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EDITORIALS: Stanley B Brown and Sally H Ibbotson Photodynamic therapy and cancer BMJ 2009; 339: b2459 [Full text]

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Indications for and efficacy of photodynamic therapy for skin cancer radically altered by combination carbon dioxide laser treatment

Kayvan Shokrollahi, Maxwell Murison, Consultant Plastic Surgeon, Welsh Centre for Burns and Plastic Surgery   (3 August 2009)

Indications for and efficacy of photodynamic therapy for skin cancer radically altered by combination carbon dioxide laser treatment 3 August 2009
Kayvan Shokrollahi, Specialist Registrar in Plastic Surgery Welsh Centre for Burns and Plastic Surgery, Maxwell Murison, Consultant Plastic Surgeon, Welsh Centre for Burns and Plastic Surgery Send response to journal: Re: Indications for and efficacy of photodynamic therapy for skin cancer radically altered by combination carbon dioxide laser treatment	Brown and Ibbotson highlight the many advantages of photodynamic therapy (PDT) for cancer treatment [1]. For non-melanoma skin tumours, especially Basal carcinoma, PDT can be very effective, especially for smaller and superficial lesions. Particular advantages include excellent cosmetic outcomes and avoidance of surgery - which has implications especially for those with multiple lesions such a transplant patients [2] or for those on anticoagulant medications. However, the 20% recurrence rate quoted for treatment of BCCs (some quote more) is one concern which precludes PDT being a gold-standard treatment. This is especially the case for the common nodular tumour subtype. One problem is the limited depth of penetration of 2mm. Whilst the suggestion that further research and development of photosensitising drugs and refinement of treatment parameters is one important direction to follow, we have achieved excellent results with BCCs especially of the nodular variety by pretreating the lesion with the ablative (and haemostatic) carbon dioxide laser before PDT is undertaken at the same sitting. The preliminary results we published [3] demonstrated efficacy and safety, and our extended series of hundreds of lesions with up to 5 years followup due to be published in the near future demonstrates excellent cosmesis but minimal recurrence. Novel strategies for pain management during the photoactivation phase of treatment are also needed, and one area we have been investogating. We would agree with the suggestion that PDT facilities should be expanded in a multidisciplinary setting, and believe that a dual-modality strategy provides all the advantages of PDT, but minimises the recurrences. This latter fact will increase the appeal for patients and clinicians alike, not least because long-term close follow-up after combined CO2 laser with PDT treatment may be less often required. References: 1) Brown, SB, Ibbotson, SH. Photodynamic therapy and cancer. Promising results need to be followed by development of more selective drugs. BMJ 2009;339:b2459 2) Shokrollahi K., Whitaker IS, Marsden N., James, W., Murison MSCM. Laser-PDT, keeping the BCCs at bay for renal transplant patients: a case report. Cases Journal, in press (accepted July 2009). 3) Whitaker IS, Shokrollahi K, James W, Mishra A, Lohana P, Murison MC. Combined CO2 laser with photodynamic therapy for the treatment of nodular basal cell carcinomas. Ann Plast Surg. 2007 Nov;59(5):484-8. Competing interests: None declared