Incomplete excision of basal cell carcinomas: a retrospective audit

Background : The reported rates of incomplete excision of basal cell carcinoma (BCC) vary widely (5–25%) among centres around the world. Incomplete excision of skin malignancy is one of the 57 clinical indicators developed by the Royal Australasian College of Surgeons and the Australian Council on Healthcare Standards to act as a measure of the standard of surgical care. The study aims to determine the rate of incomplete excision of BCC at a major cancer centre. Methods : Computerized data and patients’ records were reviewed. From January 1997 to June 2000, a total of 3558 BCC were surgically excised with curative intent, of which 223 were reported to have been removed incompletely. Results : The overall rate of incomplete excision was 6.3%. Conclusions : Given the limitations of a retrospective audit and reliability of the data, this result nevertheless compares favourably with reported figures in the literature.     

Incidence of incomplete excision in surgically treated basal cell carcinoma: a retrospective clinical audit.

All the patients who had excision of basal cell carcinoma at the regional plastic surgery unit at Manchester over a period of 2 years from January 1995 to December 1996 were included in a retrospective audit. A total of 879 lesions were excised in 754 patients. In 41 lesions (4.7%) the tumour was incompletely excised, 16 of these lesions were further excised; the rest were managed by regular follow-up. The mean age of the incomplete excision group was slightly higher. The site where the incomplete excision rate was highest was the scalps followed by the ear, canthi,eyebrows and nose. There was a higher incidence of squamous differentiation and presence of foci of squamous cell carcinoma in the lesions excised incompletely.There was no statistically significant difference among the different groups of surgeons but in individual grades the rate was lower where more wounds were repaired by direct closure. The concept of a complexity ratio (number of wounds repaired by other methods/number of wounds repaired by direct closure) can be helpful in comparing the incomplete excision rates of different grades of surgeons or departments.The excision of basal cell carcinoma is one of the commonest procedures performed by all grades of surgeons in a plastic surgery department. Incomplete excision leads to further surgery or prolonged follow-up, thus significantly affecting the outcome. As the incidence of incomplete excision can be precisely monitored, it may be a useful tool for clinical governance.     

Incomplete excision of basal cell carcinoma in the subunits of the nose.

Reconstructive procedures after resection of nasal basal cell carcinoma (BCC) vary depending on the subunit involved. The aim of the present study was to assess the influence of the location of the BCC on the rate of incomplete excisions, so we made a retrospective analysis of all nasal BCC excised at our hospital between 2002 and 2005. The incomplete excision rate was 24/148 (16%). More incomplete excision occurred on the alae (n=13) when compared to the dorsum (n=2) of the nose (p<0.05). Eight two-staged procedures resulted in incomplete resection, whereas 9 (6%) frozen section analyses were false-negative. BCC were most likely to be incompletely excised on the nasal tip and alae, and both subunits required more elaborate reconstructions. This, however, was not the result of poor estimation of the extent of the tumour and reluctance to excise more challenging areas widely for reconstruction, but to the method chosen to eradicate the tumour.     

Incomplete excision of basal cell carcinoma in the subunits of the nose

Reconstructive procedures after resection of nasal basal cell carcinoma (BCC) vary depending on the subunit involved. The aim of the present study was to assess the influence of the location of the BCC on the rate of incomplete excisions, so we made a retrospective analysis of all nasal BCC excised at our hospital between 2002 and 2005. The incomplete excision rate was 24/148 (16%). More incomplete excision occurred on the alae (n=13) when compared to the dorsum (n=2) of the nose (p<0.05). Eight two-staged procedures resulted in incomplete resection, whereas 9 (6%) frozen section analyses were false-negative. BCC were most likely to be incompletely excised on the nasal tip and alae, and both subunits required more elaborate reconstructions. This, however, was not the result of poor estimation of the extent of the tumour and reluctance to excise more challenging areas widely for reconstruction, but to the method chosen to eradicate the tumour.     

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 significance of incomplete excision in patients with basal cell carcinoma

Sixty-seven patients with incompletely excised basal cell carcinomas are reviewed. No recurrences were seen in seven patients who had immediate supplementary treatment; 23 of 60 patients submitted to a "wait and see" regimen developed recurrent disease, Recurrence was commoner in those in whom both the lateral and deep margins were involved, and when the incomplete excision was for recurrent disease. The latter recurrences were more difficult to control in patients who had previously had radiotherapy, when the deep margin was involved and when a flap had been used to close the resulting defect. A case is made for immediate re-excision for all patients with incompletely excised basal cell carcinomas.     

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.     

Recurrence of a basal cell carcinoma in a skin graft in spite of total excision. A case report

The authors report an original case of a recurrence of basal cell carcinoma in a skin graft recipient site. The skin graft was used to resurface the defect following complete excision of basal cell carcinoma in the mandibular angle area. Three answers can be given to the question of the origin of that new carcinoma: recurrence of the primary carcinoma, metastasis to a lymph node or a transfer of a basal cell carcinoma located into the skin graft which grew further. This last hypothesis remains the most probable because the histology of the two carcinomas was different and that the patient presented many others locations of basal cell carcinomas. Skin grafted areas must be checked for recurrence of basal cell carcinoma in such patients because invisible basal cell carcinoma can be transferred within the graft where they can grow for their own.     

Immediate flap reconstruction after excision of basal cell carcinoma of the face

The authors review 175 basal cell carcinomas of the face, treated primarily by surgery. The overall cure rate was 97%. Among these cases, 53 were treated by excision and immediate local flap reconstruction. Analysis of results in the latter group encourages the use of this method for virgin, untreated tumors provided basic rules of surgical oncology are followed. Furthermore, it has a definite advantage cosmetically over more conservative methods. If radiotherapy has been the initial treatment, however, immediate reconstruction after excision of a recurrent tumor should be contemplated reluctance.     

Long-term oncological outcomes after robotic partial nephrectomy for renal cell carcinoma: a prospective multicentre study

Purpose

This study aimed at reporting the long-term oncological outcomes of robotic partial nephrectomy (RPN) for renal cell carcinoma (RCC).

Methods

Data from all consecutive patients who underwent RAPN for RCC from July 2009 to January 2012 in three departments of urology were prospectively collected. Overall survival (OS), cancer-specific survival (CSS) and disease free-survival (DFS) were estimated using the Kaplan–Meier method. Prognostic factors associated with CSS were sought in univariate analysis. The log-rank test was used for categorical variables and the Cox model for continuous variables.

Results

110 patients were included with a median follow-up of 64.4 months [95% CI = (61.0–66.7)]. Median age was 61 years (29–83) with 62.7% of men and 37.3% of women. Median RENAL score was 6 (4–10) with elective indications accounting for 95% of cases. Out of 27 patients (24.5%) who experienced peri-operative complication, 12 patients (10.9%) had a major complication (Clavien-Dindo grade ≥ 3). The TRIFECTA achievement rate was 52.7%. Three patients (2.7%) experienced local recurrence and seven patients (6.4%) progressed to a metastatic disease. 5-year OS, CSS, DFS were 94.9, 96.8, 86.4%, respectively. In univariate analysis, no pre/peri-operative characteristic was associated with DFS. No port-site metastasis was observed and there was one case of peritoneal carcinomatosis.

Conclusion

In this multicenter series, long-term OS, DFS and CSS after RPN appeared comparable to large series of open partial nephrectomy, with no port-site metastasis and one case of peritoneal carcinomatosis.

     

Patient awareness and sun protection behaviour following excision of basal cell carcinoma

Background

Limited information is available regarding disease awareness and sun protection behaviour in patients previously treated for non-melanoma skin cancer.

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.     

Metastatic basal cell carcinoma with squamous appearances in the naevoid basal cell carcinoma syndrome.

A patient with the naevoid basal cell carcinoma syndrome developed a secondary carcinomatous deposit in the pelvis. Persisting tumour in the skull and the secondary deposit in the pelvis contained areas of squamous differentiation. This confirms that the appearances of baso-squamous (or transitional or metatypical-cell) carcinoma can develop from typical basal cell carcinoma which had not been subjected to radiotherapy or to more than one surgical excision.