- Email: [email protected]
Complete excision of basal cellcarcinomas
British Journal of Plastic Surgery(2002), 55, 362-367
9 2002 The BritishAssociationof Plastic Surgeons doi:l 0.1054/bjps.2002.3849
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
Short reports and correspondence M. J. Timmons MA, MChir, FRCS, Consultant Plastic Surgeon K. C. Hessel MD, MRCS, Senior House Officer N. M. Kranidhiotis BSc, AFRCSI, Senior House Officer
Complete excision of basal cell carcinomas Sir, Complete excision of basal cell carcinomas has been reported in 89.2%, 93% and 95.3% of cases. 1-3 To assess the role of these results as a standard for routine practice, we have compared them to a series of previously untreated (primary) basal cell carcinomas excised in our unit. As part of a continuing audit, the histopathology reports of 557 basal cell carcinomas excised from 440 patients over a 12 month period were reviewed. As in other series, most of the tumours (n =481, 86.4%) were located in the head and neck. Of the 557 mmours, 536 (96.2%) were completely excised. All the incomplete excisions were in the head and neck. As in previous series, 1'2 the majority of the incomplete excisions involved the lateral margins. As in Kumar et al's series, e the incomplete excision rates were similar for all grades of surgeon, from senior house officer to consultant; like Kumar et al, we believe this is due to appropriate delegation of cases. As in the three published series, 1-3 tumours in our audit were considered to be incompletely excised if the pathologist reported that the tumour extended to the surgical margins. However, in nine cases, the excision margin was very close ( n = 6) or marginal (n = 2 ) or clear but deeper excision was advisable ( n = 1). These very close margins have a practical significance. For example, in a series of 143 excised basal cell carcinomas, the recurrence rate was 33% if the excision margins were involved, 12% if the tumour was within one 400 x microscope field of the margin and 1.2% if the tumour was further from the margin. 4 If the basal cell carcinoma is 'close to jthe margin', some surgeons have stated that they would re-excise tissue. 5 It would also be better if close excision margins were identified in comparative audits. If our nine 'close to the margin' excisions are excluded from the complete excision group, our complete excision rate decreases to 95%. Combining the results of the three recently published series, 3450 out of a total of 3749 tumours were completely excised (92%). If very close excision margins were excluded, the complete excision rate would probably be only slightly less. The meaning of 'complete' excision also depends on the histopathological techniques used and on the histopathologist. 5 More detailed examination of the excised tissue would probably further reduce the complete excision rate. 5'6 Allowing for such variables, we conclude that these published series are the standard against which to judge routine practice. Except for cases involving large or 'horrifying' basal cell carcinomas and those for which Mohs' microsurgery might be indica[ed, 6'7 it is reasonable to inform patients that surgical excision ~f a primary basal cell carcinoma is nearly always c0mplete,'but that there is a 5 - i 0 % r i s k Of incomplete excision, which may require further surgery. 1 (We thank Professor D. T. Sharpe and Mr I. T. H. Foe for allowing us to include their patients in our audit, and our histopathology colleagues for allowing us to review their reports.)
Department of Plastic Surgery, Bradford Royal Infirmary, Bradford BD9 6RJ, UK.
References 1. Griffiths RW. Audit of histologically incompletely excised basal cell carcinomas: recommendations for management by re-excision. Br J Plast Surg 1999; 52: 24-8. 2. Kumar P, Orton CI, McWilliam LJ, Watson S. Incidence of incomplete excision in surgically treated basal cell carcinoma: a retrospective clinical audit. Br J Plast Surg 2000; 53: 563-6. 3. Bogdanov-Berezovsky A, Cohen A, Glesinger R, Cagnano E, Krieger Y, Rosenberg L. Clinical and pathological findings in reexcision of incompletely excised basal cell carcinomas. Ann Plast Surg 2001; 47: 299-302. 4. Pascal RR, Hobby LW, Lattes R, Crikelair GE Prognosis of 'incompletely excised' versus 'completel3~excised' basal cell carcinoma. Plast Reconstr Surg 1968; 41: 328-32. 5. Abide JM, Nahai F, Bennett RG. The meaning of surgical margins. Plast Reconstr Surg 1984; 73: 492-6. 6. Telfer NR, Colver GB, Bowers PW. Guidelines for the management of basal cell carcinoma. Br J Dermatol 1999; 141: 415-23. 7. Horlock N, Wilson GD, Daley FM, et al. Cellular proliferation characteristics do not account for the behaviour of horrifying basal cell carcinoma. A comparison of the growth fraction of horrifying and non horrifying tumours. Br J Plast Surg 1998; 51: 59-66.
doi:10.1054/bjps.2002.3845
Reconstructive surgery using an artificial dermis (Integra) Sir, With respect to the recent article by Dantzer and Braye, 1 I note that in six patients the neck was involved. I assume from the text that stitched compression dressings were used with no other form of immobilisation. No photographs are shown of any of the neck contracmres. Our experience, reported in this journal in 2000, 2 was that with rigid immobilisation we were unable to prevent recurrence of contracmre in the long term. In all these patients there was no platysma in the base of the neck wounds. We agree with Dantzer and Braye's finding that dermal replacement results in an improvement in the skin colour, texture and contour, and we now agree that better outcomes are achieved if the epidermal graft is put on after on interval of 3 weeks or more. Our further experience is that the use of Integra for hypertrophic scarfing, particularly on the chest and arm, is associated with a high rate of recurrence. Yours faithfully, Peter Haertsch FRACS, FRCSE, Plastic Surgeon Suite 309, 2 Pembroke Street, Epping, NSW 2121, Australia.
Yours faithfully, 362
9 2002 The BritishAssociationof Plastic Surgeons doi:l 0.1054/bjps.2002.3849
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
Short reports and correspondence M. J. Timmons MA, MChir, FRCS, Consultant Plastic Surgeon K. C. Hessel MD, MRCS, Senior House Officer N. M. Kranidhiotis BSc, AFRCSI, Senior House Officer
Complete excision of basal cell carcinomas Sir, Complete excision of basal cell carcinomas has been reported in 89.2%, 93% and 95.3% of cases. 1-3 To assess the role of these results as a standard for routine practice, we have compared them to a series of previously untreated (primary) basal cell carcinomas excised in our unit. As part of a continuing audit, the histopathology reports of 557 basal cell carcinomas excised from 440 patients over a 12 month period were reviewed. As in other series, most of the tumours (n =481, 86.4%) were located in the head and neck. Of the 557 mmours, 536 (96.2%) were completely excised. All the incomplete excisions were in the head and neck. As in previous series, 1'2 the majority of the incomplete excisions involved the lateral margins. As in Kumar et al's series, e the incomplete excision rates were similar for all grades of surgeon, from senior house officer to consultant; like Kumar et al, we believe this is due to appropriate delegation of cases. As in the three published series, 1-3 tumours in our audit were considered to be incompletely excised if the pathologist reported that the tumour extended to the surgical margins. However, in nine cases, the excision margin was very close ( n = 6) or marginal (n = 2 ) or clear but deeper excision was advisable ( n = 1). These very close margins have a practical significance. For example, in a series of 143 excised basal cell carcinomas, the recurrence rate was 33% if the excision margins were involved, 12% if the tumour was within one 400 x microscope field of the margin and 1.2% if the tumour was further from the margin. 4 If the basal cell carcinoma is 'close to jthe margin', some surgeons have stated that they would re-excise tissue. 5 It would also be better if close excision margins were identified in comparative audits. If our nine 'close to the margin' excisions are excluded from the complete excision group, our complete excision rate decreases to 95%. Combining the results of the three recently published series, 3450 out of a total of 3749 tumours were completely excised (92%). If very close excision margins were excluded, the complete excision rate would probably be only slightly less. The meaning of 'complete' excision also depends on the histopathological techniques used and on the histopathologist. 5 More detailed examination of the excised tissue would probably further reduce the complete excision rate. 5'6 Allowing for such variables, we conclude that these published series are the standard against which to judge routine practice. Except for cases involving large or 'horrifying' basal cell carcinomas and those for which Mohs' microsurgery might be indica[ed, 6'7 it is reasonable to inform patients that surgical excision ~f a primary basal cell carcinoma is nearly always c0mplete,'but that there is a 5 - i 0 % r i s k Of incomplete excision, which may require further surgery. 1 (We thank Professor D. T. Sharpe and Mr I. T. H. Foe for allowing us to include their patients in our audit, and our histopathology colleagues for allowing us to review their reports.)
Department of Plastic Surgery, Bradford Royal Infirmary, Bradford BD9 6RJ, UK.
References 1. Griffiths RW. Audit of histologically incompletely excised basal cell carcinomas: recommendations for management by re-excision. Br J Plast Surg 1999; 52: 24-8. 2. Kumar P, Orton CI, McWilliam LJ, Watson S. Incidence of incomplete excision in surgically treated basal cell carcinoma: a retrospective clinical audit. Br J Plast Surg 2000; 53: 563-6. 3. Bogdanov-Berezovsky A, Cohen A, Glesinger R, Cagnano E, Krieger Y, Rosenberg L. Clinical and pathological findings in reexcision of incompletely excised basal cell carcinomas. Ann Plast Surg 2001; 47: 299-302. 4. Pascal RR, Hobby LW, Lattes R, Crikelair GE Prognosis of 'incompletely excised' versus 'completel3~excised' basal cell carcinoma. Plast Reconstr Surg 1968; 41: 328-32. 5. Abide JM, Nahai F, Bennett RG. The meaning of surgical margins. Plast Reconstr Surg 1984; 73: 492-6. 6. Telfer NR, Colver GB, Bowers PW. Guidelines for the management of basal cell carcinoma. Br J Dermatol 1999; 141: 415-23. 7. Horlock N, Wilson GD, Daley FM, et al. Cellular proliferation characteristics do not account for the behaviour of horrifying basal cell carcinoma. A comparison of the growth fraction of horrifying and non horrifying tumours. Br J Plast Surg 1998; 51: 59-66.
doi:10.1054/bjps.2002.3845
Reconstructive surgery using an artificial dermis (Integra) Sir, With respect to the recent article by Dantzer and Braye, 1 I note that in six patients the neck was involved. I assume from the text that stitched compression dressings were used with no other form of immobilisation. No photographs are shown of any of the neck contracmres. Our experience, reported in this journal in 2000, 2 was that with rigid immobilisation we were unable to prevent recurrence of contracmre in the long term. In all these patients there was no platysma in the base of the neck wounds. We agree with Dantzer and Braye's finding that dermal replacement results in an improvement in the skin colour, texture and contour, and we now agree that better outcomes are achieved if the epidermal graft is put on after on interval of 3 weeks or more. Our further experience is that the use of Integra for hypertrophic scarfing, particularly on the chest and arm, is associated with a high rate of recurrence. Yours faithfully, Peter Haertsch FRACS, FRCSE, Plastic Surgeon Suite 309, 2 Pembroke Street, Epping, NSW 2121, Australia.
Yours faithfully, 362