Predictive value of basal cell carcinoma biopsies with negative margins: A retrospective cohort study

Clinical and pathological features associated with high-risk, multiple, and recurrent basal cell carcinomas: a retrospective cohort analysis from the Levantine coast of the Mediterranean Sea

Basal cell carcinoma (BCC) data coming from the Levantine coast of the Mediterranean Sea are limited. The study aimed to primarily analyze the demographic, clinical, pathological, and prognostic characteristics of BCC in this region of the world and secondarily identify features associated with high-risk, recurrent, or multiple BCCs. Patients with at least one diagnosis of BCC registered in the pathology department between January 2015 and December 2019 were included in this analytical retrospective single-center cohort study. Patients with basal cell nevus syndrome were excluded. Patients' characteristics and pathological features were collected through file check for a first analysis. Risk factors and evolution were sought through a phone call interview for the second analysis. The first analysis included 506 BCCs corresponding to 365 patients with a mean age of 65 ± 15 years, twenty-two (6%) were less than 40 years old, 180 (49.3%) were women, and 85 (23.3%) had two or more BCCs. The second analysis included 279 BCCs corresponding to 205 patients. Periorificial and infiltrative BCCs were more frequent in men. Periorificial tumors were more frequently nodular or infiltrative and were associated with recurrence. Tumors with perineural involvement were histologically never nodular nor superficial. Recurrence was more frequent in BCCs having periorificial location, a size larger than 2 cm, or an infiltrative subtype. Multiple BCCs were more frequent in patients with light skin type or familial history of skin cancer. High-risk BCCs were more common in patients with low sun exposure.

Margin Reanalysis With 3-Dimensional Micrographic Surgery Technique of Conventional Excision Specimens With Negative Margin Readings

INTRODUCTION

Mohs micrographic surgery technique allows for complete margin analysis of skin tumors, which explains its lower recurrence rates over conventional surgery. Although it is known that routine processing of excision specimens represents less than 0.5% of the margins, a direct comparison with micrographic technique has not been performed so far.

OBJECTIVE

To compare the margins of nonmelanoma skin cancers excised conventionally, processed with serial transverse cross-sectioning ("bread-loafing"), and had negative margin readings, against the margins obtained through micrographic technique from the same tumors.

MATERIALS AND METHODS

Retrospective, descriptive, historical cohort study. Inclusion criteria as follows: patients who underwent conventional excision for nonmelanoma skin cancers between 2010 and 2013 in our dermatology department and had negative margin readings. Samples were dewaxed and processed with the 3-dimensional Mohs micrographic technique.

RESULTS

One hundred one basal cell carcinomas and 26 squamous cell carcinomas were analyzed. Thirteen positive fragments were obtained, which corresponded to 11 tumors and patients; therefore, 8.7% of patients were given a false negative result in their original study. Lateral margins were more commonly affected (81.8%). There was no clear association between false negative results and histopathologic type or subtype.

CONCLUSIONS

Our study is the first of its kind in terms of methodology. The "bread-loafing" technique can incorrectly report the state of the margins of surgical pieces excised by conventional surgery. Mohs' micrographic technique is superior when it comes to evaluating margins and should be regarded as the gold standard.

The potential utility of integrated reflectance confocal microscopy-optical coherence tomography for guiding triage and therapy of basal cell carcinomas

The increasing rate of incidence and prevalence of basal cell carcinomas (BCCs) worldwide, combined with the morbidity associated with conventional surgical treatment has led to the development and use of alternative minimally invasive non-surgical treatments. Biopsy and pathology are used to guide BCC diagnosis and assess margins and subtypes, which then guide the decision and choice of surgical or non-surgical treatment. However, alternatively, a noninvasive optical approach based on combined reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) imaging may be used. Optical imaging may be used to guide diagnosis and margin assessment at the bedside, and potentially facilitate non-surgical management, along with long-term monitoring of treatment response. Noninvasive imaging may also complement minimally invasive treatments and help further reduce morbidity. In this paper, we highlight the current state of an integrated RCM/OCT imaging approach for diagnosis and triage of BCCs, as well as for assessing margins, which therefore may be ultimately used for guiding therapy.

Negative Predictive Value of Biopsy Margins in Keratinocyte Carcinoma: A Literature Review

BACKGROUND

Pathologists sometimes include commentary on margin involvement in shave biopsy reports of keratinocyte carcinoma (KC). This practice can lead to confusion regarding the need for further treatment. There is limited literature evaluating the reliability of reported histologic margin status in shave biopsies of KC.

OBJECTIVE

To evaluate the negative predictive value (NPV) of reported clear shave biopsy margins in basal and squamous cell carcinomas to determine whether this assessment is a reliable predictor of complete tumor removal.

METHODS

A literature review was performed using the PubMed database. The data were compiled, NPVs were calculated by the tumor subgroup, and a statistical analysis was performed.

RESULTS

Four studies met inclusion criteria. Two hundred twenty-one KCs were identified (n = 221). All specimens had negative-reported histologic margins (39 squamous cell carcinoma [SCC] and 182 BCC). Fifty-five cases initially noted to have negative margins on biopsy were found to have residual tumor on subsequent analysis: 5 SCC and 50 BCC, translating to 12.8% of all SCC (5/39) and 27.5% for BCC (50/182). Negative predictive values were found to be 75.1% for all KCs, 87.2% for SCC, and 72.5% for BCC.

CONCLUSION

Negative histologic margin status on shave biopsy specimens of KC has a poor NPV and is an inadequate predictor for complete tumor removal.

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.