MOC-PSSM CME Article: Nonmelanoma Facial Skin Malignancy:

Current Basal and Squamous Cell Skin Cancer Management

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Characterize basal and squamous cell carcinomas as low or high risk based on size, location, histology, and clinical features. 2. Understand appropriate surgical margins in low- and high-risk lesions, and other management options, including Mohs micrographic surgery, electrodissection and curettage, topical agents, cryotherapy, photodynamic therapy, and radiation therapy. 3. Discuss adjuvant therapies for locally advanced and metastatic disease, including radiation therapy, chemotherapy, and targeted therapies such as hedgehog pathway inhibitors. 4. Educate patients on preventive measures such as skin examinations, sun protection, oral retinoids, and oral nicotinamide (vitamin B3). 5. Devise a reconstructive plan once clear oncologic margins are obtained.

SUMMARY

With the growing incidence of basal and squamous cell carcinoma, there is an increasing demand for appropriate oncologic management and aesthetic reconstruction. The goal of this CME article is to provide a foundation of knowledge to accurately diagnose, stage, and treat nonmelanoma skin cancers. In addition, it provides the practicing plastic surgeon alternate tools for managing these skin lesions, including topical agents, destructive therapies, and radiation therapy. Lastly, reconstructive plans for selected soft-tissue defects are discussed.

Mohs versus surgical excision in nonmelanoma skin cancers: does location matter?

INTRODUCTION

Every year, nearly 1.2 million people are affected by nonmelanoma skin cancers (NMSCs) in the United States. Most published data focus on comparing the efficacy of Mohs micrographic surgery (MMS) versus traditional surgical excision (TSE) for NMSCs in H-zone lesions of the face. There is paucity of data regarding the 2 treatments in other areas such as the non-H-zone areas of the face, the trunk, and extremities. Our study focused on the efficacy of the 2 treatments in areas of the body where the skin was not of premium.

METHOD

A retrospective chart review was performed of patients with NMSCs treated with TSE at the West Los Angeles Veterans Affairs Hospital between 2000 and 2008. Patients with at least a 3-year follow-up were selected for the study. Institutional review board approval was obtained before commencement of the study. Age, sex, and race-matched patients were selected in the MMS group. Data collected included demographic data, tumor characteristics, surgical treatment, reconstructions, recurrence rates, complications, and follow-up course. Data were analyzed using SigmaStat 3.5.

RESULTS

A total of 588 patients were treated for NMSCs at our institute between 2000 and 2008, of which 289 patients had non-H-zone, extremity, and trunk lesions. The follow-up period for these patients was at least 3 years. Average age of this group was 67.1 (11.4) with 89.9% being males. Age, sex, and race-matched group of 200 patients treated with MMS for NMSCs were randomly chosen from the same time range. Average size of lesions was 17.4 (16.9) mm in the TSE group and 1.1 (0.4) mm in the MMS group (P < 0.05). Primary reconstruction was performed in non-premium areas (ie, non-H-zone areas of the face, the trunk, and extremities) in 98.7% patients in the TSE group and 61.5% patients in the MMS group (P < 0.05). Secondary reconstructive rate was 1.3% in TSE compared to 37.5% in MMS. Overall recurrence rate was 4.8% (compared to 3% with MMS). Of the 29 patients who had recurrences within the TSE group, 27 were H-zone lesions and 2 were non-H-zone lesions.

DISCUSSION

One of the primary goals of NMSC management is to treat the lesion with adequate oncologic margins, while preserving maximal function and cosmesis. Our data look at the non-premium areas to quantify the clinical efficacy of TSE versus MMS. The size of lesions treated by TSE was significantly larger than those treated by MMS in all areas of the body. The primary closure rates were significantly higher and secondary procedure rates significantly lower in the TSE group compared to the MMS group, in non-premium areas. Our data suggest that patients with NMSCs may be more effectively treated with TSE than MMS in non-premium areas of the body. Additional studies are ongoing, including economic modeling and cost analysis.

Nonpersistence of basal cell carcinoma after diagnostic shave biopsy: reconstruction when specimen is negative during surgery

BACKGROUND

Initial tissue sampling for diagnosis of suspected basal cell carcinoma (BCC) is typically performed using a shave biopsy technique or punch biopsy.

METHODS

Our realization of no residual BCC findings after excision in some patients with biopsy-proven BCC diagnosed through a shave biopsy prompted us to conduct a retrospective study of all consecutive patients with 127 BCCs who were treated in our department between 2006 and 2012. All patients with incompletely excised BCCs after shave biopsy diagnosis were operated on by a single surgeon (R.G.), eliminating variables in preoperative evaluation and surgical technique including margin control and reconstructive approach. Patient demographics, initial BCC site, size, subtype, duration between shave biopsy and surgery, size of excision, findings of intraoperative frozen section analysis, type of closure technique, and final pathology reports were analyzed.

RESULTS

There were 108 residual BCCs diagnosed after surgical excision. Most of the108 BCCs were nodular (52) or micronodular (21) subtype. Eighteen BCCs were treated with excision and primary closure. Flap procedure was performed in 64 BCCs after excision. Twenty-six defects after excision were reconstructed using skin grafts. There was no evidence of residual BCC in 15% of BCCs (19 patients) after surgical treatment. In other words, shave biopsy was found to be curative in 15% of BCCs. Seven patients in no residual BCC group received excision and primary closure. Eleven patients underwent flap reconstruction, whereas only 1 patient required skin grafting. Most of the patients in this group had nodular or micronodular type BCC (14/19).

CONCLUSIONS

We were not able to identify any clinically significant predictors of residual versus no residual BCC, at least within the context of the current study. Although most patients diagnosed with BCC had residual tumors for which they received surgical treatment, 15% of patients had to undergo primary closure, skin graft, or flap procedure for negative residual BCC. We would like to promote greater awareness on the subject among plastic surgeons treating BCCs. And, it is extremely important that the informed consent should include statements regarding possible reconstructive procedures even in the case of nonpersistent tumor from medicolegal standpoint.

Reconstructive outcomes analysis of lower eyelid and infraorbital skin defects using 2 hatchet flaps: a 6-year experience

BACKGROUND

For the past 6 years, we have used double hatchet flaps for reconstruction of lower lid and infraorbital skin defects.

METHODS

Twenty-five patients who underwent reconstruction of lower eyelid/infraorbital skin defects using double hatchet flaps were retrospectively analyzed. Defect size ranged from 11 × 11 to 15 × 15 mm. In addition, pearls and pitfalls of the technique are discussed along with the presentation of 3 cases.

RESULTS

Flaps were highly viable in all patients. There was no eyelid retraction, scleral show, ectropion, or entropion. Mean follow-up period was 13.7 months. Patient satisfaction with respect to scar appearance was assessed by the standard 5-point scale. Overall patient satisfaction score was 4 (satisfied) in 6 patients, and was 5 (very satisfied) in 19 patients.

CONCLUSIONS

On the basis of the critical review of outcomes in 25 patients, use of double hatchet flaps for the repair of lower lid and infraorbital skin defects gives an excellent functional and aesthetic result. Horizontal movement of the hatchet flaps avoids vertical skin tension in the lower eyelid, and hence minimizes potential complications.

Mohs surgery vs primary excision for eyelid BCCs

INTRODUCTION

The aims of management of basal cell carcinoma are for complete excision, and minimise damage to the surrounding tissues. Our aim is to compare the proposed defect of a primary excision biopsy with the actual defect following Mohs micrographic surgery on the same lesions.

MATERIALS AND METHODS

A cohort of 23 patients about to undergo Mohs micrographic surgery for eyelid basal cell carcinomas was recruited. The lesions were assessed regarding size and location. A digital photograph of the lesions pre Mohs excision and the defects post Mohs excision for analysis on the Photoshop Adobe package using the caliper function to measure the eyelid lesion, and defects and to calculate the area.

RESULTS

All 18 patients had solitary basal cell carcinomas; 9 (50%); 10 of the 18 cases having a larger proposed primary excision defect and the remaining 8 cases a larger post-Mohs micrographic surgery defect area.

DISCUSSION

Basal cell carcinoma is the most common non-melanoma malignant eyelid tumour. The results supported basal cell carcinomas, particularly morphoeic types, are difficult to examine, and location is a poor predictor of recurrence. We did not find that Mohs micrographic surgery universally reduces the size of the defects area. However, if the primary aim of the surgery is to cure the patient and prevent recurrence, Mohs is still the best choice.

Mohs micrographic surgery for the management of nonmelanoma skin cancers

Many treatment modalities have been described to address the growing epidemic of nonmelanoma skin cancer (NMSC). Mohs micrographic surgery (MMS) is a surgical technique that allows complete and precise microscopic margin analysis by using horizontal frozen sections. The purpose of MMS is twofold: to ensure definitive excision and to minimize loss of normal surrounding tissue. MMS offers the advantages of superior cure rates and, because tissue removal is minimized, excellent cosmetic outcomes. Therefore, MMS has become the treatment of choice for many high-risk tumors. Because this technique is labor intensive, MMS is not indicated in certain situations. Understanding the indications, advantages, and disadvantages of MMS remains paramount for facial plastic surgeons managing NMSC.