STOWE, VT. Tangential excision is a reliable, expedient alternative to conventional excision for most basal cell carcinomas on the trunk, Dr. Glenn Goldman said at a dermatology conference sponsored by the University of Vermont.
Curettage is "relatively unreliable for most basal cell carcinomas" because it is associated with a higher level of recurrence, said Dr. Goldman of the division of dermatology at the university.
"I love curetting seborrheic keratoses, squamous cell carcinoma in situ without follicular involvement, and really tiny red-skinned basal cell carcinomas, but for basal cell carcinomas that have a little bit of substance to them, [curettage] is not the best approach," he said.
On the other hand, conventional excision is surgical overkill for most basal cell carcinomas. "Most 'invasive' and even 'infiltrative' basal cell carcinomas on truncal extremities are shallow lesions, typically about 0.1 or 0.2 mm. If you do a standard excision on the back, you're cutting through centimeters of tissue in order to close the wound that really only needs to be a millimeter deep," he explained.
For tangential excision, a scalpel is used to shave a partial thickness of the dermis that includes the entire lesion. The approach "is much faster than curettage," Dr. Goldman said.
"I can do a tangential excision in one-quarter of the time it would take to curette the basal cell carcinoma. Also, tangential excision has a high cure rate, and there's no restriction on patient activity." Although tangential excisions on the trunk and extremities heal slowly, he noted, "the long-term scar is subtle."
Tangential excision also provides pathology samples of the lesions. "I send these to the lab and the pathologists do sections on them from one end to the other and provide a full pathology report with extent to margin information and so forth," Dr. Goldman said. "In my practice, this technique has been consistently successful. I've done hundreds of these and have only had two positive margins."
Performing a tangential excision takes "a bit of technique," he noted. The first step is to prep the area with alcohol and meticulously outline the lesion. After numbing the area with local anesthesia, he uses "a number 15 blade to make an incision in the papillary dermis. Next, take the blade and peel the lesion off like a shave biopsy. Toss it into a pathology bottle and there it is," he said.
After the procedure, apply pressure to the area to stop the bleeding. "Sometimes I add a little bit of aluminum chloride, but I don't ever cauterize," Dr. Goldman added.
In terms of billing for the procedure, "it's not a destruction, so it can't be billed that way, and it's not an excision because you don't penetrate to fat," he said. "You can bill it as a shave. … You may have to argue it a bit, but I've talked this over with our Medicare provider, and it is appropriate. You could also bill it as a biopsy," he said.
"One of the reasons I believe in this technique is that every patient I've ever seen who's come to me from somewhere else with hundreds of basal cells and many that have recurred after removal has not had any recurrences of the lesions I've taken off this way," Dr. Goldman concluded.