Photodiagnosis and Photodynamic Therapy (2006) 3, 128—131
HOW-TO-DO-IT
How we treat a superficial basal cell carcinoma with topical photodynamic therapy in Dundee Sally H. Ibbotson MD, FRCP ∗ Photobiology Unit, Ninewells Hospital & Medical School, Dundee, University of Dundee, Dundee DD1 9SY, United Kingdom Available online 3 May 2006 KEYWORDS Photodynamic therapy; Superficial basal cell carcinoma; 5-aminolaveluvinic acid (ALA); Methyl ester ALA (ALA)
Summary Topical photodynamic therapy (PDT) is a highly effective treatment for superficial basal cell carcinoma (SBCC) (Morton CA, Brown SB, Collins S, et al. Guidelines for topical photodynamic therapy: report of a workshop of the British Photodermatology Group. Br J Dermatol 2004;146:552—67). Treatment is well tolerated, performed on an outpatient basis and can be repeated, and excellent outcomes and cosmetic results can be achieved. We have experience of over 3000 topical PDT treatments for superficial non-melanoma skin cancer and dysplasia in the Photobiology Unit in Dundee and I will present our own experience of how to treat an SBCC with topical PDT in this article (Ibbotson SH, Moseley H, Brancaleon L, et al. Photodynamic therapy in dermatology: Dundee clinical and research experience. Photodiagn Photodyn Ther 2004;1:211—23). © 2006 Elsevier B.V. All rights reserved.
Introduction Patients are referred to the photodynamic therapy (PDT) clinic with a histologically confirmed diagnosis of superficial basal cell carcinoma (SBCC). On receipt of the referral letter, we ensure that the tumour type as stated on the pathology report is suitable for topical PDT, i.e., generally not exceeding 2 mm in histological thickness and tumours that are not nodular, morphoeic or heavily pigmented [1,2]. We would not consider PDT to be the treatment of choice for these more difficult tumour types unless, for nodular BCC, a surgical approach
∗
Tel.: +44 1382 496227; fax: +44 1382 633925. E-mail address: [email protected].
is not appropriate, in which case surface curettage would be required before PDT. Patients receive written information about the nature of PDT and what it will involve on the day and the patient’s GP will also have been informed in writing in advance of the PDT clinic. At the PDT clinic appointment, the patient will be assessed by medical or technical staff and the lesion for treatment will be photographed close up and with an overview for body site location. The site and maximum diameter of the lesion is also documented. The nature of the treatment process is gone through in detail with the patient and written consent obtained. Patients are advised when they receive their appointment to apply Vaseline to the tumour for three days before attending in order to loosen any surface crust or debris. On assessment, if
1572-1000/$ — see front matter © 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.pdpdt.2006.03.010
How we treat a superficial basal cell carcinoma with topical photodynamic therapy in Dundee
129
Figure 1 (a) Application of ALA (20%) to a SBCC on the calf after surface preparation; (b) occlusion under TegadermTM .
the lesion is still heavily crusted, then a disposable ring curette is used to gently remove any remaining debris. This procedure is performed without local anaesthetic and is not sufficient to cause pain or significant bleeding. 5-aminolaevulinic acid (ALA, 20% (w/v) in an oil in water base, Crawford’s Pharmaceuticals, UK) is applied to the lesion with a 5 mm rim of surrounding normal tissue under TegadermTM occlusion for 6 h (Fig. 1a and b). If the lesion is on a daylight-exposed site such as head or neck, then an additional light opaque dressing (Mepore® ) is applied to protect the treatment site. The patient will then either spend time in the department or leave and return for the irradiation procedure in the afternoon. After 6 h the dressing and residual ALA are removed and the tumour is examined in a dark room using Wood’s light illumination. We use a semi-quantitative scale for fluorescence according to its intensity and specificity (Table 1). Following documentation of this we then use the naked eye to view the tumour and fluorescence outline to demarcate the irradiation field to include a Table 1
5 mm rim of clinically normal appearing tissue and the maximum diameter of the irradiation field is documented. Irradiation is performed using one of several light sources that we have available in the department (Table 2). The light sources that are in most common use at present are the Aktilite® LED sources (Fig. 2a and b). In addition, we use the diode laser, although there is no evidence in the literature that superior results are obtained with laser light and lasers are much more expensive [3]. The light source used and the skin surface irradiance is documented and the duration of time required to deliver a standard dose of 125 J/cm2 for laser and non-LED sources or 37 J/cm2 for the LEDs is also documented. However, in our experience with ALA PDT, an LED dose of 37 J/cm2 results in unacceptably low clearance rates and we therefore use 75 J/cm2 for ALA PDT for SBCC using an LED source. A cooling fan and chatting with the patients to put them at ease is used routinely during irradiation, but for patients in whom pain is a significant problem during irradiation (at least 20% of our patients) we also use a Xylocaine spray, and/or a
Semi-quantitative grading of fluorescence
Fluorescence intensity Fluorescence specificity
0 = None 1 = Lesion only
1 = Minimal 2 = Mainly lesion
2 = Moderate 3 = Surrounding and lesion equal
3 = Marked 4 = Mainly surround
130 Table 2
S.H. Ibbotson Light sources used for topical PDT in our unit
Trade name
Type of source
Wavelength/band emission range (nm)
Skin surface irradiance (mW/cm2 )
Diomed® Waldmann 1200® Curelight® Aktilite 16® Aktilite 128®
Diode laser Metal halide Tungsten filament LED LED
630 580—740 560—710 600—650 600—650
120 70—90
HOW-TO-DO-IT
How we treat a superficial basal cell carcinoma with topical photodynamic therapy in Dundee Sally H. Ibbotson MD, FRCP ∗ Photobiology Unit, Ninewells Hospital & Medical School, Dundee, University of Dundee, Dundee DD1 9SY, United Kingdom Available online 3 May 2006 KEYWORDS Photodynamic therapy; Superficial basal cell carcinoma; 5-aminolaveluvinic acid (ALA); Methyl ester ALA (ALA)
Summary Topical photodynamic therapy (PDT) is a highly effective treatment for superficial basal cell carcinoma (SBCC) (Morton CA, Brown SB, Collins S, et al. Guidelines for topical photodynamic therapy: report of a workshop of the British Photodermatology Group. Br J Dermatol 2004;146:552—67). Treatment is well tolerated, performed on an outpatient basis and can be repeated, and excellent outcomes and cosmetic results can be achieved. We have experience of over 3000 topical PDT treatments for superficial non-melanoma skin cancer and dysplasia in the Photobiology Unit in Dundee and I will present our own experience of how to treat an SBCC with topical PDT in this article (Ibbotson SH, Moseley H, Brancaleon L, et al. Photodynamic therapy in dermatology: Dundee clinical and research experience. Photodiagn Photodyn Ther 2004;1:211—23). © 2006 Elsevier B.V. All rights reserved.
Introduction Patients are referred to the photodynamic therapy (PDT) clinic with a histologically confirmed diagnosis of superficial basal cell carcinoma (SBCC). On receipt of the referral letter, we ensure that the tumour type as stated on the pathology report is suitable for topical PDT, i.e., generally not exceeding 2 mm in histological thickness and tumours that are not nodular, morphoeic or heavily pigmented [1,2]. We would not consider PDT to be the treatment of choice for these more difficult tumour types unless, for nodular BCC, a surgical approach
∗
Tel.: +44 1382 496227; fax: +44 1382 633925. E-mail address: [email protected].
is not appropriate, in which case surface curettage would be required before PDT. Patients receive written information about the nature of PDT and what it will involve on the day and the patient’s GP will also have been informed in writing in advance of the PDT clinic. At the PDT clinic appointment, the patient will be assessed by medical or technical staff and the lesion for treatment will be photographed close up and with an overview for body site location. The site and maximum diameter of the lesion is also documented. The nature of the treatment process is gone through in detail with the patient and written consent obtained. Patients are advised when they receive their appointment to apply Vaseline to the tumour for three days before attending in order to loosen any surface crust or debris. On assessment, if
1572-1000/$ — see front matter © 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.pdpdt.2006.03.010
How we treat a superficial basal cell carcinoma with topical photodynamic therapy in Dundee
129
Figure 1 (a) Application of ALA (20%) to a SBCC on the calf after surface preparation; (b) occlusion under TegadermTM .
the lesion is still heavily crusted, then a disposable ring curette is used to gently remove any remaining debris. This procedure is performed without local anaesthetic and is not sufficient to cause pain or significant bleeding. 5-aminolaevulinic acid (ALA, 20% (w/v) in an oil in water base, Crawford’s Pharmaceuticals, UK) is applied to the lesion with a 5 mm rim of surrounding normal tissue under TegadermTM occlusion for 6 h (Fig. 1a and b). If the lesion is on a daylight-exposed site such as head or neck, then an additional light opaque dressing (Mepore® ) is applied to protect the treatment site. The patient will then either spend time in the department or leave and return for the irradiation procedure in the afternoon. After 6 h the dressing and residual ALA are removed and the tumour is examined in a dark room using Wood’s light illumination. We use a semi-quantitative scale for fluorescence according to its intensity and specificity (Table 1). Following documentation of this we then use the naked eye to view the tumour and fluorescence outline to demarcate the irradiation field to include a Table 1
5 mm rim of clinically normal appearing tissue and the maximum diameter of the irradiation field is documented. Irradiation is performed using one of several light sources that we have available in the department (Table 2). The light sources that are in most common use at present are the Aktilite® LED sources (Fig. 2a and b). In addition, we use the diode laser, although there is no evidence in the literature that superior results are obtained with laser light and lasers are much more expensive [3]. The light source used and the skin surface irradiance is documented and the duration of time required to deliver a standard dose of 125 J/cm2 for laser and non-LED sources or 37 J/cm2 for the LEDs is also documented. However, in our experience with ALA PDT, an LED dose of 37 J/cm2 results in unacceptably low clearance rates and we therefore use 75 J/cm2 for ALA PDT for SBCC using an LED source. A cooling fan and chatting with the patients to put them at ease is used routinely during irradiation, but for patients in whom pain is a significant problem during irradiation (at least 20% of our patients) we also use a Xylocaine spray, and/or a
Semi-quantitative grading of fluorescence
Fluorescence intensity Fluorescence specificity
0 = None 1 = Lesion only
1 = Minimal 2 = Mainly lesion
2 = Moderate 3 = Surrounding and lesion equal
3 = Marked 4 = Mainly surround
130 Table 2
S.H. Ibbotson Light sources used for topical PDT in our unit
Trade name
Type of source
Wavelength/band emission range (nm)
Skin surface irradiance (mW/cm2 )
Diomed® Waldmann 1200® Curelight® Aktilite 16® Aktilite 128®
Diode laser Metal halide Tungsten filament LED LED
630 580—740 560—710 600—650 600—650
120 70—90
