Adequacy of surgical margins, re-excision, and evaluation of factors associated with recurrence: a retrospective study of 769 basal cell carcinomas

Ürün, Yıldız Gürsel; Can, Nuray; Bağış, Merve; Solak, Sezgi Sarıkaya; Ürün, Mustafa

doi:10.1016/j.abd.2022.07.005

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ORIGINAL ARTICLE • An. Bras. Dermatol. 98 (4) • 2023 • https://doi.org/10.1016/j.abd.2022.07.005 copy

Adequacy of surgical margins, re-excision, and evaluation of factors associated with recurrence: a retrospective study of 769 basal cell carcinomas^☆ ☆ Study conducted at the Department of Dermatology, University Hospital, Trakya University, Edirne, Turkey.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Achieving adequate surgical margins and preventing recurrence are important in the treatment of basal cell carcinoma (BCC).

Objectives:

The objectives of this study were to evaluate the adequacy of surgical margins and the re-excision rates in patients with primary BCC who underwent standard surgical treatment using our proposed algorithm and to define the risk factors in patients with recurrent BCC.

Methods:

The medical records of patients who were histopathologically diagnosed with BCC were reviewed. An algorithm created based on previous literature was used to determine the distribution of optimal surgical margins adequacy and re-excision rates.

Results:

Statistically significant differences were observed between the cases with and without recurrence in age at diagnosis (p = 0.004), tumor size (p = 0.023), tumor location in the H zone of the face (p = 0.005), and aggressive histopathological subtype (p = 0.000). When the tumors were evaluated for adequacy of deep and lateral surgical margins and re-excision rates, higher rates of adequate excision (457 cases, 68.0%) and re-excision (43 cases, 33.9%) were noted for tumors in the H or M zone.

Study limitations:

Inadequate follow-up of newly diagnosed patients in terms of recurrence and metastasis and the retrospective application of our proposed algorithm are the limitations of the present study.

Conclusions:

Our results showed that if BCC was detected at an early age and at an early stage, recurrence was lower. The H and M zones were the regions with the highest rates of optimal surgical outcomes.

KEYWORDS
Carcinoma; Basal cell; Margins of excision; Neoplasm metastasis; Recurrence; Risk factor

Lesion	Mean (SD)	Median (range)	p	95% CI
Nonaggressive (n = 511, 67.1%)	3.75 (4.06)	3 (0.5-65)	0.015	0.012 -0.019
Aggressive (n = 250, 32.9%)	4.3 (4.28)	3 (0.5-35)

	Non-Recurrence (%)	Recurrence (%)	p-value	HR (95% CI)
Gender (Male)	413 (59.4)	42 (56.8)	0.657	1.116 (0.688-1.811)
Age at diagnosis	68.16 (13.5)	72.96 (12.53)	0.004	1.029 (1.009-1.049)
Ulcer	387 (55.7)	50 (67.6)	0.052	1.658 (0.996-2.759)
Immunosuppression^a a Patients with organ transplantation or HIV (human immunodeficiency virus) infection/AIDS or hematological malignancies or those for whom immunosuppression was indicated in the medical record were considered ‘‘immunosuppressive’’.	38 (7)	2 (3.6)	0.348	0.5 (0.117-2.129)
Tumor size (≥20mm)^b b Adapted from National Comprehensive Cancer Network guideline.6	70 (10.1)	14 (18.9)	0.023	2.083 (1.107-3.92)
Tumor location in H zone of the face^b b Adapted from National Comprehensive Cancer Network guideline.6	489 (70.4)	64 (86.5)	0.005	2.696 (1.358-5.354)
Aggressive^b b Adapted from National Comprehensive Cancer Network guideline.6	203 (29.5)	47 (63.5)	0.000	4.15 (2.515-6.849)
Patients with multiple BCC at diagnosis	90 (12.9)	14 (18.9)	0.156	1.569 (0.842-2.923)

	Regional metastasis n = 28 (%)
Gender
Female	11 (39.3)
Male	17 (60.7)
Age at onset of primary tumor, median (range)	79 (48-99)
Tumor site
Periocular	6 (21.4)
Auricular	5 (17.9)
Nasal	4 (14.3)
Lips	4 (14.3)
Nasolabial fold	3 (10.7)
Postauricular	2 (7.1)
Frontal, parietal, temporal, occipital	1 (3.6)
Cheeks	1 (3.6)
Neck	1 (3.6)
Chin	1 (3.6)
Tumor location in H/M/L zone of the face ^a
Tumor location in H zone of the face	25 (89.3)
Tumor location in M zone	3 (10.7)
Size of primary (mm), median (range)	20 (4-95)
Invasion of primary (mm), median (range)	12 (7-30)
Histopathologic features of primary
Basosquamous	10 (35.7)
Mixed	8 (28.6)
Infiltravite	8 (28.6)
Sclerosing/morphoeic	2 (7.1)
Metastatic sites
Lymph node	15 (53.6)
Ipsilateral bone	14 (46.7)
Ipsilateral muscle	9 (30)
Soft tissues	9 (30)
Ipsilateral cartılage	7 (23.3)
Parotid gland	3 (10)
Treatment
Surgical treatment	28 (100)
Radiotherapy	20 (71.4)
Radiotherapy + Chemotherapy	2 (6.6)

Risk factors	Surgical margin^c c Surgical margins were evaluated as deep and lateral margins. Failure of any of these surgical margins was evaluated as inadequate surgical margin excision.	n (%)
Nonaggressive + L zone^d d H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. L zone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + <20 mm^e e Tumor size.	Excision with 4 mm margins	26 (3.9)
Nonaggressive + L zone^d d H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. L zone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + ≥20 mm^e e Tumor size.	Excision with 5 mm margins	-
Nonaggressive + H/M zone^d d H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. L zone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + independent of tumor size	Excision with 5 mm margins	457 (68.0)
Aggressive + L zone^d d H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. L zone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + <20 mm^e e Tumor size.	Excision with 5 mm margins	12 (1.8)
Aggressive + L zone^d d H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. L zone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + ≥20 mm^e e Tumor size.	Surgical margin excision exceeding 5 mm	-
Aggressive + H/M zone^d d H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. L zone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + independent of tumor size	Surgical margin excision exceeding 5 mm	177 (26.3)

Risk factors	Re-excision, n (%)
Nonaggressive + L zone^b b H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. Lzone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + <20 mm	-
Nonaggressive + L zone^b b H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. Lzone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + ≥20 mm^c c Tumor size.	-
Nonaggressive + H/M zone^b b H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. Lzone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + independent of tumor size	83 (65.4)
Aggressive + L zone^b b H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. Lzone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + <20 mm^c c Tumor size.	1 (0.8)
Aggressive + L zone^b b H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. Lzone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + ≥20 mm^c c Tumor size.	-
Aggressive + H/M zone^b b H zone; ‘‘mask areas’’ of the face (central face, eyelids, eyebrows, periorbital region, nose, lips [skin and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet. M zone; cheeks, forehead, scalp, neck, and pretibia. Lzone; trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). + independent of tumor size	43 (33.9)

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E-mail: revista@sbd.org.br

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[1] ⁎ Corresponding author. E-mail: yildizgurselurun@trakya.edu.tr (Y. Gürsel Ürün).

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Adequacy of surgical margins, re-excision, and evaluation of factors associated with recurrence: a retrospective study of 769 basal cell carcinomas☆ ☆ Study conducted at the Department of Dermatology, University Hospital, Trakya University, Edirne, Turkey.

Abstract

Background:

Objectives:

Methods:

Results:

Study limitations:

Conclusions:

Adequacy of surgical margins, re-excision, and evaluation of factors associated with recurrence: a retrospective study of 769 basal cell carcinomas^☆ ☆ Study conducted at the Department of Dermatology, University Hospital, Trakya University, Edirne, Turkey.