Basal cell carcinoma histological clearance margins: an analysis of 1539 conventionally excised tumours. Wider still and deeper?

[Translated article] Basal Cell Carcinoma in the Southern Health Area of Tenerife: Key Clinical and Pathological Factors and Margin Status After Excision

BACKGROUND AND OBJECTIVE

Surgical excision is the treatment of choice for basal cell carcinoma (BCC). Complete excision with clear margins is important for reducing the risk of recurrence. The aims of this study were to describe the characteristics of BCCs in our health care area, calculate the percentage of positive margins after surgical excision, and determine the risk factors for incomplete excision.

MATERIAL AND METHODS

Retrospective observational study of BCCs that were surgically removed at Hospital Universitario Nuestra Señora de Candelaria, in Santa Cruz de Tenerife, Spain, between January 1, 2014 and December 31, 2014. Information was collected on demographic, clinical, and histologic variables, surgical approach, margin status, and the department responsible.

RESULTS

In total, 966 BCCs were diagnosed in 776 patients. Nine percent of tumors with complete data were biopsied, 89% were surgically excised, and 2% were removed by shave excision. The median age of patients with excised tumors was 71 years and 52% were men. BCCs were most often located on the face (59.1%). Surgical margins were analyzed in 506 cases, 17% of which had positive margins. Incomplete excision was significantly more common in tumors located on the face (22% vs. 10% for other locations) and in high-risk subtypes according to the World Health Organization classification (25% vs. 15% for low-risk subtypes).

CONCLUSIONS

The characteristics of BCCs in our health care area are similar to those described elsewhere. Facial location and histologic subtype are risk factors for incomplete excision. Careful surgical planning is therefore important in the initial management of BCCs with these characteristics.

Basal Cell Carcinoma in the Southern Health Area of Tenerife. Key Clinical and Pathological Factors and Margin Status After Excision

BACKGROUND AND OBJECTIVE

Surgical excision is the treatment of choice for basal cell carcinoma (BCC). Complete excision with clear margins is important for reducing the risk of recurrence. The aims of this study were to describe the characteristics of BCCs in our health care area, calculate the percentage of positive margins after surgical excision, and determine the risk factors for incomplete excision.

MATERIAL AND METHODS

Retrospective observational study of BCCs that were surgically removed at Hospital Universitario Nuestra Señora de Candelaria, in Santa Cruz de Tenerife, Spain, between January 1, 2014 and December 31, 2014. Information was collected on demographic, clinical, and histologic variables, surgical approach, margin status, and the department responsible.

RESULTS

In total, 966 BCCs were diagnosed in 776 patients. Nine percent of tumors with complete data were biopsied, 89% were surgically excised, and 2% were removed by shave excision. The median age of patients with excised tumors was 71 years and 52% were men. BCCs were most often located on the face (59.1%). Surgical margins were analyzed in 506 cases, 17% of which had positive margins. Incomplete excision was significantly more common in tumors located on the face (22% vs. 10% for other locations) and in high-risk subtypes according to the World Health Organization classification (25% vs. 15% for low-risk subtypes).

CONCLUSIONS

The characteristics of BCCs in our health care area are similar to those described elsewhere. Facial location and histologic subtype are risk factors for incomplete excision. Careful surgical planning is therefore important in the initial management of BCCs with these characteristics.

Use of preoperative and perioperative ex vivo dermoscopy for precise mapping of margins for standard surgical excision of primary basal cell carcinoma

Background The utility of preoperative and perioperative dermoscopy in standard surgical excision for radical excision of primary basal cell carcinoma remain unexplored. Aims To evaluate the use of preoperative and perioperative dermoscopy for precise mapping of margins during standard surgical excision of primary basal cell carcinoma. Methods In this retrospective, observational study, 17 patients clinically diagnosed with various morphological subtypes of basal cell carcinoma were included. Data about previous history, clinical examination of lesions and regional lymph nodes and preoperative dermoscopy were retrieved. After standard surgical excision had been carried out as per mapping of lateral margins, all the excised surgical specimens were subjected to perioperative dermoscopy and later reconfirmed with histopathology. Results Seventeen patients with mean age of 60.82 ± 9.99 years and median disease duration of 14 months were analysed. Clinically, basal cell carcinomas were of pigmented superficial subtype [6 (35.3%)], followed by pigmented nodular [5 (29.4%)], nodulo-ulcerative [4 (23.5%)] and micro nodular [2 (11.8%)]. Mean extension of clinical margin after dermoscopy was 0.59 ± 0.52 mm. Mean pre-assessed depth of tumour and mean depth of tumour were 3.46 ± 0.89 mm and 3.49 ± 0.92 mm, respectively. No recurrence was reported. Frequently found pre-operative dermoscopic features were maple leaf like structures [6 (35%)], blue grey dots and globules [6 (35%)] and short fine telangiectasias [6 (35%)]. Commonly observed perioperative dermoscopic features were: (1) irregular band with brown-grey pigmentation of dots, globules, streaks and pseudopodia like extensions [3 (50%)]; (2) irregular band of pseudo granulomatous structureless vascular areas in psoriasiform pattern with diffuse white streaks in pseudopodia like manner [1 (50%)]; (3) irregular band of pseudo granulomatous structureless vascular areas in psoriasiform pattern with streaks of white pseudopodia like structureless areas [1 (50%)]. Limitation This was a single-centre study with a small sample size. Conclusion This study highlights significance of preoperative and perioperative dermoscopy for precise planning and radical excision of primary basal cell carcinoma by standard surgical excision.

A Retrospective Study of Re-excised Skin Cancers in a Pathology Center

Surgical re-excision is the recommended treatment for the complete removal of incompletely excised skin cancers (SCs), but it may not always lead to this goal. In the present study, the re-excision rate and the presence of residual tumors in re-excised SCs were evaluated. In this retrospective descriptive study, the pathological archives of a hospital center were examined for incompletely excised tumors. Out of the 96 incompletely excised tumors, 19 cases (19.8%) underwent re-excision, of which residual tumors were observed again in 7 cases (36.8%). The highest rate of residual tumor was found in the cheek (66.66%), and the involvement with tumor remnants of both margins combined was greater than the involvement of each of the lateral and deep margins alone. Collecting and reporting of surgical results of re-excised tumors may assist clinicians in determining the patient's condition and making appropriate decisions to increase the success rate of reoperations.

Observational study of a series of basal cell carcinomas: Evaluation of location as a risk factor for recurrence

Basal cell carcinoma (BCC) is locally aggressive and its prognosis depends on the risk of recurrence. The initial location of the tumor is a key criterion for calculating the risk of recurrence. The aim of this study was to evaluate the sites that appear to be most at risk of recurrence of BCC. All cases of BCC analyzed at the anatomopathology laboratory of the University Hospital of Montpellier for 1 year were retrospectively included. In case of recurrence on the same site, only carcinomas that had previously been completely removed were analyzed. Among 803 BCC, 37 (4.6%) were confirmed as recurrent, including 34 (92%) on the head. The locations statistically at higher risk of recurrence were the temporal and frontal/temporal areas (32.4%), the medial canthus and lower eyelid area (18.9%), the ala and tip of the nose (16.2%), and the ears (8.1%). The frontal/temporal regions appear to be an area of major interest in this series. A high risk of recurrence was confirmed in the periorificial locations for the ear, the nose, and periorbital area, but not for the perioral area. In addition, the entire nose did not appear to be at risk, only the tip and the ala.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

High-contrast visualization of human skin cancers with combined reflectance confocal and moxifloxacin-based two-photon microscopy: An ex vivo study

BACKGROUND AND OBJECTIVES

Precise determination of cancer margin during skin cancer surgery is crucial for complete resection and further clinical prognosis. Although reflection confocal microscopy (RCM) has been used for perioperative guiding, its reflection contrast has limitations in detecting cancer cells in the dermis. We previously developed combined reflection confocal (RC) and moxifloxacin-based two-photon (MB-TP) microscopy for sensitive cancer detection by using multiple contrast mechanisms. In this study, the performance of combined microscopy was characterized in various skin cancer specimens and compared with standard methods.

MATERIALS AND METHODS

Seven human skin specimens in total including two normal ones, three basal cell carcinomas (BCCs), and two squamous cell carcinomas (SCCs) were collected and imaged in fresh condition. Moxifloxacin ophthalmic solution was topically instilled for cell labeling for 3-5 minutes, then mosaic imaging with the combined microscopy was conducted. The imaged specimens were imaged again after exogenous nuclear labeling for comparison and then processed for standard hematoxylin and eosin histology.

RESULTS

Combined RC and MB-TP microscopy visualized both cell and extracellular matrix structures of the skin specimens with multiple contrasts of reflection, moxifloxacin fluorescence, autofluorescence, and second harmonic generation. It distinguished normal cell structures in the skin dermis such as hair follicles, sebaceous and eccrine glands from BCC nests, and SCCs based on cell organization. Normal cell structures had organized cell arrangements for their functions, while cancer cell structures had dense and disorganized cell arrangements. Cellular features found by combined microscopy images were confirmed by both TP microscopy with nuclear labeling and histological examination.

CONCLUSIONS

The imaging results showed the potential of combined microscopy for sensitive cancer detection and in vivo guiding of skin cancer surgery.

Surgical excision of non-melanoma skin cancer: no end in site?

Non-melanoma skin cancer (NMSC) is the most common type of cancer in the UK and Ireland, accounting for approximately 20% of all new malignancies recorded, with evidence of increasing incidence. Surgical excision is regarded as the gold standard treatment for such lesions; however, incomplete excision incurs both physical and financial strain on patients and the healthcare service. Our aim is to identify which anatomical regions of the head and neck pose greater risk of incomplete excision and raise awareness for future surgical practice. Manual data collection was carried out on all patients admitted to the OMFS department for surgical excision of NMSCs between January 2016 and December 2017. Information collected included clinical notes and MDT outcomes. NMSCs excised via Mohs surgery. All tumours incompletely excised and requiring further treatment were noted with particular emphasis on the site of the lesion within the head and neck region, and the location of the positive margin on the specimen itself. A total of 506 NMSCs were excised (307 BCC, 199 SCC). Of these, 7.8% (n=24) and 6.0% (n=12), respectively, required further treatment due to incomplete excision. The incompletely exised lesions were predominately located on the nose (13.3%), temple (15.0%), and ear (12.8%). Our results demonstrate that our department is successfully excising NMSCs with minimal cases requiring further management. This study has identified anatomical profiles posing a higher risk of incomplete removal. Alongside the conventionally challenging sites of the nose and ear, we have highlighted additional risk within the temporal region. We therefore propose that Mohs surgery or a two-stage procedure should be considered as management for the temple at future MDTs.

Frequency of and risk factors for incomplete surgical margins of cutaneous cancers: a retrospective study

BACKGROUND

Incomplete resection is a problem in the management of malignancies. This study is aimed to determine frequency of and risk factors for incomplete surgical margins in skin cancers.

METHODS

In this retrospective study, resected skin cancers of a hospital from 2009 to 2020 were reviewed and, based on histopathology reports, categorized as incomplete/positive or complete/negative margins. The demographics and tumor characteristics were extracted from patients' medical files and compared between two groups.

RESULTS

Three hundred and sixty-four skin cancers were resected from 304 patients; incomplete margins occurred in 26.3%. There were no significant differences in gender, age, and site of tumors on the body parts (including head, neck, trunk, and limbs) between the positive and negative margin groups. Incomplete resections were significantly associated with size, site of tumors on various parts of the head (such as scalp, ear, nose, etc.), number of lesions excised in one session, and physician specialty.

CONCLUSIONS

Size, site of tumors on various parts of the head (such as scalp, ear, nose, etc.), number of lesions excised in one session, and physician specialty are risk factors for positive surgical margin. These characteristics may help clinicians to identify high-risk tumors and reduce the chance of incomplete cancer resection.

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta‐analysis*

BACKGROUND

Keratinocyte or nonmelanoma skin cancer (NMSC) is the commonest malignancy worldwide. The usual treatment is surgical excision. Current guidelines underestimate incomplete excision rates.

OBJECTIVES

We aimed to determine the risk of incomplete excision of NMSCs through a systematic review and meta-analysis of primary clinical studies.

METHODS

A PRISMA-compliant systematic review and meta-analysis was performed using methodology proposed by Cochrane (PROSPERO CRD42019157936). A comprehensive search strategy was applied to MEDLINE, Embase, Scopus, CINAHL, EMCare, Cochrane Library and the grey literature (January 2000-27 November 2019). All studies were included except those on Mohs micrographic surgery, frozen section or biopsies. Abstract screening and data extraction were performed in duplicate. Risk of bias was assessed using a tool for prevalence/incidence studies. The primary outcome was the proportion of incomplete surgical excisions. A random-effects model for pooling of binomial data was used. Differences between proportions were assessed by subgroup meta-analysis and meta-regression, which were presented as risk ratios (RRs).

RESULTS

Searching identified 3477 records, with 110 studies included, comprising 53 796 patients with 106 832 basal cell carcinomas (BCCs) and 21 569 squamous cell carcinomas (SCCs). The proportion of incomplete excisions for BCC was 11·0% [95% confidence interval (CI) 9·7-12·4] and for SCC 9·4% (95% CI 7·6-11·4). Proportions of incomplete excisions by specialty were: dermatology, BCCs 6·2% and SCCs 4·7%; plastic surgery, BCCs 9·4% and SCCs 8·2%; general practitioners, BCCs 20·4% and SCCs 18·9%. The risk of incomplete excision for general practitioners was four times that of dermatologists for both BCCs (RR 3·9, 95% CI 2·0-7·3) and SCCs (RR 4·8, 95% CI 1·0-22·8). Studies were heterogeneous (I²  = 98%) and at high risk of bias.

CONCLUSIONS

The proportion of incomplete excisions is higher than previously reported. Excisions performed by specialists may lower the risk of incomplete excision.

Characteristics and Recurrence of Primary Eyelid Basal Cell Carcinoma in Central Spain

Purpose:

To define the incidence, characteristics, and management of eyelid basal cell carcinoma (BCC) in Central Spain.

Methods:

This retrospective study investigates the characteristics and the outcome of eyelid BCC from 2000 to 2016 in a central region of Spain. Data were collected on demographics, skin phenotype, location of the eyelid lesion, clinical and histological diagnosis, surgery, commitment of surgical margins, and recurrence rate.

Results:

Primary eyelid BCC occurred in a mean of 20.6 lesions a year or 9.4/100,000 inhabitants/year. The mean age of BCC carriers was 69.4 ± 16.2 years, with no gender difference (P = 0.479), predominantly affecting Fitzpatrick II–III skin (81.3%) (P < 0.001). The most common location was the inner canthus (154/45.7%) (P < 0.001) and type nodular (215 cases/63.8%) (P < 0.001). The surgical margins were affected in 69 (20.5%) individuals, and the recurrence rate was 5.6 (95% confidence interval, 3.2–8.3) significantly higher in affected margins (P < 0.001). The most common location for recurrence was the inner canthus (P = 0.003), and the most common histological type for recurrence was sclerosing (16.7%), then multinodular (12.5%), and infiltrating (10.4%) with no significant difference (P = 0.27).

Conclusions:

The frequency of occurrence of eyelid BCC is much less than the estimated crude incidence for skin tumors involving all areas of the body in the Spanish population. Eyelid BCC is more common in the seventh decade of life, with no predilection for gender. Nodular histological type is the most common. The recurrence rate is 5.6%, depending on site and affected margins, even though clear free margins also can present with recurrence.

Surgical treatment of basal cell carcinoma: a case series on factors influencing the risk of an incomplete primary excision

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin cancer form, and one first-line treatment is surgical excision. Complete excision is vital to minimize risk of recurrence. Studies on occurrence of incomplete excisions have given diverse results and seldom include large populations from a dermatological setting.

OBJECTIVES

The rate of positive surgical margins in primary surgery of BCC at a tertiary dermatology clinic is studied. Factors associated with an incomplete primary excision are analysed.

METHODS

Patients scheduled for standard excision, without perioperative margin control, of BCC during the years 2008-2015 were prospectively enrolled in the study. Tumour-specific factors, including histopathologic subtype, as well as postoperative outcome were registered. Incomplete excisions were analysed in relation to patient- and tumour-related factors.

RESULTS

In total, 4.6% of 3911 BCC tumours were incompletely excised. The rate of incomplete excisions was higher for facial tumours and among tumours with an aggressive histological subtype. Morpheiform BCC on the nose or ear had the highest rate of an incomplete excision, 61.5% and 50%, respectively.

CONCLUSIONS

Most BCCs, irrespective of subtype, were completely excised during the primary excision. Tumour sites nose and ears were associated with the highest rate of positive primary surgical margins, especially for infiltrative or morpheiform BCCs. Surgery with perioperative examination of margins is strongly recommended for these tumours.

Role of Intraoperative Clean Surgical Margin Determined With Lesion Size and Duration to Obtain Apropriate Histological Clean Surgical Margin in High-Risk Basal Cell Carcinoma Patients, According to National Comprehensive Cancer Network Criteria

We aimed to elucidate the role of intraoperative clean surgical margin (iCSM) determined according to lesion size and duration to obtain appropriate histological clean surgical margin (hCSM) in high-risk basal cell carcinoma (BCC) patients evaluated according to National Comprehensive Cancer Network (NCCN) criteria considering the tumor size and/or location. The contribution of lesion area to determine iCSM was also evaluated. Patients with high-risk BCC requiring surgical management were included. iCSM, hCSM, and clinical variables including sec, age, longest edge, location and area, and follow-up duration were recorded. In total, 96 lesions were evaluated. Lesions were mostly located in the mask area and other face region (93.8%). Lesions located on the nose comprised 50%, 34.1%, and 26.3% in the BCC-5, BCC-7, and BCC-10 lesions, respectively. The hCSMs were positive in 11.5%, 9.1%, and 3.8% of the BCC-5, BCC-7, and BCC-10 lesions, respectively. The deep surgical margin was positive in 15.4%, 4.5%, and 7.7% of the BCC-5, BCC-7, and BCC-10 lesions, respectively. The calculated risk for the positive surgical margin if the BCC-10 lesions were done like the BCC-7 was 15.4%. No recurrence was during follow-up duration. As supported by the findings of the present study, to obtain an adequate hCSM in the high-risk BCC lesions, the iCSM determined according to NCCN recommendations may not be optimal. Nevertheless, after their categorization according to lesion size and disease duration for excision with 5-, 7-, and 10-mm iCSMs, it is possible to obtain a small but important improvement in the outcome of patients.

Peripheral histological clearance of cutaneous BCC and SCC excised using the wet blotting technique

Introduction

Accurate identification of the peripheral margin of cutaneous basal cell and squamous cell carcinomas plays a crucial role in ensuring complete excision of the skin cancer. The recommended margin of excision for cutaneous malignancies varies in the current guidelines. The aim of this study was to assess the success rate of peripheral margin clearance with a 4 mm peripheral margin of excision when the clinical margin of the lesion has been identified using the wet blotting technique.

Methods

The peripheral margin of each skin cancer was marked using the wet blotting technique and a 4-mm margin of excision rule was applied to all skin cancers regardless of their type and other clinical features. Data collection was performed from patients who were operated on over a period of 34 months (2011 to 2014). Information gathered included patient demographics, clinical details of the lesion and histopathological data.

Results

The total number of patients identified were 456. The case notes were reviewed and eventually 276 patients were included and 180 patients were excluded. The histology report showed 95–97% clearance of the peripheral margin in all BCCs and SCCs regardless of their clinical features and their location.

Conclusions

Our study has shown that a standard rule of maintaining a 4 mm margin around all head and neck skin BCCs and SCCs, measured after the visible margin of the lesion had been accurately identified by the wet-blotting technique, can successfully achieve 95–97% peripheral clearance of all lesions, irrespective of the subtype, size and location.

Validation of a new technique to freezing and embedding tissue in Mohs surgery, using an animal model

PURPOSE

To validate the innovative Dry Ice method, comparing it with two standard methods currently used for tissue processing in Mohs surgery, the Heat Sink method and the Miami Special.

METHODS

Forty eight samples of pigs kin with the standard beveled Mohs technique were used, and randomly allocated into six groups. Each group was processed with one of the 3 methods and evaluated for: The freezing time, the depth required to cut into the block to obtain a complete section, and the quality of histological slides analyzed with a image software. The statistical analysis was performed with the software SAS(r) System. The inferential analysis was made by one-way ANOVA.

RESULTS

The Miami Special showed a processing time significantly shorter than Dry Ice method and Heat Sink method. There was no significant difference in the depth required to cut into the blocks, and area of surgical margins visualized.

CONCLUSION

The Dry Ice method was as efficient as the other two methods currently used in Mohs surgery, considering the individual advantages and disadvantages of each method.

Head and neck nonmelanoma cutaneous malignancy treatment in a skin cancer referral center

OBJECTIVE

The purpose of our study was to determine the level of accuracy provided by clinical diagnosis in head and neck cutaneous malignancy as confirmed by histopathologic examination of the specimen in a skin cancer referral center. Positive predictive value was selected as a reliable measure of diagnostic accuracy. We also aimed to audit our surgical outcomes and record and present the completeness of excision, the rates of recurrence and metastasis, and the reconstructive method.

STUDY DESIGN

We reviewed the electronic charts of 867 consecutive patients with skin tumors and calculated the positive and negative predictive values of clinical diagnosis.

RESULTS

The positive predictive value was 91% for basal cell carcinoma and 78.8% for squamous cell carcinoma. Of the 178 histologically diagnosed squamous cell carcinomas, 15 were metastatic.

CONCLUSIONS

In a skin cancer referral center, expert clinical diagnosis may safely overcome the need for preoperative biopsy. Relying on clinical diagnosis to formalize a treatment plan for head and neck nonmelanoma skin cancer is safe and efficient. This is more reliable in cases of basal cell carcinoma compared with suspected squamous cell carcinomas.

Marking sutures to orientate specimens of basal cell carcinoma: do they really make a difference?

Traditionally, marking sutures have been used to orientate specimens of non-melanomatous skin cancers, and they provide an identifiable point as a reference for monitoring and further treatment. For histopathological purposes, the orientated specimen is marked with different inks, which enables measurement to the nearest lateral and deep margins, and if invaded, guides further excision. We retrospectively analysed 688 specimens of basal cell carcinoma (BCC) from the head and neck from two separate years: 2010 and 2012. Marking sutures were used in 663 (96%) cases. There were 21 invaded margins (3%), 17 (81%) at the lateral margin and 4 (19%) at the deep margin. Of the 17 with invaded lateral margins, 10 were from the nose, and the remaining 7 from other sites including the ear (n=2), and neck, forehead, temple, eyelid, and cheek (n=1 each). Of the 663 marked specimens, the marking stitch was useful in only one patient who needed another operation (0.2%). We suggest that routine orientation of BCC, even from high risk areas, is not necessary. If the operating surgeon questions the size of the margin when a lesion is ill-defined or of a high-risk histological subtype, then excision with monitored en-face margins should be considered with traditional Mohs surgery or a reliable modified version.

Nasal basal cell carcinomas. Can we reduce surgical margins to 3mm with complete excision?

BACKGROUND

The purpose of this study was to evaluate the incomplete excision rate of nasal basal cell carcinomas (BCC) resected with different margins to demonstrate that 3-mm surgical margins could be used as safety margins to reduce esthetic consequences with a low risk of incomplete excision.

METHODS

All patients with BCC of the nose excised from January 1st 2008 to December 31st 2011 were included. Data were analyzed and reviewed retrospectively. Tumors were treated with different surgical margins of excision: 3mm, 4mm, and 5mm. The primary outcome variable was the rate of incomplete excision. Other study variables were the histologic subtype, size, and recurrent lesions.

RESULTS

Of the 132 patients, 115 were included corresponding on with 127 BCC. Median age was 75.5 (64-83) and sex ratio M:F=1.05. Of the 127 BCC, 80 were aggressive histologic subtype (63%), and 11 were recurrent (8.7%). The overall rate of incomplete excision was 17.3% (n=22). Of these 22, 17 (77.3%) were of an aggressive subtype. The incomplete excision rates within the groups were 12.5% (n=4), 22.2% (n=10), and 16% (n=8), respectively within the group with 3-, 4- and 5-mm surgical margins. No significant difference was observed between the groups (P=.519). The incomplete excision rate was not independently associated with the surgical margins, histologic subtype and recurrent type (P>.05).

CONCLUSION

Three-millimeters margins could possibly be used to treat nasal BCC in chosen cases. Regarding the high rate of incomplete excision, reconstruction should be performed after receiving the pathologic report.

Retrospective Outcome Analysis of 39 Patients Who Underwent Lip Surgery for Cutaneous Carcinoma

PURPOSE

The treatment of lip carcinomas needs tumor surgical resection with safety margins respect. The aim of this study was to report the oncologic and aesthetic/functional outcomes of a retrospective monocentric case series of 39 patients treated for cutaneous lip cancer.

METHODS

This retrospective study assessed 56 patients who were treated for a lip carcinoma between 2008 and 2012 and included 39 patients with cutaneous lip basal cell carcinoma or squamous cell carcinoma. Clinical, surgical and pathological data were reviewed, and patients were interviewed for follow-up data. A comparison was made between the marked surgical margins and the margins observed under microscopy after histologic process.

RESULTS

The most frequent tumor type was basal cell carcinoma in 69.2 %. The measured surgical margins were superior to the histological margins in 24 cases (61.5 %) and were inferior in 13 cases (33.3 %). Overall survival and recurrence-free survival rates at 1 year were 97.5 and 95 % respectively.

CONCLUSION

Differences between the surgical margins and the final histologic margins were the main finding of this retrospective study. These differences were attributed to surgical practices and modification during the histological process. Nevertheless, we did not observe a higher rate of recurrence or death in our study than in literature.

The Role of Embryologic Fusion Planes in the Invasiveness and Recurrence of Basal Cell Carcinoma: A Classic Mix-Up of Causation and Correlation

Background:

The facial embryologic fusion planes as regions of mesenchymal and ectodermal fusion of the primordial facial processes during embryological development have been suggested to influence the spread, invasiveness, pathogenesis, and recurrence of cutaneous carcinoma. This study sought to establish whether basal cell carcinoma (BCC) originating in embryologic fusion planes has a greater propensity for earlier depth of invasion, leading to an increased rate of lesion recurrence.

Methods:

Facial BCCs excised in a single surgeon practice over 2 years were allocated into 2 anatomic domains according to their correlation with embryologic fusion planes. Lesion depth of invasion, surface area, and margins of excision were analyzed in conjunction with recurrence data over the following 70–80 months.

Results:

Of the 331 lesions examined, 70 were located in embryologic fusion planes. No difference was found in the mean surface area and depth of invasion for lesions located in the 2 domains (P > 0.05). Ten lesion recurrences were identified, none of which were located in embryologic fusion planes. Recurrent lesions were excised with a significantly greater percentage of close and incomplete excision margins (P < 0.05).

Conclusions:

BCC arising in embryologic fusion planes are not more invasive or at greater risk of recurrence. Excision margins seem to have the greatest influence on lesion recurrence. Because of the paucity of superfluous tissue and the cosmetic and functionally sensitive nature of these areas of embryologic fusion, specialist treatment of these lesions is recommended to ensure that adequacy of excision is not neglected at the cost of ease of closure and cosmesis.

Surgical treatment of basal cell carcinoma: an algorithm based on the literature

Although basal cell carcinoma can be effectively managed through surgical excision, the most suitable surgical margins have not yet been fully determined. Furthermore, micrographic surgery is not readily available in many places around the world. A review of the literature regarding the surgical treatment of basal cell carcinoma was conducted in order to develop an algorithm for the surgical treatment of basal cell carcinoma that could help the choice of surgical technique and safety margins, considering the major factors that affect cure rates. Through this review, it was found that surgical margins of 4mm seem to be suitable for small, primary, well-defined basal cell carcinomas, although some good results can be achieved with smaller margins and the use of margin control surgical techniques. For treatment of high-risk and recurrent tumors, margins of 5-6 mm or margin control of the surgical excision is required. Previous treatment, histological subtype, site and size of the lesion should be considered in surgical planning because these factors have been proven to affect cure rates. Thus, considering these factors, the algorithm can be a useful tool, especially for places where micrographic surgery is not widely available.

Comparing disciplines: outcomes of non melanoma cutaneous malignant lesions in oral and maxillofacial surgery and dermatology

300 cases of non-melanoma cutaneous lesion procedures carried out by the Oral and Maxillofacial Surgery and Dermatology departments in a North West London hospital over a 6 month period between September 2011 and February 2012 were included in a retrospective case control study. The results from each speciality were compared. The mean age of the OMFS group was 75.8 years compared to 69.9 years in the dermatology group. There was no statistically significant difference in gender between the 2 groups. The OMFS group treated a higher proportion of atypical (17%) and malignant (64.9%) cases compared to the dermatology group (11.3% and 50.5% respectively). This could also account for the fact that the OMFS group carried out a higher number of full excisions compared to dermatology. Both groups had a similar number of false positives (a benign lesion initially diagnosed as malignant) and a similar proportion of false negatives (a malignant lesion initially diagnosed as benign). Overall, the results show that both specialities had similar outcomes when managing non-melanoma cutaneous lesions. Both groups adhere to the guidelines set out by the British Association of Dermatologists and the National Institute of Clinical Excellence when managing such lesions.

Basal cell carcinoma of the head and neck region: a retrospective analysis of completely excised 331 cases

The aim of the study is to analyze all completely excised BCCs in the head and neck region with regard to age, sex, personal and familial history, skin type, tumor localization and size, histopathological subtype of tumor, reconstruction method, and recurrence rates. Incompletely excised BCCs were not included in this study since incomplete excision is the most important preventable risk factor for recurrence. In 320 patients, 331 lesions were retrospectively evaluated by dividing into the following 8 subunits: scalp, frontotemporal, orbital, nose, cheek, auricula, perioral, and chin-neck area. Most of the patients were in 60-70 age group (34.7%). The nose (32.3%) was the most common site of presentation. Clinically, all lesions and, histopathologically, most of the lesions (42.2%) presented were of the nodular type. All cases of recurrence after complete excision (n = 9, 2.7%) were located in the median parts of the head and neck region and were mainly diagnosed histopathologically as sclerotic and micronodular. Even though completely excised, head and neck region BCCs, especially which are more prone to recurrence due to anatomical and histopathological properties, should be more closely monitored in order to decrease morbidity and health care costs.

Nonmelanoma skin cancer of the head and neck: surgical treatment

This article focuses on the surgical treatment of nonmelanoma skin cancers of the head and neck. The risk factors of nonmelanoma skin cancers for recurrence and metastases that are important for choosing the best treatment option are summarized. Surgical treatment options including surgical excision with standard margins, frozen section, staged surgery, and Mohs micrographic surgery are described. Indications, techniques, outcomes, and advantages and disadvantages of each approach are reviewed. Finally, management of incomplete excisions is discussed.

Incompletely excised basal cell carcinoma: residual tumor rates at Mohs re-excision

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin cancer, and incompletely excised BCC is a commonly encountered clinical scenario.

OBJECTIVE

To investigate the incidence of histologic and clinical evidence of residual BCC at Mohs micrographic surgery (MMS) for the treatment of incompletely excised BCC.

METHODS AND MATERIALS

One hundred incompletely excised BCCs, from our practice and referred to our practice by local family doctors, treated using MMS between 2005 and 2007 were studied. Patient data included sex, age, anatomic location of tumor, histologic subtype, margin involved, initial closure and closure after MMS, and Mohs stages required for histologic clearance.

RESULTS

Sixty-nine percent of incompletely excised BCCs had residual tumor at MMS re-excision, and 12% had clinically evident residual disease.

CONCLUSION

Immediate re-excision using MMS is recommended for treatment of incompletely excised BCC because the majority of cases have histologically detectable BCC. Watch and wait advice could lead to significant morbidity because recurrence may necessitate more extensive closures and costs. Long-term follow-up is recommended. It is important to conduct self-audits of incomplete excisions and follow up these patients.

Basal cell carcinoma of the head and neck region: an analysis of 171 cases

Objective. To analyze the pattern of presentation of basal cell carcinoma (BCC) and margin status for excised specimens in the head and neck region. Study Design. Retrospective cross-sectional. Duration of Study. January 2009 to December 2011. Methodology. The database of the pathology department was searched to identify records of all malignant skin tumors that underwent standard excision with margins. Out of these records, tumors with a diagnosis of BCC in the head and neck region were retrieved and separated. Age, gender, anatomic location, pattern of tumor, and margin status were noted. Results. A total of 171 cases of BCC from various sites of head and neck were retrieved. Male to female ratio was 1.4 : 1. The age ranged from 22 to 90 years. Seventy-six cases presented on right side, 79 on left, and 16 were in the midline. Most common anatomical site was the nose followed by the cheek. Nodular lesions were the most common (46.2%) followed by pigmented variety (18.7%). Margins were clear in 77 (45.1%) cases, involved in 86 (50.2%) cases, and close in 8 (4.7%) cases. Conclusion. Nose was the most common site followed by the cheek. Nodular and pigmented varieties were the most frequent and margins were involved in more than fifty percent of the cases.

Oncologic clearance with preservation of reconstructive options: literature review and the 'delayed reconstruction after pathology evaluation (DRAPE)' technique

Intraoperative frozen section and Mohs' micrographic surgery (MMS) are two techniques used to ensure oncological clearance without resorting to unnecessarily wide margins that might compromise reconstructive options for definitive wound closure. In addition to some technical issues, these techniques are suboptimal for resection of tumours such as melanoma, where specific tissue margins at histopathology are required to ensure minimal risk of local recurrence. We describe a technique that minimizes the amount of tissue excised and uses definitive paraffin sections interpreted in a pathology laboratory in order to delay reconstruction until after clear oncologic margins are obtained. This 'delayed reconstruction after pathology evaluation (DRAPE)' technique is particularly directed at extensive and complicated skin lesions, located in areas of the body that can be difficult to reconstruct and are prone to disfigurement and/or loss of function. A review of the literature is undertaken, establishing the role of each technique in achieving clear surgical margins. A case example is presented, highlighting the role of the DRAPE approach. The DRAPE technique is presented as a useful option for high-risk lesions, especially within aesthetically sensitive regions or for complex reconstructions, and when reconstruction can be reasonably delayed while tumour clearance is established.

Evaluation of surgical margins in Basal cell carcinoma by surgical specialty

BACKGROUND

Complete surgical excision is the most common treatment for basal cell carcinoma (BCC), and this intervention is often performed by surgeons who are not dermatologists (e.g., plastic surgeons, general surgeons, oral and maxillofacial surgeons, ophthalmologists, and otorhinolaryngologists).

OBJECTIVES

To determine positive margin rates in BCCs removed by surgeons from different specialties and to identify clinical and pathologic factors that might explain potential differences between specialties.

METHODS

We retrospectively reviewed the pathology reports of all BCCs diagnosed at Hospital Universitari Vall d'Hebron between January 2009 and March 2001. The statistical methods included a descriptive analysis of clinical and pathologic variables, standard statistical analyses, and multivariate logistic regression.

RESULTS

We included 921 BCCs from 750 patients; 549 of the tumors had been excised by a dermatologist. The overall positive margin rate was 12.6%, but the rate for tumors removed by dermatologists was significantly lower than that for those removed by other specialists (6.7% vs 21.5%). There was a 3.8-fold increased relative risk of positive margins following excision by a surgeon who was not a dermatologist, independently of patient age, tumor site, maximum diameter of the resected specimen, and histologic subtype.

CONCLUSIONS

Accurate macroscopic identification of tumor margins, which are often difficult to see, and familiarity with the natural history of BCC are key factors in the successful surgical treatment of BCCs. The higher rate of tumor-free margins achieved by dermatologists in this study is probably mainly due to their greater experience in these 2 areas.

[Diagnosis and treatment management of basal cell skin carcinoma - guidelines analysis]

Basal cell carcinoma (BCC) is the most frequent skin cancer in France. BCC has above all a local evolution with an important locoregional morbidity. BCC are found in 80% in the cervicofacial region. Surgery is currently recognized to be the most reliable treatment. The surgeon needs to achieve an in sano excision and must recover the defect with the less aesthetic consequences. The aim of this work is to combine and to get-at-able the recommandations of the "Haute Autorité de santé" of 2004, and also to supply some details for the clinical practice of the plastic surgeon.

Basal cell carcinoma of the head and neck region in ethnic chinese

Objectives. This study aims to report our experience in the management of HNBCC in ethnic Chinese over a 10-year period. Methods. A retrospective review of all ethnic Chinese patients with HNBCC treated in a tertiary centre from 1999 to 2009. Results. From 1999 to 2009, 225 patients underwent surgical excision for HNBCC. Majority were elderly female patients. Commonest presentation was a pigmented (76.2%) ulcer (64.8%) over the nose (31.6%). Median skin margin taken on tumour excision was 2.0 mm; primary skin closure was achieved in 51.8%. Postresection skin margin was clear in 75.4%. Of those with inadequate skin margins, 56.7% opted for further treatment, 43.4% for observation. Recurrence rates were 2.6% and 13.8%, respectively (P = 0.106). Overall recurrence rate was 5.5%. Conclusions. HNBCC commonly presented as pigmented ulcers over the nose of elderly female patients in our locality. Adequate tumour excision ± reconstruction offered the best chance of cure. Reexcision of those with inadequate skin margins improved local tumour control.

Basal cell carcinoma of the head region: therapeutical results of 350 lesions treated with Mohs micrographic surgery

BACKGROUND

Basal cell carcinoma (BCC) is a non-melanocytic skin tumour with a high risk of recurrence after incomplete treatment, especially the aggressive subtypes (basosquamous, micronodular and morphea BCC). The percentage of recurrence also depends on the anatomical site of the tumour. Nose-cheek fold, paranasal fold, retroauricular fold and internal canthus are considered to be critical sites.

OBJECTIVE

The aim of this study was to report on recurrence rates for BCC treated with Mohs micrographic surgery (MMS).

MATERIAL AND METHODS

We retrospectively studied 350 BCCs of the head region treated with MMS. Results were analysed with chi-squared test and Fisher test and were considered significant when P value was ≤0.05.

RESULTS

In our study, the percentage of BCC recurrence rate after MMS was of 3.4% for primary BCC and 4.9% for recurrent BCC; these were similar to the recurrence rates reported in the literature.

CONCLUSIONS

Low recurrence rate can be achieved when treated with MMS; it is the treatment of choice for many BCC of the head. Aggressive histopathological subtypes, critical head sites and recurrence after incomplete excision are the most important indications for MMS.

Basal cell carcinoma: 10 years of experience

Introduction. Basal cell carcinoma (BCC) is a locally invasive malignant epidermal tumour. Incidence is increasing by 10% per year; incidence of metastases is minimal, but relapses are frequent (40%–50%). The complete excision of the BCC allows reduction of relapse. Materials and Methods. The study cohort consists of 1123 patients underwent surgery for basal cell carcinoma between 1999 and 2009. Patient and tumor characteristics recorded are: age; gender; localization (head and neck, trunk, and upper and lower extremities), tumor size, excisional margins adopted, and relapses. Results. The study considered a group of 1123 patients affected by basal cell carcinoma. Relapses occurred in 30 cases (2,67%), 27 out of 30 relapses occurred in noble areas, where peripheral margin was <3 mm. Incompletely excised basal cell carcinoma occurred in 21 patients (1,87%) and were treated with an additional excision. Discussion. Although guidelines indicate 3 mm peripheral margin of excision in BCC <2 cm, in our experience, a margin of less than 5 mm results in a high risk of incomplete excisions.

Risk and outcome analysis of 1832 consecutively excised basal cell carcinomas in a tertiary referral plastic surgery unit

BACKGROUND

Basal cell carcinomas are the most prevalent of all skin cancers worldwide and form the majority of the surgical workload for most modern cutaneous malignancy centres. Primary surgical removal of basal cell carcinomas remains the gold standard of treatment but, despite almost two centuries of surgical experience, rates of incomplete surgical excision of up to 50% are still reported. The aim of this study was to assess, quantify and perform comparative analysis of the outcomes and predictive factors of consecutive primarily-excised basal cell carcinomas in a tertiary centre over a six-year period.

METHODS

Retrospective audit was conducted on all patients who underwent surgical excision of basal cell carcinomas from January 2000 to December 2005. Assessment parameters included patient biographics, tumour management differences and detailed histopathological analysis of tumour margins and subtypes.

RESULTS

One thousand eight hundred and thirty two basal cell carcinomas were excised from 1329 patients over the designated time period. Two hundred and fifty one (14%) lesions were incompletely excised with 135 (7.4%) involving the peripheral margin only, 48 (2.6%) the deep margin only and 41 (2.2%) involving both. Nasal location was the most common predictor of incomplete excision.

CONCLUSIONS

Overall basal cell carcinomas excision rates compared favourably with international reported standards but attention to a variety of surgical and histological risk factors may improve this further.

Lip cancer: incidence, trends, histology and survival: 1970-2006

BACKGROUND

High levels of lip cancer have been reported among Israelis over the last four decades. Epidemiological descriptions and analyses for this region have not previously been presented.

OBJECTIVES

To establish the incidence, trends and histology of lip cancer and associated demographic variables in Israel over time.

METHODS

Data for 1970-2006 were derived from the Israel National Cancer Registry. Incidence and trends over time and analyses by lip site, sex, age, origin, histology and 5-year survival were studied.

RESULTS

Of 4337 new cases, most were found among men (61.4%), people aged over 53 years (75.5%), and those with lighter skin (62.6%). Lip cancer cases were 40 times more prevalent in the external than in the inner lip. The dominant tumour type was squamous cell carcinoma at the external lower lip and intraoral lip mucosa (predominantly in men) and basal cell carcinoma (originating from skin) at the external upper lip (predominantly in women). Minor salivary gland tumours, melanoma and metastases were also reported. Slight increases in the trend of upper lip cancer and decreases for lower lip cancer were reported.

CONCLUSIONS

Men, fair-skinned individuals and those over 53 years of age were at higher risk for lip cancer. A higher incidence of external lip cancer, compared with internal, may indicate a major role for sun exposure rather than smoking. The effect of public awareness campaigns as well as occupational changes, both related to sun exposure, should be studied carefully as potential factors in the changing incidence of lip tumours.

A relative value unit-based cost comparison of treatment modalities for nonmelanoma skin cancer: effect of the loss of the Mohs multiple surgery reduction exemption

BACKGROUND

The incidence of skin cancer has increased dramatically, with as many as 2.8 million skin cancers treated in 2005. In an era of decreasing reimbursement, insurer policy changes, and increasing pressure to deliver cost effective care, physicians should understand the total cost of different skin cancer treatment modalities in order to determine which yields the best value for patients.

OBJECTIVE

To estimate the costs of treating nonmelanoma skin cancers by multiple modalities based on their assigned relative value unit (RVU) values.

METHODS

The cost analysis was performed for the treatment of two skin cancer examples, a basal cell carcinoma (BCC) on the central cheek and a squamous cell carcinoma (SCC) on the forearm of varying sizes. The estimated costs of treatment of each of the skin cancers was calculated for treatment with electrodessication and curettage (EDC), imiquimod immunotherapy, Mohs micrographic surgery, traditional surgical excision with permanent section margin evaluation in an office setting (with immediate repair or with repair delayed until clear margins are confirmed), surgical excision with frozen section margin control in both an ambulatory surgery center and hospital-based setting, and radiation therapy. The effect of the loss of exemption from multiple surgery reduction on the cost of Mohs surgery is also examined.

RESULTS

Our estimation of costs for each of the treatment modalities reveals that EDC is the least expensive option, with average costs of $471 (BCC cheek) and $392 (SCC arm). Imiquimod treatment and office-based excision with immediate repair of the surgical defect have similar total average costs of $959 (BCC cheek) and $931 (SCC arm) and $1006 (BCC cheek) and $907 (SCC arm), respectively. If repair of the defect is delayed until negative surgical margins are confirmed by permanent section, the cost of excision increases to $1170 and $1041. The average cost of Mohs micrographic surgery is $1263 (BCC cheek) and $1131 (SCC arm). Mohs surgery's recent loss of multiple surgery reduction exemption has decreased the cost of Mohs surgery by 9% to 25%. Excision with frozen section margin control in an ambulatory surgery center results in costs of $2334 (BCC cheek) and $2200 (SCC arm). However, if the excision is performed in a hospital operating room, the procedure is substantially more expensive, at $3085 and $2680. The cost of radiation therapy treatment is $2591 to $3460 for the BCC of the cheek and $2559 to $3431 for the SCC of the arm, depending on the fractional dose used.

LIMITATIONS

These are cost estimates based on literature examples and 2008 RVU values; variations related to individual practices and procedure valuations by private insurers are expected.

CONCLUSION

Tumor destruction by EDC or imiquimod and office-based procedures, such as traditional surgical excision or Mohs surgery, are the lowest cost options for treatment of nonmelanoma skin cancer.

Randomized comparison of Mohs micrographic surgery and surgical excision for small nodular basal cell carcinoma: tissue-sparing outcome

BACKGROUND

Mohs micrographic surgery (MMS) is recognized globally as the criterion standard for high-risk basal cell carcinoma (BCC). The main advantage of MMS over conventional surgery is the chance of complete tumor removal, but it is also thought, based on experience, to be tissue sparing.

OBJECTIVE

To determine whether MMS leaves smaller surgical defects than standard surgery.

METHODS AND MATERIALS

This was a randomized trial involving 30 patients with a clinical diagnosis of BCC. Patients were randomly assigned to MMS or standard surgery. In the standard surgery group the BCCs were excised with 4-mm margins. In the MMS group, tumors were excised with 2-mm margins and subsequent stages of MMS until the tumor was completely removed. An observer unaware of the treatment allocation calculated the defect size. The main outcome measure was defect size in mm(2).

RESULTS

The median area of the surgical defects in the MMS group was 116.6 mm(2), versus 187.7 mm(2) in the standard surgery group (95% confidence interval for difference=61-126, p<.001).

CONCLUSIONS

This is the first randomized trial demonstrating that MMS is a tissue-sparing treatment.

TRIAL REGISTRATION

http://www.clinicaltrials.gov Identifier: NCT00571363. The authors have indicated no significant interest with commercial supporters.

Basal cell carcinoma of the nose: an Australian and New Zealand radiation oncology patterns-of-practice study

Patients with a basal cell carcinoma (BCC) of the nose may be recommended radiotherapy (RT) with a wide variation in techniques and prescribed dose fractionation schedules between clinicians. The aim of this study was to ascertain variability in the patterns of practice among Australian and New Zealand radiation oncologists (ROs) when treating BCC arising on the nose. A postal survey was sent to 222 practising ANZ ROs detailing 12 different clinical scenarios of a BCC arising on the nose. The treatment selected for each scenario was analysed according to clinician's attitudes, training, experience and the availability of resources. The response rate was 74% (165/222) with 90 respondents treating non-melanoma skin cancer. Training was perceived to have a marked influence on treatment practice by most (79%). In total, 72% of ROs were 'very certain' in their choice of a dose fractionation schedule for obtaining local control and 61% for a satisfactory cosmetic outcome, respectively. Most (76%) favoured low-voltage photons over electrons as the optimal method of treatment, although for certain clinical scenarios most would use electrons. Dose fractionation schedules were highly variable with a lower total dose and hypofractionation favoured for older patients. Low-voltage photons were favoured for the T1 BCC and electrons for the T2 and T4 BCC. Nearly one-third of the ROs chose megavoltage photons for the T4 lesion. There is marked variation in treatment practices in terms of recommending RT over other treatment options, the choice of RT method, the dose fractionation schedule, the extent of field margins and the point of dose prescription.

Metatypical basal cell carcinoma: a clinical review

Background

Metatypical cell carcinoma can be considered as a new entity of skin cancer, being an intermediate typology between basal cell carcinomas and squamous cell carcinomas. The behaviour of the metatypical cell carcinoma lies between these two varieties of skin cancer. It is difficult to perform a differential diagnosis based on morphological and clinical features – therefore it is only possible by accurate histology.

Methods

The authors have retrospectively analysed clinical records of 240 patients who were affected by metatypical skin cancer and who were treated by surgery, radiotherapy and chemotherapy.

Results

MTC affected more males than females (62.5% vs 37.5%) than males. The most affected site was the cervicofacial area, 71.7%; then the trunk, 10%; the limbs, 9.6%; the scalp 3.7%; and other regions 5%. A recurrence occurred in 24 cases (10%), mainly in head and neck area.

Conclusion

In this manuscript, the authors have emphasised the importance of conducting a differential diagnosis, and the importance of the specific treatment for metatypical skin cancer, even though more clinical studies and long-term follow-ups are required before establishing specific guidelines.