Immunocryosurgery for patients with therapeutically challenging basal cell carcinomas: Report of two representative cases

Surgery, including Mohs’ technique, is regarded the reference modality for the treatment of most basal cell carcinomas (BCCs) (1). Yet surgical treatment in challenging cases (large, multiple, confluent or recurrent BCCs) can be an arduous undertaking with relatively high relapse rates, particularly when conventional surgery is employed. ‘Immunocryosurgery’ has been recently introduced as a non-surgical, tissuesparing combination of cryosurgery during ongoing topical imiquimod for the treatment of ‘nonsuperficial’ BCCs (2). Herein, on the occasion of two cases, we would like to highlight the efficacy of immunocryosurgery as a treatment alternative for patients with challenging BCCs: (i) multiple/concurrent facial tumors that require extensive surgery and (ii) BCC relapses that would have mandated major reconstructive headand-neck surgery. Patient 1: A 71-year-old farmer presented with multiple (n = 18) facial BCCs (Figure 1A, B). Pathology confirmed diagnosis in two excised (eyelid BCCs) and six biopsied tumors. His medical history included prostate cancer, coronary heart disease and hyperlipidemia on goserelin acetate, clopidogrel and simvastatin, respectively. Excessive sun exposure was his only risk factor for multiple BCC. Nevoid BCC syndrome was excluded based on history, physical examination and assessment of relevant radiological signs. Daily 5% imiquimod cream (Aldara; Meda) was applied every evening on the nasal and left parietal lesions. After 2 weeks, no inflammation was evident and 0.1% tazarotene gel (Zorac; Pierre Fabre) was added every morning. Two weeks later (Figure 1C), a mild, open spray liquid N2 cryosurgery was applied to the inflamed BCCs (two freeze– thaw cycles (FTCs); 15-second freezing time each) and tazarotene and imiquimod were continued for an additional 4 weeks after cryosurgery. In this way, 16 tumors were treated in groups of three to five tumors and within 4 months the patient was diseasefree. During the 24-month follow-up, one tumor recurred (Figure 1D, arrow). Conclusively, in this patient, 15/16 tumors were effectively treated with one cycle of immunocryosurgery. Patient 2: A 63-year-old male was referred for a neglected, 28 17-mm, biopsy-proven recurrent BCC on his right ear 5 years after surgical removal of the primary (Figure 1E). His medical history included type II diabetes on glimepiride, arterial hypertension and coronary heart disease on olmesartan and metoprolol. After 3 weeks on daily imiquimod, liquid N2 cryosurgery was performed (open spray, two FTCs, 15-second freezing time each) followed by 3 additional weeks of imiquimod. The tumor cleared and has remained relapse-free for 18 months (Figure 1F).