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

The use of a surgical logbook to improve training and patient safety: A retrospective analysis of 6 years' experience in Bristol, UK

Background

Logbooks can be a useful educational tool. Although their use in medical training has been greatly explored, there is limited research into their application throughout a clinician's career. We created a surgical logbook to allow clinicians to record their skin surgery procedures and reflect on the histological diagnosis and clearance margins achieved.

Objectives

We provide a retrospective analysis to evaluate the usefulness of the logbook as an analytical and educational tool in a dermatology department, particularly for maintaining exemplary complete excision rates.

Methods

Data was collected from clinicians who conducted skin surgery in Bristol, UK. Cases were entered at the time of surgery, collecting data on body site, clinical margin, suspected diagnosis, type of procedure and closure. Following receipt of histological results, data on histological excision margins and tumour type was entered. Each clinician submitted data for a minimum of 3 months each year, and data collection ran from April 2012 until March 2018.

Results

Data from 5161 excision surgeries was collected over the 6-year period. On histological diagnosis, excisions constituted 50% Basal Cell Carcinoma (BCC), 12% Squamous Cell Carcinoma (SCC), 9% Malignant Melanoma (MM) and 1% Lentigo Maligna (LM), and 28% 'Other' (rarer malignancies, melanoma wide local excision scars and pre-cancerous/benign lesions). The department was found to have good diagnostic concordance: BCC 92%, SCC 87%, MM 80% and LM 53%. Overall complete excision rate was high at 97.07%. The most successfully excised cancer was BCC (97.50%), then SCC (97.14%) MM (96.48%) and LM (95.23%). The department provided many complex surgeries including 8.3% flaps and 8.5% grafts. Average lesion diameter was 11 mm (range 2-90 mm). There was a significant improvement in excision rates seen over the years for BCC, MM and LM. Although there was no significant difference found for SCC, this group began the study with already high clearance rates.

Conclusion

This surgical logbook supports improved training and continues professional development. We encourage more departments to use this logbook and share the data that they produce. This could improve their excision rates, patient experience, and save them up to £28 000 per year.

Adequacy of surgical margins, re-excision, and evaluation of factors associated with recurrence: a retrospective study of 769 basal cell carcinomas

BACKGROUND

Achieving adequate surgical margins and preventing recurrence are important in the treatment of basal cell carcinoma (BCC).

OBJECTIVES

The objectives of this study were to evaluate the adequacy of surgical margins and the re-excision rates in patients with primary BCC who underwent standard surgical treatment using our proposed algorithm and to define the risk factors in patients with recurrent BCC.

METHODS

The medical records of patients who were histopathologically diagnosed with BCC were reviewed. An algorithm created based on previous literature was used to determine the distribution of optimal surgical margins adequacy and re-excision rates.

RESULTS

Statistically significant differences were observed between the cases with and without recurrence in age at diagnosis (p=0.004), tumor size (p=0.023), tumor location in the H zone of the face (p=0.005), and aggressive histopathological subtype (p=0.000). When the tumors were evaluated for adequacy of deep and lateral surgical margins and re-excision rates, higher rates of adequate excision (457 cases, 68.0%) and re-excision (43 cases, 33.9%) were noted for tumors in the H or M zone.

STUDY LIMITATIONS

Inadequate follow-up of newly diagnosed patients in terms of recurrence and metastasis and the retrospective application of our proposed algorithm are the limitations of the present study.

CONCLUSIONS

Our results showed that if BCC was detected at an early age and at an early stage, recurrence was lower. The H and M zones were the regions with the highest rates of optimal surgical outcomes.

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.

A multicentre review of the histology of 1012 periocular basal cell carcinomas

AIMS

To evaluate primary periocular basal cell carcinomas (BCCs) in depth including comparing histological margins with subtype, location and surgical specialty after wide local excision.

METHODS

A retrospective review was performed for all BCCs excised from three hospitals over 5 years, covering a population of just over 1 million. Tumours were classified according to histological subtype location. Incomplete excision rates and margins were analysed in detail and comparisons made.

RESULTS

The most common subtype found was nodular followed by infiltrative. Lesions were most commonly located at the lower lid. Infiltrative BCCs were associated with perineural invasion and incomplete excision despite the largest peripheral margins. Superficial BCCs had the smallest mean peripheral margin but the largest mean deep margin. 2 mm histological margins gave an 83.7% complete excision rate, 6.4% incomplete excision rate and 7.1% where the clearance margin was 0.3 mm or less.

CONCLUSION

Distribution of eyelid BCCs based on subtype and periocular location mirrored the general consensus. Infiltrative BCCs should be excised with wider margins or referred for Mohs surgery, especially if the medial canthus is involved. Superficial BCCs should be excised with wider but shallower surgical margins. Ophthalmologists were more likely than dermatologists or plastic surgeons to incompletely excise a periocular BCC, which is reflective of their more difficult case mix.

A retrospective study of 694 Basal Cell Carcinoma excisions to quantify deep margin documentation and clearance compared to histological type and surgical margin

AIMS

Basal cell carcinoma (BCC) is the most common malignancy worldwide. Although rarely a risk to life, they are potentially destructive and disfiguring. Current treatment guidelines are predominantly based on low-risk BCC and make no recommendations regarding the deep excision margin. We aim to clarify the prevalence of high-risk BCC and appropriate surgical management of the deep margin.

METHODS

Data of 556 patients presenting for primary excision of 694 basal cell carcinoma to CUH Plastic Surgery between January 2017 and April 2018 were collected by capture of demographics, surgical notes and histology. We defined the deep surgical margin as numbered anatomical planes, with subcutaneous fat as 0, the first plane under this as 1 and so forth. This allowed comparison of the surgical excision depth, and resulting deep margin histology, across disparate sites. Histological margin clearance was analysed using ordinal regression of age, site, size, histological type and surgical margin. This allowed identification of factors associated with clear, close or incomplete lesion excision. Subgroup analysis was then performed to make recommendations for surgical margins to achieve adequate lesion clearance.

RESULTS

Six hundred ninety-four BCCs were identified, 66% were male and the average age of patients was 74 years. Of the BCCs, 49% were nodular but 39% were mixed. An infiltrative component was seen in 24% (mixed infiltrative), but only 4% were purely infiltrative. Mean size, site and patient age were similar across histological types. Deep margin involvement was very rare in nodular or superficial BCCs but occurred in 7% of pure infiltrative and 5% of mixed infiltrative. Peripheral margins were very rarely involved in nodular BCCs but occurred in 9% of mixed infiltrative and 10% infiltrative despite similar surgical margins. A deep margin of the first underlying anatomical plane resulted uninvolved margins in 95% of infiltrative or mixed infiltrative BCC, but subcutaneous fat was sufficient for clearance in 95% of nodular, superficial and mixed non-infiltrative BCC.

CONCLUSIONS

High-risk BCC was a common finding in our patient population. This was based not only on site and size but also on histological type. Infiltrative and mixed infiltrative BCCs have a higher risk of close or involved deep margins than other types. We recommend that they are excised to the first underlying anatomical plane. Nodular, superficial and mixed non-infiltrative BCC can usually be safely excised with a cuff of fat alone.

Review of outcomes of 500 consecutive cases of non-melanoma skin cancer of the head and neck managed in an oral and maxillofacial surgical unit in a District General Hospital

We provide a non-melanoma skin cancer (NMSC) service for skin cancers of the head and neck in the south-west of England. We hypothesised that certain anatomical sites such as the nose and eyelid would have a higher incidence of close or involved margins than others, and that the choice of repair might influence the excised margins. We therefore retrospectively analysed the data of 500 consecutive NMSC that were operated on in the oral and maxillofacial surgery unit of Taunton and Somerset NHS Trust. The database reports were crosschecked against the Trust's own pathology reporting system to ensure that they were accurate. Data collected included clinical and personal details of patients, anatomical sites, type of reconstruction, histopathological diagnosis, excision margins, and complications. Of the 500 patients reviewed 362 (72%) were basal cell carcinomas (BCC) and 138 (28%) squamous cell carcinomas (SCC). The outcomes of 243 patients treated by primary closure, 134 treated by reconstruction with local flaps, and 123 treated by skin grafts, were reviewed with particular attention paid to the anatomical site and excision margins. There was an overall incomplete excision rate of 10.8% (n=54) and 29 patients developed complications (5.8%). We confirmed that rates of close or incomplete margins are more likely in certain anatomical sites such as the nose, forehead, and ear. The rate of involved margins was unaffected by choice of surgical technique.

Clinical and pathologic parameters predicting recurrence of facial basal cell carcinoma: a retrospective audit in an advanced care center

OBJECTIVES

This study was designed to investigate the associations between clinical, pathologic, and therapeutic parameters of facial basal cell carcinoma (BCC) and recurrence rates in patients treated at an advanced care center.

METHODS

A retrospective cohort study was performed. Patients who presented to an advanced care center within a 6-year period with facial BCC and who received surgical treatment were included for further review according to predefined inclusion criteria. The predictor variable was defined as "negative-margin (R0) resection after the first surgery". The primary outcome variable was defined as "BCC recurrence". Descriptive and inferential statistics were computed. The significance level was set at P ≤ 0.05.

RESULTS

A total of 71 patients (29 female, 42 male; average age: 71.76 years) were found to meet all of the study inclusion criteria. All BCCs had been referred, and 50.7% had been submitted to previous surgery. The mean ± standard deviation tumor diameter was 2.3 ± 1.8 cm. Recurrence of BCC was observed in 11 patients (15.5%). Large tumor diameters, increased patient age, and failure to achieve R0 resection at the first surgical appointment significantly increased recurrence rates.

CONCLUSIONS

Complete facial BCC excision at the first surgical appointment is pivotal in reducing the likelihood of recurrence. The influence of the anatomic location of facial BCC on recurrence rates may be limited.

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.

Basal cell carcinomata: Risk factors for incomplete excision and results of re-excision

INTRODUCTION

Re-excision of incompletely excised basal cell carcinomas (BCCs) can be unsatisfactory in the absence of residual tumours. Recommended guidelines do suggest re-excision as a treatment modality; however, its value has been questioned due to low or variable residual tumour presence. We analysed the incomplete excision and re-excision rates and the presence of residual tumours over an 18-month period in a single unit.

METHOD

Using pathology results and case notes, 2586 primary excisions of BCCs in 1717 patients were reviewed.

RESULTS

The incomplete excision rate was reported to be 7.1% (184/2586). Excision of a lesion by multiple excision lesion procedure was associated with a higher rate of incomplete excision when compared to single lesion excision procedure (61.5% vs. 38.5%). Of the incompletely excised BCCs, 33.6% (62/184) were re-excised, of which 62.9% (39/62) had residual tumours. Although the figures are small, most anatomical sites examined had a residual tumour presence >50%.

CONCLUSION

After evaluating each patient individually, considering the high residual tumour rate, re-excision of an incompletely excised BCC would be a worthwhile procedure.

Basal cell carcinoma of the skin (part 2): diagnosis, prognosis and management

Basal cell carcinoma (BCC) is a heterogeneous malignant neoplasm with different biological and clinical behaviors, often slow growing and rarely metastatic and conveying an excellent prognosis. However, BCC is the most frequent skin cancer worldwide and can cause great morbidity, as most occur in high visible areas of the body, often relapse and may invade and destroy local tissues. This review aims to present a concise and updated overview of BCC histopathology and clinical presentation and progression. We also present a summary of currently available treatment options and some of the new promising agents.

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.

Basal cell carcinoma of the outer nose: overview on surgical techniques and analysis of 312 patients

Background:

Basal cell carcinoma of the nose is common, with a potential of local recurrence and high-risk features.

Materials and Methods:

We provide a review on anatomy of the nose, tumour surgery and defect closure on the nose. We analysed our own patients with nasal BCC of a 24 months period.

Results:

We identified 321 patients with nasal BCC. There was a predominance of female patients of 1.2 to 1. The mean age was 74.8 years. Slow Mohs technique was employed for all tumours until 3D tumour-free margins were achieved. That resulted on average in 1.8 ± 0.7 Mohs stages. The most common histologic types were solitary (n = 182), morpheic (79), and micronodular (20), Perineural infiltration was evident in 56 tumours. Primary closure after mobilisation of soft tissue was possible in 105 BCCs. Advancement flaps were used in 91 tumours, rotation flaps in 47, transposition flaps in 34 tumours, and combined procedures in 6 cases. In 36 patients full-thickness skin grafting was performed. In two patients healing by second intention was preferred. Partial flap loss was seen in four patients (1.4%). All of them had significant underlying pathologies. None of the tumours treated showed a relapse during the observation time. However, this is a limitation of the present study since follow-up was on average only 10 months.

Conclusions:

BCCs of the nose are common. Only 3D-controlled micrographic surgery (Mohs or slow Mohs) guarantee a high rate of complete tumour removal and a very low risk of recurrence.

A study of Basal cell carcinoma in South asians for risk factor and clinicopathological characterization: a hospital based study

Objectives. Although the incidence of skin cancers in India (part of South Asia) is low, the absolute number of cases may be significant due to large population. The existing literature on BCC in India is scant. So, this study was done focusing on its epidemiology, risk factors, and clinicopathological aspects. Methods. A hospital based cross-sectional study was conducted in Punjab, North India, from 2011 to 2013. History, examination and histopathological confirmation were done in all the patients visiting skin department with suspected lesions. Results. Out of 36 confirmed cases, 63.9% were females with mean ± SD age being 60.9 ± 14.2 years. Mean duration of disease was 4.7 years. Though there was statistically significant higher sun exposure in males compared to females (P value being 0.000), BCC was commoner in females, explainable by intermittent sun exposure (during household work in the open kitchens) in women. Majority of patients (88.9%) had a single lesion. Head and neck region was involved in 97.2% of cases, with nose being the commonest site (50%) with nodular/noduloulcerative morphology in 77.8% of cases. Pigmentation was evident in 22.2% of cases clinically. Nodular variety was the commonest histopathological variant (77.8%). Conclusions. This study highlights a paradoxically increasing trend of BCC with female preponderance, preferential involvement of nose, and higher percentage of pigmentation in Indians.

The use of frozen section in the excision of cutaneous malignancy: a Queensland experience

Frozen section is known to be a valuable tool in the setting of indistinct lesions, lesions in cosmetically or functionally important areas, and those with recurrent or residual tumors. Most non-Mohs surgery studies comparing frozen section with paraffin sections suggest a concordance rate of 85% to 90%, whereas studies with Mohs surgery often suggest concordance rates of 95% to 98%. We do not perform Mohs surgery at our institutions but feel that the accuracy of frozen section is relatively high. Frozen-section data from between 2005 and 2011 was analyzed, and a total of 150 cases was found and assessed. Most of the cases were basal cell carcinomas and squamous cell carcinomas, with most arising in the head and neck region. Half of the resections were for previous incomplete margins with the other half being primary excisions. The frozen section was accurate in 97.7% of the cases when compared with the formal paraffin sections. However, the incomplete rate was higher at 14.8% because of patients with known positive margins on frozen section and the use of less accurate techniques of specimen analysis. We feel that, when used appropriately, frozen section can be a reliable tool and that a negative result should provide the surgeon enough reassurance as to undertake immediate reconstruction.

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.