Use of an audit to improve surgical treatment of facial basal cell carcinoma

Background

Basal cell carcinoma (BCC) is the most prevalent form of skin cancer and the choice of current treatment strategies depends on several criteria including patient age, size of the lesion, histological subtype, and localization.

Methods

A retrospective chart review was conducted including all patients with facial BCCs, together with neck, ear, and scalp, who underwent surgical excision between January 2005 and December 2010. An audit was designed to compare the outcome of two subsequent study phases.

Results

During the first 4-year study period, a total amount of 273 tumors were excised in 251 patients (mean age, 65.6 years; 112 males, 139 females). The overall rate of positive margins was 44/273 (16.1 %). In the second study period, a total amount of 244 tumors were excised in 228 patients (mean age 63.4 years; 105 males, 123 females). In this group, 17 excisions had positive excision margins on pathohistological report (7.0 %)

Conclusions

Our findings demonstrate that performing an internal audit may improve treatment quality and therefore may be helpful in optimizing the effectiveness of present treatment modalities and their costs and the development of standards and guidelines.

Level of Evidence

Level III, risk/prognostic study.     

Giant basal cell carcinoma surgical management and reconstructive challenges

Basal cell carcinoma is exceedingly common, but tumors >5 cm in size or giant basal cell carcinomas (GBCCs) are rare. We retrospectively review 10 GBCCs in 8 patients treated by aggressive surgical excision and reconstruction in a single operative procedure. With the exception of 1 chest lesion, all GBCCs involved the face or scalp. The 10 large defects were reconstructed with 5 free-tissue transfers, 2 pedicled musculocutaneous flaps, and 3 rotational skin flaps. There has been no evidence of local recurrence or metastasis in a mean follow-up of 29 months. Neglect has a well-established role in the presence of GBCCs, with undiagnosed preexisting medical problems also common. Surgical excision and reconstruction is the treatment of choice and can be readily accomplished in a single procedure with few complications, good oncologic control, and acceptable cosmetic results.     

The excision width in surgical treatment of basal cell carcinoma

Basal cell carcinoma originates from pluripotent cells of basal layer of epiderm, external covering of hair follicles, sebaceous glands or other skin adnexa. It is characterized by local infiltrating and sometimes destructive growth. There are several types of basal cell carcinomas that may be manifested in over 12 clinical forms. Surgical treatment depends to a large extent on the histological type, localization and its clinical manifestation. The analysis included 250 patients of both gender and different age, operated for basal cell carcinoma. Clinical characteristics of basal cell carcinoma and the width of the excision were described. It was concluded that the width of the excision of basal cell cancer was in relation to histological type.     

The interdisciplinary management of anal epidermoid carcinoma

Background: The treatment of primary epidermoid anal carcinoma has changed substantially the latest 2 decades. Radical radiotherapy with or without chemotherapy has been widely accepted. However, the optimal treatment is not yet settled. Methods: Since 1978, patients from the Uppsala region, Sweden, were primarily treated with radiotherapy plus bleomycin with surgery only in those with residual disease after a dose of 40 Gy. The total radiation dose in patients not having surgery was approximately 60 Gy. This policy was not introduced in most other Swedish regions until 1984. Population-based materials between 1978 and 1984 from the Uppsala (n=50) and the Stockholm (n=91) Health Care Regions were compared. Results: Comparisons of these entirely unselected materials indicate that a primarily nonsurgical approach improves 5-year survival in the order of 25 to 30% units. Results are favourable also after long-term follow-up. Bleomycin does not seem to add therapeutic benefit. Conclusions: A primarily non-surgical approach is to be preferred, first because it more often results in preserved anal function than surgery, and second because it also improves survival. The place for surgery is still unknown. Should it be used early in patients where the likelihood of tumor control with radio-chemotherapy is not sufficiently high as adapted in Sweden, or should it be reserved for patients in whom the cancer recurs? The latter approach may seem more attractive since it maximizes anal preservation, but healing after surgery in an area where a high tumoricidal radiation dose has been given is impaired. This is not the case after a lower, preoperative dose where the aim is to kill microscopic disease only. Therefore, an interdisciplinary management of this group of patients is essential, where surgeons, radiotherapists and medical oncologists work close to each other. Since anal carcinoma is a rare condition, it is also necessary to centralize the treatment.     

The surgical management of facial nerve injury

Treatment of facial nerve injuries depends upon a detailed understanding of its anatomic course, accurate clinical examination, and timely and appropriate diagnostic studies. Reconstruction depends upon the extent of injury, the availability of the proximal stump. and the time since injury and duration of muscle denervation. Although no alternative is perfect, these techniques, in combination with static and ancillary procedures. can protect the eye, prevent drooling, restore the smile, and improve facial symmetry. New techniques (including single-stage free tissue transfers and bioengineered nerve grafts), further research on the characteristics of the facial musculature, and methods of preserving the neuromuscular junction will undoubtedly manifest themselves as further refinements of established surgical techniques.     

The in situ surgical management of renal cell carcinoma and transitional cell carcinoma of the kidney

Summary In situ renal surgery can result in successful treatment of renal cell carcinoma or transitional cell carcinoma of the kidney in carefully evaluated patients. In our increasingly older population, more patients may present with impaired renal function from contralateral renal or renal vascular disease. As a result there will be more candidates for in situ surgical excision of renal tumors, in addition to those patients who have been the primary candidates in the past with bilateral tumors or tumors in solitary kidneys.     

Safety and efficacy of surgical treatment of carotid stump syndrome: pilot study

Surgical exclusion of the internal carotid artery (ICA) stump combined with endarterectomy of the external carotid artery is an established treatment approach. The aim of this pilot study was to compare the risk of cerebrovascular events between surgical treatment and best medical treatment in patients with ICA occlusion and carotid stump syndrome. Forty patients (23 males; age: 43-80 years; mean age: 61.1 ± 9.0 years) with carotid occlusion and carotid stump syndrome were enrolled. Ten patients with asymptomatic ICA occlusion and 10 patients with symptomatic ICA occlusion and carotid stump syndrome were enrolled to the best medical therapy group. Patients with chronic ICA occlusion, carotid stump syndrome, and one (15 patients) or recurrent (three patients) episodes of ipsilateral stroke or transient ischemic attack were enrolled to the surgical group. Neurological examination was undertaken on the day of randomization and then every 6 months in all patients for 4 years. All vascular events and death were recorded. Only one vascular event occurred in patients with symptomatic ICA occlusion without recurrent stroke or transient ischemic attack who were treated medically. No other vascular event was noted in the other subgroups. One patient with symptomatic carotid occlusion without recurrent stroke died due to myocardial infarction 6 months after surgery. Surgical treatment of carotid stump syndrome seems to be a safe procedure. Nevertheless, the benefit of a surgical approach in comparison with the best medical treatment is not clear.     

The role of lymphadenectomy in the surgical management of renal cell carcinoma

After decades of evaluation, the role of lymphadenectomy in the management of renal cell carcinoma remains a controversy. Contemporary series suggest that the true incidence of isolated lymph node metastases in clinically localized disease is small, and the location of such metastases is unpredictable. While several institutional series have suggested a therapeutic benefit for extended lymphadenectomy, there remains a lack of randomized data to support its routine use. Despite this, there remains a role for lymphadenectomy in individuals with high risk of lymph node metastasis or known lymphadenopathy in whom few other options exist for aggressive, potentially curative therapy.     

The relationship between basal joint arthritis and carpal tunnel syndrome: an MRI pilot study

PURPOSE: This investigation explored 2 questions. First, does basal joint arthritis lead to morphologic alterations that significantly narrow the carpal tunnel? Second, does trapezial excision alter the morphology of the carpal tunnel and decompress the median nerve? METHOD: Four patients with basal joint arthritis alone were treated with ligament reconstruction and tendon interposition (LRTI) arthroplasty. Three patients with basal joint arthritis and carpal tunnel syndrome were treated with LRTI and carpal tunnel release. Preoperative and postoperative magnetic resonance imaging (MRI) scans were obtained to assess differences in carpal tunnel volume and morphology between the groups before and after surgery. RESULTS: The difference in preoperative carpal tunnel volume between groups was not significantly different. Carpal tunnel volume increased by 7% with LRTI and by 24% after LRTI and carpal tunnel release. The anteroposterior diameter of the carpal canal increased in both groups to allow a volar migration of the median nerve. CONCLUSION: LRTI increases the anteroposterior diameter and volume of the carpal tunnel. A larger comparative study would be necessary to determine whether LRTI is sufficient to decompress the carpal tunnel.     

Perioperative care of patients with nasal basal cell carcinoma after surgical repair

对8例鼻部基底细胞癌患者,采用额旁正中皮瓣十鼻中隔粘软骨膜瓣或鼻前庭双蒂推进瓣为衬里,行癌灶切除后继发缺损的修复手术,加强围术期护理.结果 8例患者术后皮瓣全部成活,无并发症发生.随访6个月,鼻外形轮廓较好,基本恢复正常外观.提出完善的术前宣教、准备及术后病情观察与护理,有助于满足患者的生理及心理需求,提高患者围术期生活质量.     

鼻部基底细胞癌患者的围术期护理

对8例鼻部基底细胞癌患者,采用额旁正中皮瓣+鼻中隔粘软骨膜瓣或鼻前庭双蒂推进瓣为衬里,行癌灶切除后继发缺损的修复手术,加强围术期护理。结果8例患者术后皮瓣全部成活,无并发症发生。随访6个月,鼻外形轮廓较好,基本恢复正常外观。提出完善的术前宣教、准备及术后病情观察与护理,有助于满足患者的生理及心理需求,提高患者围术期生活质量。     

Management of extensive facial basal cell carcinoma by excision and microvascular tissue transfer.

Management of large or recurrent basal cell carcinomas (BCCs) on the face can be difficult, especially where radiotherapy has been the primary treatment. Free tissue transfer using microvascular surgery permits wide excision margins ensuring clearance of the tumour without being compromised by concern over closure, since the free flap can be designed after the excision of the tumour and its size and composition can thus be custom made. Age alone should not be a contraindication to this major procedure.