title: Fractionated 5-aminolevulinic acid photodynamic therapy after partial debulking versus surgical excision for nodular basal cell carcinoma: a randomized controlled trial with at least 5-year follow-up.
abstract: BACKGROUND
  Although effective in superficial basal cell carcinoma (BCC), the treatment effect of photodynamic therapy (PDT) in nodular BCC (nBCC) is still questionable. The relation between tumor thickness and PDT failure is unclear.
  
  
  OBJECTIVE
  We sought to compare long-term effectiveness of fractionated 20% 5-aminolevulinic acid (ALA)-PDT with prior partial debulking versus surgical excision in nBCC. The effect of tumor thickness on ALA-PDT failure was analyzed.
  
  
  METHODS
  173 primary, histologically proven nBCCs in 151 patients were randomized to fractionated ALA-PDT (n = 85) or surgical excision (n = 88). Two PDT illuminations were performed with a 1-hour interval. Follow-up was at least 5 years posttreatment. Clinical recurrences were confirmed histologically.
  
  
  RESULTS
  A total of 171 nBCCs were treated and had a median follow-up of 67 months (range 0-106). At 60 months, 23 tumors had recurred in the ALA-PDT group and 2 tumors in the surgical excision group. Cumulative recurrence probabilities 5 years posttreatment were 30.7% (95% confidence interval [CI] 21.5%-42.6%) for ALA-PDT and 2.3% (95% CI 0.6%-8.8%) for surgical excision (P < .0001). Two tumors in the ALA-PDT group recurred at 72 and 91 months posttreatment. Cumulative probability of recurrence-free survival post-PDT was 65.0% (95% CI 51%-76%) for nBCC measuring greater than 0.7 mm in thickness and 94.4% (95% CI 67%-99%, P = .018) for tumors less than or equal to 0.7 mm.
  
  
  CONCLUSIONS
  Tumor thickness on punch biopsy specimen might differ from the total lesion thickness.
  
  
  CONCLUSIONS
  In nBCC, 5-year cumulative probability of recurrence after surgical excision is lower than after fractionated ALA-PDT with prior debulking. Although surgical excision remains the gold standard of treatment, PDT might be an alternative for inoperable patients with thin (≤0.7 mm) nBCC.
authors.affiliation: Department of Dermatology, Maastricht University Medical Center, Maastricht, The Netherlands. mh.roozeboom@mumc.nl
authors.forename: Marieke H
authors.initials: MH
authors.lastname: Roozeboom
authors.forename: Martine A
authors.initials: MA
authors.lastname: Aardoom
authors.forename: Patty J
authors.initials: PJ
authors.lastname: Nelemans
authors.forename: Monique R T M
authors.initials: MR
authors.lastname: Thissen
authors.forename: Nicole W J
authors.initials: NW
authors.lastname: Kelleners-Smeets
authors.forename: Danielle I M
authors.initials: DI
authors.lastname: Kuijpers
authors.forename: Klara
authors.initials: K
authors.lastname: Mosterd
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000622:Aminolevulinic Acid / Q000494:pharmacology*; D002280:Basal Cell Carcinoma / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D003131:Combined Modality Therapy; D016001:Confidence Intervals; D062109:Dermatologic Surgical Procedures / Q000379:methods; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007150:Immunohistochemistry; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000628:therapy; D009367:Neoplasm Staging; D010778:Photochemotherapy / Q000379:methods*; D018570:Risk Assessment; D012878:Skin Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000622:Aminolevulinic Acid
keywords: ALA; BCC; CI; MAL; PDT; RCT; aminolevulinic acid; basal cell carcinoma; confidence interval; failure; methylaminolevulinate; nBCC; nodular basal cell carcinoma; photodynamic therapy; randomized controlled trial; recurrence; surgical excision; thickness; treatment