1. Analysis of Incompletely Excised BCCs (4.68%)
The fate of incompletely excised Basal Cell Carcinomas of the head and neck, do we need to re-excise? A series of 1410 patients
Tarun Mittal BDS MFDSRCS (Ed) Senior House Officer
William Smith FDSRCS FRCS (Ed) FRCS (Eng) Consultant Oral & Maxillofacial Surgeon
Phillip Ameerally BDS MBBS (Hons) FDS FRCS Consultant Oral & Maxillofacial Surgeon
Department of Oral and Maxillofacial Surgery
Introduction
BCCs are the most common skin malignancy1
BCCs are known to nearly never metastasise2
Aggressiveness of the lesion can be related to its subtype3
Principal treatment is surgical removal with a margin4
British Association of Dermatologists quote 85% cure rate with 3mm margin, 95% with 5mm5,6
Incomplete excision rates range 0.7-9%7,8
Analysis of Incompletely Excised BCCs (4.68%)
Aims
Determine incomplete excision rate
Evaluate incidence of residual tumour following re-excision
Identify any prognostic factors of incomplete excision
Methods
Prospectively maintained databases of 2 surgeons
1471 BCCs in 1070 patients
Lesions excised with 3-5mm margin, unless poorly defined or morpheic
Reconstruction with
Primary closure
Local flap
Wolfe Graft
Delayed closure
Healing by secondary intention
Results
1070 patients, 1471 BCCs
57% Female, average age 64.7
75% referred from dermatologists
83% treated under LA
15.3% with preoperative histology available
Incomplete excision rate 4.68%
Cohort Characteristics
Distribution of lesions
Site
% of total
Nose
23.98
Cheek
19.02
Temple
15.37
Forehead
13.23
Ear
7.51
Site
% of total
Scalp
5.38
Lip
5.10
Neck
4.69
Eyelid
4.14
Chin
1.59
High Risk Sites
Discussion
Nose Cheek and Ear represent anatomical sites most commonly associated with incomplete excision
Nose (6.72% incomplete excision rate)
Alar (9.72%) most problematic region
Cheek (3.80% incomplete excision rate)
Nasolabial fold (13.04%) most problematic region
Ear (12.15% incomplete excision rate)
Concha (25%) and
Posterior Auricular Sulcus (14.70%) most problematic regions
Majority of lesions located in ‘high risk’ sites of head and neck
Areas associated with increased incidence of incomplete excision represent areas with reduced excess tissue available
More conservative margins taken
Reconstruction more difficult
Patients with BCCs are often of advanced age with other significant co-morbidities
52.24% of incompletely excised lesions underwent further excision
60% of these lesions displayed histological signs of residual tumour
Histology of lesions
Histology
% of total
Nodular
34.29
Mixed
21.76
Ulcerative
10.52
Unknown
10.45
Morphaeic
9.02
Infiltrative
6.01
Histology
% of total
Multicentric
2.65
Micronodular
1.57
Cystic
1.15
Pigmented
1.00
Superficial
0.72
Basosquamous
0.21
Adenoid
0.14
Conclusions
Incomplete excision rate of 4.68%
Residual tumour present in 60% of lesions that were treated with further surgery
Watch and wait is a valid for selective cases
Lesions of the Nose, Ear and Nasolabial fold are at higher risk of incomplete excision
These lesions may be candidates for earlier excision or Mohs surgery
References
J. S. Gilbody et al, What causes basal cell carcinoma to be the commonest cancer? Australian Journal of Public Health, 18(2), pp
P. T. Ting, et al, Metastatic basal cell carcinoma: report of two cases and literature review. Journal of Cutaneous Medicine and Surgery, 9(1), pp
D. Costantino et al, Basosquamous carcinoma—an under-recognized, high-risk cutaneous neoplasm: case study and review of the literature. Journal of Plastic, Reconstructive and Aesthetic Surgery, 59(4), pp
N. R. Telfer et al, Guidelines for the management of basal cell carcinoma. British Journal of Dermatology, 141(1), pp
H. Breuninger et al, Prediction of subclinical tumor infiltration in basal cell carcinoma. Journal of Dermatologic Surgery and Oncology, 17(7), pp
N. R. Telfer et al, Guidelines for the management of basal cell carcinoma. British Journal of Dermatology, 159(1), pp
A. W. Wilson et al, Surgical management of incompletely excised basal cell carcinomas of the head and neck. British Journal of Oral and Maxillofacial Surgery, 42(4), pp
Griffiths, R.W., Audit of histologically incompletely excised basal cell carcinomas: recommendations for management by re-excision. British Journal of Plastic Surgery, 52(1), pp