Evaluation of cosmetic results of a randomized trial comparing surgery andradiotherapy in the treatment of basal cell carcinoma of the face

Basal cell carcinoma is the most frequent cutaneous carcinoma, and it is ch aracterized by its local spreading and an exceptional tendency to metastasi ze. Radical excision or destruction ensures the highest chance of cure. The most frequent site of this tumor is the face, where radical excision is li mited by the proximity of essential anatomic structures. The main difficult y is to avoid mutilation and to provide good cosmetic results despite the v icinity of the eyes, the nose, and the mouth. Surgery and radiotherapy are known to provide similar chances of cure, but results concerning cosmetic s equelae are controversial, depending sometimes on the specialty of the phys ician in charge of the treatment. A randomized trial was performed at the Gustave-Roussy Institute to compare basal cell carcinomas of the face treated either by surgery or by radiothe rapy. In summary, a significant advantage was observed in favor of surgery, as has been published elsewhere. Looking at the details of the cosmetic re sults, we analyzed the specific methodology of the cosmetic evaluation set up to eradicate the usual bias owing to subjective judgments. We looked als o to the evolution of the cosmetic results with time. A panel of five judge s performed repeated evaluations during the follow-up, and standardized pho tographs were taken at each visit and rated later by three nonmedical judge s. In total, 174 patients were treated by surgery and 173 by radiotherapy; the choice of the treatment was allocated by randomization. Postoperative c omplications were higher in the radiotherapy group. The final cosmetic results after 4 years of follow-up were rated significan tly better with surgery than with radiotherapy (good in 87 percent versus 6 9 percent according to the patient, 79 percent versus 40 percent according to the dermatologist, and respectively for each of the observers). Evolutio n of the ratings during the follow-up demonstrated an improvement of the co smesis after surgery and stable or deteriorated results after radiotherapy. The same trend was observed regardless of the site of the tumor on the fac e, except for the nose, where the difference-still in favor of the surgery- was not significant. Concordance of all assessments in our study was the ma in guarantee of reliability of our methodology for cosmetic evaluation.