyfikator Czasopisma: 201159.Przypisane dyscypliny naukowe: Nauki o kulturze fizycznej (Dziedzina nauk medycznych i nauk o zdrowiu); Nauki o zdrowiu (Dziedzina nauk medycznych i nauk o zdrowiu).© The Authors 2023;This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, PolandOpen Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium,provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike.(http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited.The authors declare that there is no conflict of interests regarding the publication of this paper.Received: 04.03.2023. Revised: 14.03.2023. Accepted: 14.03.2023. Published: 15.03.2023.Basal cell carcinoma in the elderlyCryosurgery or surgery – a case study with reference to the literatureKamil Kapłon A-D*Uniwersytecki Szpital Kliniczny w Poznaniu ul. Przybyszewskiego 49, 60-355 Poznańhttps://orcid.org/0000-0002-8110-9352e-mail: kamil.kaplon.2022@gmail.comLaura Wojtala E-FUniwersytecki Szpital Kliniczny w Poznaniu, ul. Przybyszewskiego 49, 60-355 Poznańhttps://orcid.org/0000-0002-5715-2334Weronika Pawlak E-FSamodzielny Publiczny Zakład Opieki Zdrowotnej Ministerstwa Spraw Wewnętrznych i Administracji wPoznaniu im. prof. Ludwika Bierkowskiego. ul. Dojazd 34, 60-631 Poznańhttps://orcid.org/0000-0002-6016-1119Weronika Pawłocik E-FWojewódzki Szpital Zespolony w Lesznie, ul. Jana Kiepury 45, 64-115 Lesznohttps://orcid.org/0000-0001-7439-0820Lena Musiał E-FSzpital Średzki Serca Jezusowego Sp. z o.o. ul. Żwirki i Wigury 10, 63-000 Środa Wielkopolskahttps://orcid.org/0000-0002-1998-6477Agnieszka Możdżyńska E-FSzpital Średzki Serca Jezusowego Sp. z o.o. ul. Żwirki i Wigury 10, 63-000 Środa Wielkopolskahttps://orcid.org/0000-0001-8590-0486Julia Szymańska E-FSzpital Miejski im. Franciszka Raszei ul. Mickiewicza 2, 60-834 Poznańhttps://orcid.org/0000-0001-6113-5046Ewa Grabowska E-FNowodworskie Centrum Medyczne ul. Miodowa 2, 05-100 Nowy Dwór Mazowieckihttps://orcid.org/0000-0003-1426-520544Anna Rymarz E-FSzpital MSWiA w Lublinie ul. Grenadierów 3 20-331 Lublinhttps://orcid.org/0000-0003-3387-1569Dominika Kojder E-FSamodzielny Publiczny Zakład Opieki Zdrowotnej w Przeworsku ul. Szpitalna 16 37-200 Przeworskhttps://orcid.org/0000-0002-8915-4959A- Conception and study design; B - Collection of data; C - Data analysis; D - Writing the paper;E- Review article; F - Approval of the final version of the article*Corresponding authorABSTRACTIntroductionThe aging of society leads to an increase in the occurrence of basal cell carcinoma (BCC). BCC includes bothsuperficial and nodular lesions with a good prognosis as well as foci that are difficult to treat and require amultidisciplinary approach. There are two basic methods of treating BCC, surgery to remove the tumor andcryosurgery. The paper presents a case of an 82-year-old female patient suffering from BCC in a non-advancedstage of the disease with the presentation of subsequent stages of treatment.Aim of the studyAn attempt was made to confront an alternative method of BCC treatment by cryosurgery with the first-choiceprocedure - surgical excision of the tumor with a margin of healthy tissues.Description of the caseAn individual clinical case study including the patient's medical records.ConclusionsThe work emphasizes the importance of comprehensive care for a patient diagnosed with BCC.Individualization of the diagnostic and therapeutic process is the basis for dealing with the elderly patient.Keywords: Carcinoma, Basal Cell; Cryosurgery; General SurgeryIntroductionBasal cell carcinoma (BCC) is the most common skin cancer in the world [Figure 1]. It extremely rarelymetastasizes to internal organs that is in less than 0.1% of cases [1]. The molecular basis of tumor developmentis the activation of the Hedgehog signaling pathway [2]. BCC development factors include chronic, intermittentexposure to ultraviolet radiation, fair skin, age over 50 with a peak incidence over 75, male gender,immunodeficiencies, and some hereditary diseases such as Gorlin-Goltz syndrome or parchment skin [3]. Basalcell carcinomas are a heterogeneous group of neoplasms, including superficial and nodular lesions with a goodprognosis, as well as foci difficult to treat, requiring consultation of multidisciplinary teams [2]. Advancedtumors, i.e. those that have metastasized to local or distant lymph nodes and organs, or locally invasive tumorsthat massively infiltrate important structures such as eyes, nose and brain, currently account for approximately 1-10% of BCC. A special form of BCC characterized by an increased risk of malignancy is giant basal cellcarcinoma (GBCC), described as an aggressive tumor with the largest transverse dimension exceeding 5 cm. In1% of cases, GBCC develops on the basis of BCC [4].Primary health care plays a key role in the initial differentiation of skin lesions. When BCC is suspected, thepatient is referred to a dermatology clinic where it is possible to exclude other malignant skin tumors, e.g.melanoma. It should be remembered that BCC covers approximately 80% of non-melanoma skin tumors [5]. Aquick diagnosis and the use of appropriate therapy enable the majority of patients with BCC to be cured [6].45The first-line treatment for BCC is surgical resection with a margin of healthy tissue or Mohs surgery.Alternative methods of treatment mainly include cryosurgery, brachytherapy, photodynamic therapy andchemotherapy [2].The prognosis of advanced basal cell carcinoma of the skin has improved with the development of systemicdrugs targeting the Hedgehog signaling pathway (vismodegib, sonidegib). The indications for the use of thesemedications are BCCs that do not meet the criteria for surgical treatment or radiotherapy, or in the case ofrecurrence after surgical treatment [7].Fig.1. Typical image of basal cell carcinoma of the skin (illustrative photo) [8].Case presentationAn 82-year-old patient reported to a primary care physician in August 2021 with a tumor located within the righttemple, 1x1 cm, roundly framed, without signs of purulent secretion. The woman reported no pain. The patienthad a medical history of post-pulmonary embolism and was taking an anticoagulant drug (acenocoumarol at adose of 3 mg per day). A primary care physician with suspected BCC referred the patient to a dermatology clinicfor further diagnosis and treatment.In August 2021, a dermatologist examined with a dermatoscope and concluded that the skin lesion was a BCC.During the same visit, he performed cryosurgery in the outpatient setting. It should be noted that no lesionbiopsy was taken prior to the procedure. The wound was protected with a sterile dressing. A regular change ofthe dressing was recommended and a follow-up visit was scheduled (one month after the tumor was removed).During the first follow-up visit proper wound healing was observed.46Six months after the procedure, in February 2022, the patient returned to the dermatologist due to bleeding fromthe site of the primary location of the tumor [Fig. 2.]. The lesion’s size increased to 2x1.5 cm. The patientreported no other complaints. The dermatologist recommended surgical excision of the lesion.Fig. 2. Recurrence of BCC after cryosurgical treatment.In February 2022 surgical oncologist took a biopsy that confirmed the tumor as a BCC. In April 2022 the lesionwas removed within the boundaries of healthy tissues. Five surgical sutures were placed and a daily change ofthe sterile dressing with the wound washing using an octenidine solution was recommended. 6 months after thesurgical procedure (October 2022), no signs of BCC recurrence were found [Fig. 3]. There weren’t anyindications for adjuvant treatment in the form of brachytherapy.Fig. 3. The scar after surgery. No BCC features.47DiscussionThe choice of appropriate treatment for non-advanced BCC has been a controversial issue for many years. Manydermatology offices are equipped with equipment for cryosurgery, as one of the basic methods of combatingcommon and plantar warts, anogenital warts, molluscum contagiosum or seborrheic warts. The low operatingcosts of this type of procedure and the possibility of obtaining a quick therapeutic effect encouragedermatologists to use this method also in the treatment of tumors [Fig. 4.], [9].Fig. 4. "Cryogun" used to atomize liquid nitrogen [10].The procedure is performed on an outpatient basis and does not require the discontinuation of anticoagulantdrugs or bridging therapy necessary during preparation for surgery. However, cryosurgery is an alternativetreatment for BCC. The first-choice method remains surgical excision within healthy tissues afterhistopathological diagnosis of the lesion [11].Dermoscopy is an excellent tool for the initial diagnosis of malignant skin neoplasms, but it does not replacehistopathological examination, the result of which determines the final diagnosis of the disease [12]. Only amutual dialogue between the two diagnostic methods enables a comprehensive BCC qualification according tothe Sabbatsberg model [Fig. 5].A modification of traditional cryosurgery turns out to be freezing after taking a histopathological biopsy,according to Swedish scientists Oscar Finskas et al. The application of the procedure is limited to the diagnosesof Glas IA and IB and II according to the Sabbatsberg model, i.e. BCC with a low risk of malignancy [13].It should be remembered that the result of a standard biopsy does not provide the doctor with details of the GlasII stage, therefore it seems reasonable to direct patients with histopathological diagnosis of BCC directly forsurgery under local anesthesia.48GLAS IA – non agressive GLAS IB – non agressive1. growth pattern: nodular or nodulo-ulcerativemultifocal appearance, superficial, often cell-sparsetumors with histologic appearance with aboveaccording to 3-4.2. invasion depth: not involving subcutaneoustissues, cartilage, musculature, or bone3. invasion front: round distinct border zone againstunderlying tissue4. size and appearance: relative cell-rich tumors,distinct rounded border zones. obvious palisadingappearanceGLAS II – intermediate forms between I and IIIGLAS III1. growth pattern: infiltrative2. invasion depth: subcutaneous tissue, cartilage and bone involving3. invasion front: irregular diffuse invasion without a clear border4. size and appearance: relative cell sparse clusters of cells with pointy irregular offshoots. no palisadingappearance. many cell clusters 1-2 cells thick, here and there wedge-shaped appearanceFig. 5. Histological definition according to Sabbatsberg's model [14].ConclusionsIn this case, cryosurgery did not stop the development of the disease. Finally, 8 months after freezing, the patientwas qualified for surgical treatment. The procedure was performed with a margin of healthy tissues under localanesthesia without complications, and after another 6 months no signs of BCC recurrence were found. In thiscase, the use of cryosurgery extended the diagnostic and therapeutic process of BCC. Immediatehistopathological biopsy of the tumor could significantly shorten the path from the final diagnosis to long-termelimination of the lesions. The choice of treatment method for BCC should take into account the generalcondition of the patient, the progression of the neoplastic disease and the patient's preferences. Referring elderlypatients for BCC cryosurgery, as if by choice, without taking into account additional prognostic factors, seems tobe an unjustified therapeutic procedure.Conflicts of InterestThe authors have declared no conflict of interest.References[1] Lackey LP, Sargent LA, Wong L, Brzezienski M, Kennedy JW. Giant basal cell carcinoma surgicalmanagement and reconstructive challenges. Ann Plast Surg. 2007; 58:250.[2] Nicole Basset-Seguin, Florian Herms. Update on the Management of Basal Cell Carcinoma. Acta DermVenereol 2020; 100: adv00140.[3] Gilbody JS, Aitken J, Green A. What causes basal cell carcinoma to be the commonest cancer? Aust J PublicHealth. 1994; 18(2): 218-21.[4] Khadija Bellahammou, Asmaa Lakhdissi, Othman Akkar, et al. Metastatic giant basal cell carcinoma: a casereport. Pan African Medical Journal. 2016; 24:157.[5] Liza Brown, Jennifer David, Stanley Skopit. Locally Advanced Basal Cell Carcinoma: Two Severe CasePresentations and Review. J Drugs Dermatol. 2018; 17(3):358-362.[6] Owain T. Jones, Charindu K. I. Ranmuthu, Per N. Hall. Recognising Skin Cancer in Primary Care. Adv Ther2020; 37:603–616.49[7] Erica Tillman, Palak Kishorkumar Parekh, Ronald Eugene Grimwood Jr. Locally Destructive MetastaticBasal Cell Carcinoma. Cutis. 2019; 103(1):E23-E25.[8] Klaus D. Peter; CC BY 3.0;https://upload.wikimedia.org/wikipedia/commons/e/e2/Basalioma_02.jpg (download date: 16.01.2023).[9] Clebak KT, Mendez-Miller M, Croad J. Cutaneous Cryosurgery for Common Skin Conditions. Am FamPhysician. 2020; 101(7):399-406.[10] Warfieldian, CC BY-SA 3.0, https://upload.wikimedia.org/wikipedia/commons/a/a0/Cryogun.jpg(download date: 16.01.2023).[11] Pabiańczyk R, Cieślik K, Tuleja T. Metody leczenia raka podstawnokomórkowego skóry. Chirurgia Polska.2011; 13(1): 48–58.[12] Forum Dermatologicum 2019, tom 5, nr 2, 51–79 2019; Via Medica ISSN 2451–1501.[13] Oscar Finskas, Oscar Zaar, Karin Svedberg. Cryosurgery of Periocular Moderately Aggressive Basal CellCarcinoma. Acta Derm Venereol 2020; 100: adv00336.[14] Jernbeck J, Glaumann B, Glas JE. Basal cell carcinoma. Clinical evaluation of the histological grading ofaggressive types of cancer. Lakartidningen 1988; 85: 3467–3470. Swedish.

Basal cell carcinoma in the elderly Cryosurgery or surgery – a case study with reference to the literature

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Basal cell carcinoma in the elderly Cryosurgery or surgery – a case study with reference to the literature

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