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

Importance of Both Clinical and Dermoscopic Findings in Predicting High-Risk Histopathological Subtype in Facial Basal Cell Carcinomas

INTRODUCTION

Being able to recognize high-risk facial basal cell carcinoma (BCC) may lead to fewer incomplete excisions and inappropriate treatments.

OBJECTIVES

We sought to investigate clinical and dermoscopic criteria for predicting facial BCC subtypes, analyze the interobserver agreement between readers, and develop a diagnostic algorithm to predict high-risk histopathological subtype.

METHODS

In this single-center, retrospective investigation, 6 independent readers evaluated predefined clinical and dermoscopic criteria in images of histopathologically verified primary facial BCCs including: topography, border demarcation, vessels, ulceration, white porcelain areas, shiny white blotches and strands, and pigmented structures and vessels within ulceration.

RESULTS

Overall, 297 clinical and dermoscopic image pairs were analyzed. The strongest associations with high-risk subtype were: "bumpy" topography (OR 3.8, 95% CI, 3.1-4.7), ill-defined borders (OR 3.4, 95% CI 3.1-4.7), white porcelain area (OR 3.5, 95% CI 2.8-4.5), and vessels within ulceration (OR 3.1, 95% CI 2.4-4.1). Predominantly focused vessels were a positive diagnostic criterium for either nodular (OR 1.7, 95% CI 1.3-2.2) or high-risk (OR 2.0, 95% CI 1.6-2.5) subtypes and a strong negative diagnostic criterium for superficial BCC (OR 14.0, 95% CI 9.6-20.8). Interobserver agreement ranged from fair to substantial (κ=0.36 to 0.72). A diagnostic algorithm based on these findings demonstrated a sensitivity of 81.4% (95% CI, 78.9-83.7%) and a specificity of 53.3% (95% CI, 49.7-56.9%) for predicting high-risk BCC subtype.

CONCLUSIONS

Integration of both clinical and dermoscopic features (including novel features such as topography and vessels within ulceration) are essential to improve subtype prediction of facial BCCs and management decisions.

Assessment of Standard Surgical Excision Efficacy and Analysis of Recurrence-Associated Factors in 343 Cases of Nasal Basal Cell Carcinoma: A Single-Center Retrospective Study

In Caucasians, basal cell carcinoma, the predominant non-melanoma skin cancer type, poses challenges for surgeons due to anatomical and aesthetic concerns, particularly when located on the nose. The study aimed to evaluate tumor distribution, size, morphological subtypes, surgical outcomes, radicality levels, and their correlation with recurrence rates. A retrospective analysis encompassed 343 cases of nasal skin cancer over a four-year period from 1 January 2019 to 31 December 2022. The research cohort comprised 252 female and 91 male participants, averaging 75.2 years old. Tumors were most found on the left sidewall of the nose (25.4%) and the dorsum (24.8%). The infiltrative morphological subtype was predominant (70.8%). Standard surgical excision with fasciocutaneous plastic was the preferred surgical procedure. Radical excision, defined by the absence of tumor cells in a resection margin, was accomplished in 79.0% of lesions, whereas 16.9% demonstrated incomplete excision, signifying the presence of tumor cells in the resection margin. Non-radically excised tumors exhibited a significantly higher recurrence rate (24.1%) compared to those with radical excision (6.3%). In nasal reconstruction, diverse surgical techniques are essential for precise adaptation based on factors like tumor characteristics and patient needs. Despite surgeons' careful adherence to excision margin guidelines, the possibility of non-radical outcome cannot be eliminated.

European consensus-based interdisciplinary guideline for diagnosis and treatment of basal cell carcinoma-update 2023

Basal cell carcinoma (BCC) is the most common malignant tumour in white populations. Multidisciplinary experts from European Association of Dermato-Oncology (EADO), European Dermatology Forum, European Society for Radiotherapy and Oncology (ESTRO), Union Européenne des Médecins Spécialistes, and the European Academy of Dermatology and Venereology developed updated recommendations on diagnosis and treatment of BCC. BCCs were categorised into 'easy-to-treat' (common) and 'difficult-to-treat' according to the new EADO clinical classification. Diagnosis is based on clinico-dermatoscopic features, although histopathological confirmation is mandatory in equivocal lesions. The first-line treatment of BCC is complete surgery. Micrographically controlled surgery shall be offered in high-risk and recurrent BCC, and BCC located on critical anatomical sites. Topical therapies and destructive approaches can be considered in patients with low-risk superficial BCC. Photodynamic therapy is an effective treatment for superficial and low-risk nodular BCCs. Management of 'difficult-to-treat' BCCs should be discussed by a multidisciplinary tumour board. Hedgehog inhibitors (HHIs), vismodegib or sonidegib, should be offered to patients with locally advanced and metastatic BCC. Immunotherapy with anti-PD1 antibodies (cemiplimab) is a second-line treatment in patients with a progression of disease, contraindication, or intolerance to HHI therapy. Radiotherapy represents a valid alternative in patients who are not candidates for or decline surgery, especially elderly patients. Electrochemotherapy may be offered when surgery or radiotherapy is contraindicated. In Gorlin patients, regular skin examinations are required to diagnose and treat BCCs at an early stage. Long-term follow-up is recommended in patients with high-risk BCC, multiple BCCs, and Gorlin syndrome.

[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.

Association of the Depth of Invasion With Recurrence Rates of Basal Cell Carcinoma in a Tertiary Health Care Facility: A Retrospective Study Over a Period of Six Years

Background Basal cell carcinoma (BCC) is one of the most common types of cutaneous malignancies and the most frequently occurring form of cancer worldwide. The incidence of basal cell carcinoma is difficult to determine due to its wide geographic variations; however, it has been increasing worldwide with an annual increase of 7% in the number of reported cases. Although BCC is more prevalent in the aging population, diagnosis in younger individuals is steadily increasing. BCC has overall low mortality, however, it leads to significant economic and physical impact on patients and their families along with adding burden to the healthcare system. The primary risk factor for the development of BCC is increased cumulative sun exposure, particularly to UV radiation. The UV index of Karachi averages around 12 (extremely high) during summer months, putting the population at a significantly higher risk of developing BCC in the long term. Objectives This audit was undertaken with the following primary objectives: to use the data collected to determine possible prognostic factors for BCC, to measure the rate of recurrence and the number of new primary tumors detected, to study the completeness of follow-up by patients, and to co-relate histopathological findings with the recurrence rate of basal cell carcinoma. Methods A retrospective analysis was performed for all patients with BCC who had undergone surgical resection over a six-year time period. Patient charts were reviewed for demographic information, tumor size, onset-to-diagnosis, anatomic location, clinical subtype, histologic differentiation, method of surgical treatment, and recurrence. Data were entered and analyzed in SPSS version 23 (IBM Corp., Armonk, NY). Results The review identified cases of BCC in 99 patients. Of the 99 patients, 60.39% were men and 38.38% were women. The most frequent age group was 65-85-year-olds (42 patients, 42.85%) for BCC. Based on the aesthetic units of the face, the most common location was the nasal unit (30 cases, 30.30%) for BCC. Most of the lesions were closed primarily; however; local flaps were used in the case of surgical defects. The recurrence rate was 19.19% for BCC in this study. Our study included 1.0% of patients who were classified as Clark classification level 2 of BCC, 6.1% as Clark level 3, 23.4% as Clark level 4, and 0.16% as Clark level 5. Recurrence rates were seen to increase with increasing Clark classification level in this study. Conclusion In our study, many characteristics of BCC were compared to previously published reports and the results were seen to be generally similar. This study correlates the recurrence of BCC with Clark's classification, showing that depth of invasion is a significant factor in predicting recurrence. There is a paucity of literature regarding the depth of invasion of BCC along with its' Clarks classification and recurrence. Further studies can help explore and establish the characteristics of BCC.

Incidence and trends of basal cell carcinoma in Sweden: A population-based registry study

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin cancer. Incidence is largely unknown because of incomplete, or lack of, registration in most countries.

OBJECTIVES

To assess current incidence rates and recent trends for BCC in the Swedish population.

METHODS

Patient- and tumour-related features of all histologically confirmed BCC tumours diagnosed in Sweden from 2004 to 2017 were extracted from the population-based Swedish BCC Registry. Incidence rates were standardized to the 2013 European Standard Population and trends were analysed using Poisson regression models.

RESULTS

Age-standardized person-based incidence rate of BCC in Sweden in 2017 was 405/100 000, rising from 308/100 000 in 2004, corresponding to an annual relative increase of 1.8% (women, 2.1%; men, 1.4%). Incidence was highest in the elderly and the most common tumour site was the head and neck. In 2017, the most common BCC subtypes were nodular and micronodular/infiltrative BCC (each 31%). Incidence of aggressive BCC subtypes increased faster than other subtypes.

CONCLUSIONS

BCC incidence rates in Sweden are relatively high and increasing. The increasing trends were more pronounced in women and for aggressive BCC subtypes.

Outpatient surgical management of non-melanoma skin cancers of the head and neck in a regional centre: an analysis of costs and outcomes

BACKGROUND

Non-melanoma skin cancer is the most commonly diagnosed malignancy in Australia. Lesions of the head and neck are often outside the scope of primary care providers. The challenges of cancer care in regional Australia necessitate careful resource planning. This study presents an outpatient model that minimizes health service cost with local general practitioner follow-up.

METHODS

A retrospective review of 105 patients with 122 skin lesions in a dedicated Facial Lesion Assessment Management and Excision clinic was performed from July 2018 to 2019. Clinical outcomes, patient travel and cost analysis/comparison were recorded.

RESULTS

There were 85 malignant cases with 59 basal cell carcinomas and 25 squamous cell carcinomas. For basal cell carcinoma, clear margins (≥3 mm), close margins (<3 mm) and positive margins were achieved in 24 (48%), 23 (46%) and three (6%) cases, respectively. For squamous cell carcinoma, clear margins (≥5 mm), close margins (<5 mm) and positive margins were achieved in seven (38.8%), 11 (61.1%) and none (0%) of the cases, respectively. Complications included one haematoma and two wound infections. For 37% of patients living >100 km from the department, 72.3% had local general practitioner follow-up. Inpatient cost was $2870, $5697 and $9300 for primary closure, local flap and full-thickness skin graft, respectively, and outpatient cost was $746 for a single facial lesion.

CONCLUSION

This study presents a cost-effective model for the management of non-melanoma skin cancers with improved departmental efficiency and streamlined patient care in an outpatient skin cancer management model in a regional centre.

[Diagnosis and treatment of basal cell carcinoma : A question of the risk of recurrence]

Basal cell carcinoma is the most common type of cancer in Central Europe and has a high medical relevance. Due to its high tendency of recurrence, an important parameter in the planning of therapy is the risk of recurrence. After clinical and histological diagnosis, the majority of tumors are treated surgically, although radiation and topical procedures are also possible therapeutic alternatives in certain constellations. Hedgehog inhibitors, a completely new class of substances, have recently been approved for rare metastatic and locally advanced diseases, thus significantly expanding the range of treatments. This article provides an overview of the current guideline-based diagnosis and therapy of basal cell carcinomas in Germany.

It's time for Mohs: Micrographic surgery for the treatment of high-risk basal cell carcinomas of the head and neck regions

Basal cell carcinoma (BCC) is the most common variety of non-melanoma skin cancer and its incidence is increasing worldwide. The centrofacial sites (area H) are considered a high-risk factor for BCC local recurrence. Mohs micrographic surgery (MMS) is a technique that allows intraoperative microscopic control of the surgical margins and is a good treatment option when tissue conservation is required for esthetic or functional reasons or for high-risk lesions. The present study aimed to evaluate the recurrence rate of head and neck high-risk BCCs comparing MMS vs conventional surgical excision. Clinical data of patients diagnosed from September 2014 to March 2017, referring to the Dermatology Unit of the Policlinico Sant'Orsola-Malpighi, University of Bologna, were retrospectively evaluated (285 treated with MMS and 378 treated with traditional surgery). Of the 285 patients treated with MMS, 9 experienced a recurrence (3.1%). Of the 378 patients treated with traditional surgery, 53 relapsed (14%), 13 of whom presented residual tumor on the deep or lateral margins of the main surgical specimen. Our study confirms the trend reported in the literature that MMS represents the best treatment option for high-risk BCCs arising in the head and neck region or presenting as a recurrence (P < .00001). Many more MMS centers and more trained dermatologists are needed worldwide in order to deal with the increasing number of BCC diagnosed every year.