ANSWER
The one inappropriate choice—and therefore, the correct answer—is ED&C (choice “a”). Of all the choices, this option has the greatest potential for an unacceptable scar and for a recurrence of the cancer. All the other choices are entirely appropriate.
DISCUSSION
Had this been a far older patient with little concern about appearance, ED&C would have been a perfectly acceptable choice. But this patient made her expectations clear enough, effectively ruling out such an approach. A plastic surgeon (choice “b”) could be expected to not only obtain adequate margins around this cancer, but to be able to close the defect with an acceptable cosmetic outcome. Mohs surgeons (choice “d”) have the unique ability to examine the excised tissue margins at the surgical bedside, closing only when those margins are determined microscopically to be clear. They also have the ability to close larger defects in difficult areas such as this, obtaining an acceptable final result.
Had the patient or situation contraindicated surgery, at least two options would remain. The first is imiquimod (choice “c”) cream, which has a proven ability to destroy basal cell carcinomas (when applied several times a week over a period of six weeks to three months). Uncertain results can, and often do, necessitate a biopsy to confirm total destruction, and the patient has to endure weeks of redness and irritation at the site during treatment.
The other option is radiation therapy (choice “e”), an extremely effective nonsurgical alternative. However, it requires multiple treatment sessions over several weeks and can damage surrounding skin.