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CLINICAL TRIAL
Year : 2013  |  Volume : 58  |  Issue : 4  |  Page : 327
Aminolevulinic acid-photodynamic therapy of basal cell carcinoma and factors affecting the response to treatment: A clinical trial


1 Skin Research Center, Shahid Beheshti University of Medical Sciences, Sydney, Iran
2 Department of Pathology, Royal North Shore Hospital, Sydney, Australia

Date of Web Publication25-Jun-2013

Correspondence Address:
Zohreh Tehranchinia
Skin Research Center, Shahid Beheshti University of Medical Sciences, Shohada-e Tajrish Hospital, Shahrdari St, 1989934148, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.113968

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   Abstract 

Background: Basal cell carcinoma (BCC) is the most common type of skin cancer in humans. Photodynamic therapy (PDT) is a non-invasive therapeutic modality that may be considered as a valuable treatment option for BCC. This study was designed with the aim of evaluating the efficacy of PDT in treatment of BCC and factors that may affect the response rate. Materials and Methods: This clinical trial was conducted on 12 patients (28 BCC lesions) who were treated with aminulevulinic acid (ALA)-PDT, monthly, up to 6 sessions and the clinical response, cosmetic results, and possible side effects were evaluated. Results: The study was performed on 28 BCC lesions from 12 patients. Complete response was achieved in 9 (32.1%) lesions. Complete response rate was higher in younger patients ( P < 0.01) and those with smaller lesions ( P < 0.001). Superficial type also had significant higher response rate ( P < 0.05). Patients with history of radiotherapy for the treatment of tinea capitis in childhood showed less response ( P < 0.05). Cosmetic results were excellent or good in 77.5% cases. After 6 months of follow-up, none of the resolved lesions recurred. Conclusion: PDT would be a good therapeutic option in treatment of BCC with acceptable efficacy and low side effects. Younger patients, superficial BCCs, and smaller lesions show better response to ALA-PDT. History of radiotherapy may be associated with a lower response rate.


Keywords: Aminolevulinic acid, basal cell carcinoma, photodynamic therapy, non-melanocytic skin cancer


How to cite this article:
Tehranchinia Z, Rahimi H, Ahadi MS, Ahadi MS. Aminolevulinic acid-photodynamic therapy of basal cell carcinoma and factors affecting the response to treatment: A clinical trial. Indian J Dermatol 2013;58:327

How to cite this URL:
Tehranchinia Z, Rahimi H, Ahadi MS, Ahadi MS. Aminolevulinic acid-photodynamic therapy of basal cell carcinoma and factors affecting the response to treatment: A clinical trial. Indian J Dermatol [serial online] 2013 [cited 2019 May 23];58:327. Available from: http://www.e-ijd.org/text.asp?2013/58/4/327/113968

What was known?
Basal cell carcinoma is the most common type of skin cancer. Photodynamic therapy is a non invasive therapeutic modality that may be considered a valuable strategy in treatment of BCC.



   Introduction Top


Nonmelanoma skin cancers (NMSCs) are the most common tumors in humans. The incidence of NMSC is continuously rising (3-8% per year). About 40-50% of patients with history of nonmelanoma skin cancers may develop further NMSCs within 5 years. [1]

Basal cell carcinoma (BCC) is the most common skin cancer with significant local tissue invasion and morbidity. [2] For many years, the conventional therapy for BCC has been simple surgical excision. However, since BCC usually occurs on sun-exposed areas of the body (like face and scalp), development of new therapeutic strategies with best cosmetic outcomes and minimal scar formation is of increasing interest. Furthermore, all non-excisional approaches such as cryotherapy, radiation therapy, curettage and cautery, laser and cytotoxic drugs (e.g., 5-fluorouracil and chemical peels) are quite nonspecific and do not target the tumor itself, thereby leading to unwanted effects in the surrounding tissue including scar formation or other cosmetically disfiguring events. [1]

In comparison with other therapeutic options for BCC, photodynamic therapy (PDT) is a relatively new treatment modality that has the advantages of being noninvasive and causing minimal damage to the surrounding tissue due to the relatively selective uptake of photosensitizer agents by malignant cells. [3] Furthermore, PDT could be used as a valuable alternative option in patients who are not appropriate candidates for surgical excision such as patients with large lesions, [4] with multiple BCCs due to previous radiotherapy, [5] with residual or recurrent tumor after other therapeutic modalities, [6] who are receiving anticoagulant medications, [4] with Gorlin syndrome, [7],[8] diabetic, [9] immunosuppressed or post-transplantation patients, [9],[10] and those who are susceptible to keloid or hypertrophic scar formation. [9]

Several previous studies reported different response rates of superficial BCC to PDT. [4],[8],[9],[10] Furthermore, the results of PDT on nodular [2],[6],[11] and pigmented [4] BCCs have been controversial. Hence, this study was designed to evaluate the efficacy of PDT in treatment of different types of BCC and the factors affecting its response rate.


   Patients and Methods Top


This study was a clinical trial performed on 12 patients (8 males and 4 females) with BCC. The patients were recruited from a dermatology clinic after which the provisional diagnosis of BCC was made by a dermatologist. The diagnosis was confirmed by an incisional biopsy of the lesion. In cases that multiple lesions were present in the same anatomical region, a single biopsy was taken from the thickest lesion and other morphologically similar lesions were treated similar to the index one. Patients were excluded from the study for any of the following reasons: Age < 18 years, history of any type of photodermatoses or dermatoses that might be aggravated by light exposure (i.e., porphyria, xeroderma pigmentosa, and lupus erythematosus), history of consumption of phototoxic drugs within the last 30 days, pregnancy or breast feeding, history of receiving any other treatment for the lesion within the last 6 months, and having rodent ulcer, morphea form or infiltrative type of BCC. In addition, antinuclear antibody (ANA) was checked in all patients before initiation of treatment for screening of possible photosensitization susceptibility and ANA-positive patients were excluded.

The study design was assessed and approved by the institutional ethics committee. All patients received comprehensive information about the treatment protocol, and probable side effects of the PDT and signed the informed consent forms.

For patients who entered the study, topical aminulevulinic acid (ALA) in form of 20% weight-based ALA/water-in-oil cream was topically applied to the lesion and to the 1-cm diameter of the tumor-free adjacent skin. After application of the cream, the lesion was covered by light-proof, non-adhesive dressing to prevent exposure to the light. After 6-8 h, the occlusive dressing was removed and the remaining cream was gently cleaned off. Then, the patient received illumination from Waldmann PDT 1200 (Waldmann Medizintechnik, VS-Schwennigen, Germany) that produced a circular field of incoherent red light with a diameter of 15 cm and wave length of 630 nm (range 600-730 nm). Each lesion was irradiated with a dose of 120 J/cm 2 and at an intensity of 200 mW/cm 2 . A margin of normal skin equal to the size of the lesion was included in the irradiation. A hand-held electric fan was used close to the treatment site to reduce the pain and discomfort, and the patient's eyes were covered by special shields during irradiation. Patients were instructed to use icepacks and zinc oxide ointment during the first 24 h after PDT to decrease post-treatment erythema and edema and to continue ointment administration for 2 weeks. Monthly follow-up assessment was performed by the same investigator. At each visit, photography of all lesions was taken, clinical response was determined by inspection and palpation, and adverse effects were recorded. Clinical response was defined as "complete response" (CR) when there was no visible or palpable lesion and as "incomplete response" (IR) with the presence of any visible or palpable residual lesion. IR had two subgroups: "Partial response" (PR) when the diameter of lesion was reduced but still visible or palpable and "no response" (NR) when the diameter of the lesion was not reduced. At each session, if the lesion showed no response, the patient was referred for surgical excision of the lesion and, if partial response was detected, another treatment cycle was administered (maximum of 6 sessions). The lesions that did not show complete response after 6 sessions of treatment were excised. Whenever CR was observed in a lesion, the treatment was terminated (Diagram 1 [Additional file 1]) and the lesion was assessed for cosmetic results on the basis of a four-point scale: (1) Excellent: No scarring, atrophy, or induration, mild or no redness, or dyspigmentation compared to the adjacent skin; (2) Good: No scarring, atrophy, or induration, moderate redness or dyspigmentation compared to the adjacent skin; (3) Moderate: Mild to moderate scarring, atrophy, or induration; and (4) Poor: Extensive scarring, atrophy, or induration. At the same time, with the patient's consent, a post-treatment biopsy was performed for lesions with complete clinical response, aiming for serial histological examinations and confirmation of clinical assessment. The lesions with CR were followed-up for 6 months after the last treatment session.

The collected data were analyzed statistically by t-test and Fisher's exact test. P value < 0.05 was considered significant.


   Results Top


Twelve patients (8 males and 4 females) with a total number of 28 BCC lesions were enrolled and treated with ALA-PDT. The mean patient age was 59.1 years (age range 22-72 years).

Of these, 28 BCC lesions, 15 were nodular, 7 were pigmented, and 6 were superficial. None of our patients had nevoid BCC syndrome. Thirteen lesions were located on the face, 13 on the scalp, and 2 on the ear.

The mean diameter of BCCs was 20 mm in the longest axis (range: 2-100 mm). All patients completed the treatment course. The average number of treatment sessions was 4.9 (range: 1-6). [Table 1] shows the frequency of treatment sessions.
Table 1: Frequency of photodynamic therapy sessions in patients with basal cell carcinoma


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History of radiotherapy (for the treatment of tinea capitis in childhood) was positive in 17 cases (60.7%).

Of 28 lesions, 9 (32.1%) showed complete response [Figure 1], 14 (50%) showed partial response [Figure 2], and 5 (17.9%) did not show any response to PDT.
Figure 1: Basal cell carcinoma of scalp. (a) Before photodynamic therapy, (b) with complete response after photodynamic therapy

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Figure 2: Pigmented BCC of scalp. (a) Before photodynamic therapy, (b) With partial response after photodynamic therapy

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Biopsy was performed on three of the lesions with clinical CR, and complete histological resolution of the tumor was confirmed in all of them. From 9 lesions with CR, final cosmetic result was excellent in 5, good in 2, and moderate in the remaining 2. No serious adverse events or deaths were encountered during this study. None of the patients discontinued the study as a consequence of an adverse event. Only local pain was reported in 11 cases that were mild and tolerable in 9 cases. However, 2 patients reported severe pain and burning sensation during the treatment.

The mean age of patients with CR was 53.6 years and, of those with IR, it was 61.8 years. t-test showed that younger patients had a significant higher complete response rate to PDT (P < 0.01). The mean diameter of lesions was 13 mm in cases with CR and 23.2 mm in those with IR. T-test showed that this difference was significant and lesions with lower diameter had higher response rate to PDT (P < 0.001).

In addition, lesions were divided into two groups: Superficial and non-superficial (including nodular and pigmented types) and the response rates were compared [Table 2]. We found a significant relation between the type of BCC and response to PDT (P < 0.001); in other words, superficial BCCs [Figure 1] showed better response to PDT (relative risk = 6.8; attributable risk = 43.9); Three out of 15 nodular BCCs and two out of 5 pigmented BCCs [Figure 2] had complete response to PDT [Table 3]. Fifty four percent of cases with negative history of radiotherapy had CR. However, only 18% of lesions with positive history of radiotherapy showed CR [Table 2]. Thus, a significant relation was found between positive history of radiotherapy and poor response to PDT (P < 0.05; relative risk = 5.6; attributable risk = 37). In our study, all patients with a history of radiotherapy had been irradiated for the treatment of tinea capitis in childhood.
Table 2: Evaluation of the relation of response rate of BCC to PDT and associated factors


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Table 3: Response rates of different types of BCC to PDT


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No significant relation was found between patient's sex and localization of the lesion with the response rate [Table 2]. All 9 lesions with complete response were followed-up for 6 months and no recurrence was observed.


   Discussion Top


In our study, 66.6% of superficial BCCs (sBCCs) showed complete response to PDT. Complete response rate for sBCCs has been reported to be 80-100% in previous studies. [12],[13] This difference in efficacy could be partially attributed to the fact that only small-sized lesions were included in most of the previous studies, whereas our study included several large-sized BCCs that would have been difficult to treat by conventional methods. Similarly, Madan et al., recently reported that none of the "giant" BCCs had complete response to PDT and all of them ultimately required excision. [14] Furthermore, in our study, all lesions with partial response showed > 80% reduction in size at the end of treatment course. Therefore, a better response and even complete resolution could be expected in these lesions after continuing the treatment and having more PDT sessions.

In our trial, 29% of pigmented BCCs (pBCCs) showed complete response to PDT. However, Pintion et al., reported CR in none of four pBCCs in their study. [12]

Treatment of nodular BCCs (nBCCs) yielded controversial results in the previous studies. The CR rate varied between 10% in the study of Wolf et al., [15] to 94% in the report of Mosterd et al., [16] while the CR rate of nBCCs was 20% in our study. A possible explanation for these differences could be due to a small sample size in some of the previous studies. Furthermore, different criteria were used to evaluate complete response and different treatment schedules (such as the duration of ALA administration before irradiation, wave length, and dose of irradiation) were applied. [12] Finally, in some studies, a few additional strategies were implemented. For instance, Rhodes et al., used methyl-ALA (instead of ALA) to improve the penetration of photosensitizer into the tumor. [2] However, in another study by Kujipers et al., no difference was found between methyl-ALA and ALA in treatment of BCC. [17] Thompson et al., used multifiber light delivery with direct contact to the surface of the tumor to improve efficacy of PDT and reported 75% complete response rate for nBCCs. [18] We compared complete response rate of sBCCs with non-superficial BCCs and found that complete response rate was 6.8-fold greater in sBCCs. In previous studies, higher response rates were reported for sBCCs, but to our knowledge, no statistical comparison and relative risk determination were performed in previous studies.

In our study, ALA-PDT was well tolerated and adverse effects (if any at all) were limited to mild local pain and erythema. The adverse events of PDT were also reported to be minimal in other studies. Wang et al., found that patients who received PDT for their BCCs experienced similar pain in comparison with cryotherapy. [19]

In our study, the cosmetic outcome was graded as excellent or good in 77.5% of cases, which is comparable with reported rates of 79-93% in previous studies. A randomized study showed that cosmetic outcomes of PDT was superior to that by cryotherapy; [20] and another study by Basset-Seguin reported excellent cosmetic outcomes with PDT in 60% of cases, which is similar to our results, and showed a better outcome as compared to that by cryotherapy (16% excellent for cryotherapy). [21] In our study, the cosmetic results were evaluated immediately after completing the treatment protocol. However, since Vinciullo et al., reported that cosmetic results showed further gradual improvement over time, [22] we might expect to find better outcomes after a longer follow-up period.

We found significant relation between patient's age and response to PDT. In other words, patients who showed CR were significantly younger. To our knowledge, this was not evaluated and reported in previous studies.

Our study showed that lesions with larger diameter had significantly lower response rate. This result is comparable with that of Madan et al., who reported that none of giant BCCs showed complete response to PDT. [14] However, Rhodes et al., did not find any significant relation between the size of the lesion and response rate. [2]

The other factor that had significant association with response rate was history of radiotherapy (for treatment of tinea capitis in childhood). In our study, patients with positive history of radiotherapy had significantly lower CR rate to PDT. To our knowledge, this association has not been evaluated and reported prior to our study. This may be due to the higher prevalence of nodular and pigmented types in radiation-induced BCCs. [23]

We found no significant relation between patient's sex and localization of the tumor and response rate to PDT, which is similar to reported results by Rhodes et al.[2]

In our study, none of the resolved lesions recurred during the 6-month follow-up period. In previous studies, the follow-up period varied between 6 months and 5 years; therefore, different recurrence rates have been reported. Although, our follow-up period was relatively short and more recurrences may be observed after longer follow-up, study by Varma et al., showed that most recurrences occur during the first 6 months. [24] Fai et al., reported a recurrence rate of 15% after 12 months [25] and, in another study, the recurrence rate after 48 months was 20%. [13] Five-year follow-up in another study suggested that recurrence rates after PDT were comparable with recurrence rates after cryotherapy. [21] In two other investigations, recurrence rates were even lower for lesions ≤ 1 cm in size (only 6% after 36 months). [20] In these studies, the recurrence rate at 48 months was equal to that at 36 months following treatment with PDT (i.e., there were no additional recurrences after 36 months).

Finally, it should be mentioned that BCC is not a life-threatening cancer. Therefore, different factors such as efficacy, cosmetic results, cost effectiveness, and patient's preferences should be considered in determining the treatment of choice for each patient. Several studies showed that patients prefer PDT to conventional therapies of BCC [26] and its cost effectiveness has been proven as well. [27] Considering these factors, in addition to high efficacy and better cosmetic results, PDT can be a suitable therapeutic option in patients with BCC, especially sBCC. However, further studies are recommended to compare different regimens of PDT and factors that may improve its efficacy.

 
   References Top

1.Kuijpers DI, Thissen MR, Neumann MH. Basal cell carcinoma: Treatment options and prognosis, a scientific approach to a common malignancy. Am J Clin Dermatol 2002;3:247-59.  Back to cited text no. 1
    
2.Rhodes LE, de Rie M, Enstrom Y, Groves R, Morken T, Goulden V, et al. Photodynamic therapy using topical methyl aminolevulinatevs surgery for nodular basal cell carcinoma: Results of a multicenter randomized prospective trial. Arch Dermatol 2004;140:17-23.  Back to cited text no. 2
    
3.Tierney E, Barker A, Ahdout J, Hanke CW, Moy RL, Kouba DJ. Photodynamic therapy for the treatment of cutaneous neoplasia, inflammatory disorders, and photoaging. Dermatol Surg 2009;35:725-46.  Back to cited text no. 3
    
4.Kaviani A, Ataie-Fashtami L, Fateh M, Sheikhbahaee N, Ghodsi M, Zand N, et al. Photodynamic therapy of head and neck basal cell carcinoma according to different clinicopathologic features. Lasers Surg Med 2005;36:377-82.  Back to cited text no. 4
    
5.Hallaji Z, Rahimi H, Mirshams-Shahshahani M. Comparison of risk factors of single Basal cell carcinoma with multiple Basal cell carcinomas. Indian J Dermatol 2011;56:398-402.  Back to cited text no. 5
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6.Horn M, Wolf P, Wulf HC, Warloe T, Fritsch C, Rhodes LE, et al. Topical methyl aminolaevulinate photodynamic therapy in patients with basal cell carcinoma prone to complications and poor cosmetic outcome with conventional treatment. Br J Dermatol 2003;149:1242-97.  Back to cited text no. 6
    
7.Chapas AM, Gilchrest BA. Broad area photodynamic therapy for treatment of multiple basal cell carcinomas in a patient with nevoid basal cell carcinoma syndrome. J Drugs Dermatol 2006;5(2 Suppl):3-5.  Back to cited text no. 7
    
8.Madn V, Loncaster JA, Allan D, Lear JT, Sheridan L, Leach C, et al. Nodular basal cell carcinoma in Gorlin's syndrome treated with systemic photodynamic therapy and intersitial optical fiber diffuser laser. J Am Acad Dermatol 2006;55:S85-9.  Back to cited text no. 8
    
9.Braathen LR, Szeimies RM, Basset-Seguin N, Bissonnette R, Foley P, Pariser D, et al. Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: An Interenational Consensus. J Am Acad Dermatol 2007;56:125-43.  Back to cited text no. 9
    
10.Perpett AN, McGregor JM, Warwick J, Karran P, Leigh IM, Proby CM, et al. Treatment of post-transplant premalignant skin disease. A randomized intrapatient comparative study of 5-fluorauracil cream and topical phototherapy. Br J Dermatol 2007;156:320-8.  Back to cited text no. 10
    
11.Wulf HC, Pavel S, Stender I, Bakker-Wensveen CA. Topical photodynamic therapy for prevention of new skin lesions in renal transplant recipients. Acta Derm Venereol 2006;86:25-8.  Back to cited text no. 11
    
12.Calzavara-Pinton PG. Repetitive photodynamic therapy with topical aminolevulinic acid as an appropriate approach to the routine treatment of superficial nonmelanoma skin tumors. J Photochem Photobiol 1995;29:53-7.  Back to cited text no. 12
    
13.Vinciullo C. MAL-PDT in difficult to treat basal cell carcinoma. An Australian study: 48 month follow up data. Poster present at 3 rd Meeting of the European association of dermato-oncology Rome, June 23-25, 2006. J Invest Dermatol 2006;126(Suppl 2):534.  Back to cited text no. 13
    
14.Madan V, West CA, Murphy JV, Lear JT. Sequential treatment of giant basal cell carcinomas. J Plast Reconstr Aesthet Surg 2009;62:e368-72.  Back to cited text no. 14
    
15.Wolf P, Rieger E, Kerl H. Topical photodynamic therapy with endogenous porphyrins after application of 5-aminolevulinic acid. An alternative treatment modality for solar keratoses, superficial squamous cell carcinomas, and basal cell carcinomas? J Am Acad Dermatol 1993;28:17-21.  Back to cited text no. 15
    
16.Mosterd K, Thissen MR, Nelemans P, Kelleners-Smeets NW, Janssen RL, Broekhof KG, et al. Fractionated 5-aminolaevulinic acid-photodynamic therapy vs. surgical excision in the treatment of nodular basal cell carcinoma: Results of a randomized controlled trial. Br J Dermatol 2008;159:864-70.  Back to cited text no. 16
    
17.Kujipers DI, Thissen MR, Thissen CA, Neumann MH. Similar effectiveness of methyl aminolevulinate and 5-aminolevulinate in topical photodynamic therapy for nodular basal cell carcinoma. J Drugs Dermatol 2006;5:642-5.  Back to cited text no. 17
    
18.Thompson MS, Anderson-Engles S, Svanberg S, Johansson T, Palsson S, Bendso N, et al. Photodynamic therapy of nodular basal cell carcinoma with multifiber contact light delivery. J Environ Pathol Toxical Oncol 2006;25:411-24.  Back to cited text no. 18
    
19.Wang I, Bendsoe N, Klinteberg CA, Enejder AM, Andersson-Engels S, Svanberg S, et al. Photodynamic therapy vs cryosurgery of basal cell carcinoma: Result of phase III clinical trial. Br J Dermatol 2001;144:832-40.  Back to cited text no. 19
    
20.Basset-Seguin N, Ibbotson SH, Emtestam L. MAL-PDT versus cryotherapy in primary sBCC: Results of 36 months follow-up. J Eur Acad Dermatol Venereol 2004;18(Suppl 2):412.  Back to cited text no. 20
    
21.Basset-Seguin N, Ibbotson SH, Emtestam L, Tarstedt M, Morton C, Maroti M, et al. Topical methyl aminolaevulinate photodynamic therapy versus cryotherapy for superficial basal cell carcinoma: A 5 year randomized trial. Eur J Dermatol 2008;18:547-53.  Back to cited text no. 21
    
22.Vinciullo C, Elliott T, Francis D, Gebauer K, Spelman L, Nguyen R, et al. Photodynamic therapy with topical methyl aminolaevulinate for 'difficult-to-treat' basal cell carcinoma. Br J Dermatol 2005;152:765-72.  Back to cited text no. 22
    
23.Meibodi NT, Maleki M, Javidi Z, Nahidi Y. Clinicopathological evaluation of radiation induced basal cell carcinoma. Indian J Dermatol 2008;53:137-9.  Back to cited text no. 23
[PUBMED]  Medknow Journal  
24.Varma S, Wilson H, Kurwa HA, Gambles B, Charman C, Pearse AD. Bowen's disease, solar keratoses and superficial basal cell carcinomas treated by photodynamic therapy using a large-field incoherent light source. Br J Dermatol 2001;144:567-74.  Back to cited text no. 24
    
25.Fai D, Arpaia N, Romano I, Vestita M, Cassano N, Vena GA. Methyl-aminolevulinate photodynamic therapy for the treatment of actinic keratoses and non-melanoma skin cancers: A retrospective analysis of response in 462 patients. G Ital Dermatol Venereol 2009;144:281-5.  Back to cited text no. 25
    
26.Weston A, Fitzgerald P. Discrete choice experiment to derive willingness to pay for methyl aminolevulinate photodynamic therapy versus simple excision surgery in basal cell carcinoma. Pharmacoeconomics 2004;22:1195-2008.  Back to cited text no. 26
    
27.Caekelbergh K, Annemans L, Lambert J, Roelandts R. Economic evaluation of methyl aminolaevulinate-based photodynamic therapy in the management of actinic keratosis and basal cell carcinoma. Br J Dermatol 2006;155:784-90.  Back to cited text no. 27
    

What is new?
1. Younger patients, superficial BCCs, and smaller lesions show better response to ALA.PDT. 2. History of radiotherapy may be associated with lower response rate.


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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