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, 1994. What causes basal cell carcinoma to be the commonest cancer? Australian Journal of Public Health, 18(2), pp.218-21. P. T. Ting, et al, 2005. Metastatic basal cell carcinoma: report of two cases and literature review. Journal of Cutaneous Medicine and Surgery, 9(1), pp.10-15. D. Costantino et al, 2006. 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.424-28. N. R. Telfer et al, 1999. Guidelines for the management of basal cell carcinoma. British Journal of Dermatology, 141(1), pp.415-23. H. Breuninger et al, 1991. Prediction of subclinical tumor infiltration in basal cell carcinoma. Journal of Dermatologic Surgery and Oncology, 17(7), pp.574-78. N. R. Telfer et al, 2008. Guidelines for the management of basal cell carcinoma. British Journal of Dermatology, 159(1), pp.35-48. A. W. Wilson et al, 2004. Surgical management of incompletely excised basal cell carcinomas of the head and neck. British Journal of Oral and Maxillofacial Surgery, 42(4), pp.311-14. Griffiths, R.W., 1999. Audit of histologically incompletely excised basal cell carcinomas: recommendations for management by re-excision. British Journal of Plastic Surgery, 52(1), pp.24-28.