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ORIGINAL ARTICLE
Year : 2022 | Volume
: 16
| Issue : 4 | Page : 115-119
Requirement of re-excision in surgical margin positive basal cell carcinoma cases without macroscopic residual lesions (our experience of 714 cases and a review of the literature)
Dinçer Altinel1, Gaye Toplu2, Merdan Serin3
1 Plastic, Reconstructive and Aesthetic Surgery Department, Istanbul Training and Research Hospital, Health Sciences University, Istanbul, Turkey
2 Private Practice, Goztepe Training and Research Hospital, Medeniyet University, Istanbul, Turkey
3 Plastic, Reconstructive and Aesthetic Surgery Department, Goztepe Training and Research Hospital, Medeniyet University, Istanbul, Turkey
Correspondence Address:
Dr. Merdan Serin
Plastic, Reconstructive and Aesthetic Surgery Department, Goztepe Training and Research Hospital, Medeniyet University, Istanbul
Turkey
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjd.tjd_45_22
Background: Basal cell carcinoma (BCC) is a local aggressive tumor, which almost never metastasizes. In this study, we investigated the results of our BCC cases in the last 9 years. Objective: The aim of this study was to better understand the re-excision requirements in positive surgical margin BCC cases. Methods: Seven hundred fourteen patients operated between 2012 and 2021 were included in the study. Localization, subtype, and re-excision results were investigated. Statistical Analysis Used: Descriptive analysis was performed. Results: The mean patient age was 66.9 years (range = 17–98 years). The most common localization for BCC was nasal region (n = 235), and the most common histopathological subtype was nodular (n = 298). Seventy-eight patients had positive margins following the excision. Thirty-eight re-excisions were performed. Thirty-one re-excisions revealed scar without any residue tumor. None of the 78 cases with positive surgical margin returned with a relapse. Conclusion: We evaluated the reliability and efficiency of our excision limits with the pathological evaluation. We achieved significantly high cure rates, even by reducing our excision margins up to 1 mm in critical anatomical structures.
Keywords: Basal cell carcinoma, excision margin, skin cancer
Basal cell carcinoma (BCC) is the most common type of skin cancer. BCC emerges from pluripotent stem cells in the epidermis basal layer of the skin.[1],[2],[3],[4] Although histopathologically, BCC is a malignant tumor, it rarely metastasizes.[5],[6]
BCC is separated into a few histopathological subtypes. These subtypes are basically divided into two groups, a more moderate group and a more aggressive group. Nodular type is the most common subtype and is included in the moderate group. It takes its name from the appearance of nodular structure around an ulcer, formerly named as rodent ulcer. The superficial subtype is another nonaggressive subgroup. Different from nodular type, it has the appearance of flat reddish plaque. The subtypes in the aggressive group include micronodular, infiltrative, sclerosing, and metatypical.
BCC is considered as a local aggressive tumor. Because metastases are seen at a rate close to zero, the main and most effective treatment of the tumor is a surgical removal. If the tumor is completely removed, additional treatment is not needed. The lesion is initially very small and maintains its size and shape for years, especially in the less-aggressive subtypes. After a time, the lesion starts to grow slowly and become clearer. Most tumors are discovered early and successfully treated by timely intervention.
Local invasive tumors are more difficult to treat. Especially in areas with special anatomical structures such as the face region, the reconstructive process must be continued very carefully. The objective of the surgical process is to protect tissues as much as possible and to get esthetic and functional satisfaction.
The aim of this study was to investigate the re-excision requirements in positive surgical margin BCC cases.
Patients and MethodsWe evaluated 714 patients that we operated and followed between 2012 and 2021 in this retrospective study. Patient consents were received prior to surgery. Ethical approval was obtained. We only included lesions diagnosed with BCC. Patients with a minimum of 1 year follow-up were included in the study. Patients with basosquamous carcinoma were not included. Forty patients had multiple BCC lesions. Only the largest lesion was included in the study. One hundred forty-five patients were diagnosed by dermatoscopic examination of the lesions. Five hundred sixty-nine patients were diagnosed with punch biopsies.
Prior to surgery, the boundaries of the lesion and excision were marked, and the total excision was performed. We applied 1–2 mm excision limits on anatomically critical areas such as ear, eyelid, and nose. We applied excision limits between 3 and 5 mm in other areas. None of the other treatment options described in the literature, such as curettage, cryotherapy, immunotherapy, and topical chemotherapy application, were used in this study. Only total surgical excision was performed. Mohs surgery technique was not used in any of the cases.
Primary lesions were removed with a macroscopic boundary in the range of 1–5 mm, considering their anatomical regions. We applied the macroscopic re-excision limit in the range of 1–3 mm according to the anatomic region in residential lesions.
Statistical analysis was performed using GraphPad Prism version 7.00 for Windows. Descriptive analysis was performed, and percentages of cases were calculated (GraphPad Software, La Jolla, California, USA).
ResultsThe mean follow-up time was 3.2 years. There were 311 female and 403 male patients. The mean patient age was 66.9 (range = 17–98 years). The most common localization for BCC was nasal region (n = 235), cheek (n = 98), and periorbital region (n = 96) [Table 1]. The most common histopathological subtypes were nodular (n = 298), infiltrative (n = 145), and solid (n = 88) types [Table 2]. Seventy-eight patients had positive margins following the excision [Table 1] and [Table 2]. Forty patients did not want any more surgery, so re-excision was not performed. These patients were monitored monthly for a relapse. Thirty-eight patients accepted the surgery and re-excisions were performed. The highest number of re-excision was performed from the nasal region (n = 14; 35%) followed by periorbital, temporal, and cheek [Table 1] and [Table 2]. Thirty-one re-excisions revealed scar without any residue tumor [Table 3] and [Table 4]. None of the 78 cases with positive surgical margin returned with a relapse during the 1-year follow-up period. 70% of the cases were primarily closed [Table 5]; 82% of the cases were performed under local anesthesia [Table 6] [Figure 1].
Table 1: Number of total/positive surgical margin/re-excision cases according to the location
Table 2: Number of total/positive surgical margin/re-excision cases according to the histopathological subtypes
Table 4: Demographic characteristics of patients who underwent re-excision (n = 38)
Figure 1: (a) BCC lesion on the cheek; (b) and (c) the elevation of cervicofacial flaps; (d) following the closure of the defect Discussion BCC excision requirements have been discussed in various studies to find the answer to the question “what is the safe excision margin?” In these studies, the safe margin has varied significantly between 3 mm and 10 mm for primary lesions. In localizations that are more critical anatomically such as ear, eyelid, and nose, excision limits have been pushed down to 2–3 mm. Outside of these regions, it has been increased up to 10 mm in areas that provide primary closure of larger excisions due to the existence of more mobile skin.[6],[7],[8],[9],[10]
Using the advantages of Mohs surgery, it is possible to reduce safe excision limits up to 1 mm. However, the use of the classic excisional biopsy technique continues because the Mohs method is not readily available in every country and hospital and requires experience.[6],[7] Nonsurgical cryotherapy can also be used for the treatment of BCCs in the early period, if there is no additional diseases that affect the immune system or if there is no genetic predisposition, but it would be safer to consider surgery without allowing the lesion to grow too much and invade to adjacent structures over a particular size and where other methods are considered ineffective.
Because of the low risk of metastasis of BCC, we did not apply an excision margin over 5 mm in any lesion. In patients with residual lesions who go to re-excision in the early period, excisions were performed with macroscopic boundaries. Gurunluoglu et al. showed that in 15% of their BCC patients, no residue lesion was found despite initial diagnosis. Kimyai-Asadi et al. showed that margins less than 4 mm were inadequate in only 20% of the patients. Konopnicki et al. also showed that the BCC excision margin could be safely reduced to 3 mm. All of these findings support the idea that the excision margins of BCCs can be reduced. In our study, we applied 1–2 mm excision limits on anatomically critical areas and 3–5 mm in other areas.[11],[12],[13],[14],[15],[16],[17],[18]
Patients with a positive surgical margin were re-excised in the early period, usually within 3–4 weeks following suture removal and epithelialization of the suture line. All of the patients going to re-excision did not have the presence of macroscopic lesion. Only scar formation was observed. There was no need for a second re-excision in any of the patients. No neoplastic cell was found in the majority of the cases in the post re-excision pathology report, and most findings were reported as scar tissue or fibroblastic proliferation.
None of the lesions with negative surgical margin was re-excised, even if the surgical margin was under 1 mm in some patients. We believe that these patients do not need to go to re-excision unless there are macroscopically suspicious new or residual lesions. Because the tumor is progressing very slowly and the metastasis rate is considered to be near to zero, the surgery was not done until the macroscopic lesion was not observed.
In conclusion, our results show that significantly high cure rates, even by reducing the excision margins up to 1 mm in critical anatomical structures, can be achieved. Despite these results, it should be noted that minimum follow-up duration for the inclusion of patients in this study was 1 year. This period can be short for recurrences at the deep surgical margin. Longer follow-up studies are required to change current margin recommendations.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflict of interest
There are no conflicts of interest.
References
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