Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 2057e2063

Risk and outcome analysis of 1832 consecutivelyexcised basal cell carcinoma’s in a tertiary referralplastic surgery unit*

Vinod Malik*, King Soon Goh, Sum Leong, Angeline Tan, David Downey,David O’Donovan

Department of Plastic Surgery, St James Hospital, James’s Street, Dublin 8, Ireland

Received 13 June 2009; accepted 19 January 2010

KEYWORDSBasal cell carcinomas;Management;Excision rates;Incomplete excisions;Audit

* This paper has been presented in* Corresponding author. C/O Mr Davi

1 410 3432.E-mail address: malikv54@hotmail

1748-6815/$-seefrontmatterª2010Britdoi:10.1016/j.bjps.2010.01.016

Summary Background: Basal cell carcinomas are the most prevalent of all skin cancersworldwide and form the majority of the surgical workload for most modern cutaneous malig-nancy centres. Primary surgical removal of basal cell carcinomas remains the gold standard oftreatment but, despite almost two centuries of surgical experience, rates of incompletesurgical excision of up to 50% are still reported.

The aim of this study was to assess, quantify and perform comparative analysis of theoutcomes and predictive factors of consecutive primarily-excised basal cell carcinomas ina tertiary centre over a six-year period.Methods: Retrospective audit was conducted on all patients who underwent surgical excisionof basal cell carcinomas from January 2000 to December 2005. Assessment parametersincluded patient biographics, tumour management differences and detailed histopathologicalanalysis of tumour margins and subtypes.Results: One thousand eight hundred and thirty two basal cell carcinomas were excised from 1329patients over the designated time period. Two hundred and fifty one (14%) lesions were incom-pletely excised with 135 (7.4%) involving the peripheral margin only, 48 (2.6%) the deep margin onlyand 41 (2.2%) involving both. Nasal locationwas themost commonpredictorof incomplete excision.Conclusions: Overall basal cell carcinomas excision rates compared favourably with internationalreported standards but attention to a variety of surgical and histological risk factors may improvethis further.ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

the British Association of Plastics, Reconstructive and Aesthetics Surgeons on the 9th July 2008.d O’Donovan, St James’s Hospital, James’s Street, Dublin 8, Ireland. Tel.: þ353 1 416 2652; fax: þ353

.com (V. Malik).

ishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

2058 V. Malik et al.

Jacob Arthur in Dublin in 1827 first coined the term ‘rodentulcer’ to describe what we now know as a basal cellcarcinoma (BCC).1 BCC is the most prevalent skin cancerworldwide2,3 and is the most common cancer amongstCaucasians with a lifetime risk of one in every five and anincreasing incidence.4,5 Basal cell carcinomas tend to belocally invasive, at times being destructive but metastaticspread is rare.6 Complete eradication of the BCC is theoverall management aim and surgical excision remainsaccepted as the most frequent7,8 and successful treatmentmodality.9,10

Surgical resection with an adequate margin of normaltissue is the accepted standard of practise.11 Reportedrecurrence rates are around 1%12 when a BCC is completelyexcised as compared to recurrence rates of over 30%12e15

when a BCC is incompletely excised. The literaturedemonstrates wide variations in institutional experiences ofthe management of BCC’s with incomplete excision ratesranging from 0.7%16e 50%.17

The purpose of this study was to retrospectively assessthe demographic profiles, treatment experiences andcomplete excision rates of all patients presenting withbasal cell carcinomas to a tertiary referral unit successivelyover a six-year period.

Patients and methods

The hospital histopathology database identified patients byusing ‘BCC’ as a keyword for search criteria. All patientswith BCC excised solely by the department of plasticsurgery from January 2000 to December 2005 were includedfor retrospective analysis. The practise in our unit for thesurgical management of BCC’s involves all procedures beingcarried out in the minor theatre in the surgical day ward orin the main theatre under anaesthetic if required. Thesurgical excision policy involves primary clinical margins ofexcision of 3 mm circumferentially for all facial lesions and5e10 mm for all trunk and limb lesions.

Patients having incisional, punch or shave biopsies wereexcluded from our analysis. Histology reports providedinformation on histology type, completeness of excisionand details of margin involvement. The histopathologistdescribed the presence of tumour cells involving thesurgical margins as an incomplete excision. Further patientinformation was compiled from medical charts, theatre logsand in-house hospital computer records. These resourcesprovided us with patient details for variables such as age,gender, presenting diagnosis, source of referral, tumoursite, operator experience, anaesthetic used, method ofclosure, complications and follow up management.

Results

Overall data

One thousand eight hundred and thirty two basal cellcarcinomas were surgically excised from 1329 patients overthe six-year study period. Two hundred and fifty one lesionswere reported as incompletely excised. Details of margininvolvement for incomplete excisions showed 135 involving

lateral margins, 48 involving the deep margin and 41involving both lateral and deep margin. Margin involvementin 27 lesions was not recorded in the histology report.Overall incidence of incomplete excision was 14%.

Age and gender

Overall patients had a mean age of 67.5-years (range: 22e98-years). The mean age of patients with complete exci-sions was 64.8-years (range: 22e98 years) while patientswith incomplete excisions had a mean age of 67.7-years(range: 26e96 years).

Gender distribution showed an equal distribution ofmale and female patients. There was a slightly higherincidence of males (54%) in the incomplete excision groupas compared to the females (46%).

Presenting diagnosis

Ninety percent of all the lesions analysed were noted asprimary tumours, while 8.5% of lesions were noted asrecurrences. The initial presumed diagnosis of the assessingclinician was not discernable from the hospital records inthe case of 1.5% of lesions.

Referral source

The majority of patients were tertiary referrals fromgeneral practitioners (33%), dermatologists (27%) and otherhospitals (23%). A small group of patients (5%) were knownto the outpatient plastic department clinics from previousvisits. A further (12%) of patients had no documentedreferral source in the hospital notes.

Anatomical sites

One thousand six hundred and twenty three (89%) of theexcised lesions were in the head and neck area. Seventy-five (4%) of the lesions involved the trunk and a further 130(7%) lesions were on the limbs. In descending order, themost commonly involved sites were the nose (19%), cheek(13%), forehead (12%), temple (11%) and medial canthus(6%).

The site involving the most incomplete excisions was thenose 64 (25%). In descending order, the other most commonsites for incomplete excisions were the cheek (13%), temple(13%), forehead (12%), medial canthus (9%), eyelid (6.4%),pre-auricular (5.6%) and ear (4%). Table 1 details basal cellcarcinomas according to their anatomical distribution andincidence of incomplete excisions.

Anaesthetic used

A total of 1499 procedures were performed. Local anaes-thesia was employed in 77% of cases, while 16% of patientsreceived a general anaesthetic. In 7% of procedures theanaesthetic employed for surgical excision could not beobtained from hospital notes. In one procedure the patientreceived a spinal anaesthetic.

Table 1 Anatomical distribution of basal cell carcinoma

Site TotalNumberof Lesion

% ofTotal

No ofincompleteexcisions

% of allincompleteexcisions

Nose 350 19 64 25Cheek 235 13 33 13Forehead 224 12 29 12Temple 204 11 33 13Med Canthus 108 6.0 22 9.0Lower limbs 91 5.0 1 0.4Eyelid 88 4.8 16 6.4Trunk 75 4.2 1 0.4Ear 66 3.6 10 4.0Pre-auricular 62 3.4 14 5.6Neck 56 3.1 4 1.6Lips 41 2.3 4 1.6Upper limbs 39 2.1 3 1.2Lat Canthus 34 1.9 6 2.4Back 34 1.9 1 0.4Scalp 33 1.8 0 0Chin 26 1.4 3 1.2Post-auricular 26 1.4 3 1.2Eyebrow 22 1.2 3 1.2Mandible Area 8 0.4 0 0Face

(not specified)6 0.3 1 0.4

Unknown 4 0.2 0 0

Total 1832 100 251 100

Table 2 Overall histology subtype of basal cellcarcinomas

HistologySubtypes

TotalNumberof Lesion

% ofTotal

No ofincompleteexcisions

% of allincompleteexcisions

Undefined a 833 46 82 33Mixed b 308 17 68 27Nodular 179 9.8 20 8.0Nodulocystic 83 4.2 7 2.8Sclerosing 82 4.2 24 9.3Superficial 64 3.4 7 2.8Infiltrative 54 2.9 19 7.5No Tumour 51 2.8 0 0Multifocal 49 2.7 6 2.4Basosquamous 40 2.2 2 0.8Micronodular 31 1.7 9 3.6Adenoid 27 1.5 5 2.0Cystic 13 0.7 0 0Desmoplastic 9 0.4 2 0.8Morphoeic 6 0.3 0 0Other Tumour 2 0.2 0 0Unknown 1 0.0 0 0

Total 1832 100 251 100a No BCC subtypes recorded by histopathologist on histology

report.b � 2 subtypes of BCC present.

Risk and outcome analysis 2059

Surgical experience

Surgical procedures for removal of BCC’s in the departmentwere performed by consultants, registrars and senior houseofficers. Most of the lesions were excised by senior staffwith the consultants excising 36% of lesions and registrarsexcising 33% of lesions. The senior house officer excised 22%of lesions. The particular surgeon who excised the lesionscould not be identified from the hospital notes in 9% ofcases.

The rate for incomplete excision of BCC’s was highestamongst consultants (35%) followed by registrars (33%) andlowest for senior house officers (25%). In 7% of cases, thesurgeon responsible for the incompletely excised lesioncould not be identified from the hospital notes.

Closure

Primary closure (46%) was the commonest methodemployed to close the wound. Full thickness skin graft(25%), skin flaps (12%) and split skin graft (9%) were theother most common methods used for closure. A smallgroup of lesions (1%) were left to heal by secondaryintention. For 7% of the lesions, the kind of closureemployed could not be obtained from the hospital notes.

Complications

Documented complications were found in 81 (4.4%) of theoverall 1832 lesions. In 80 of the lesions excised,

incomplete hospital records meant that the incidence ofpost operative complications could not be ascertained.

Histology subtypes

In 833 (46%) of lesions, the histological subtype was notreported by the histopathologist on the histology report,and so the subtype was chronicled as ‘undefined’. Thehistology subtypes in 999 (55%) lesions were reported, ofwhich commonly encountered subtypes were mixedpatterns (i.e. � 2 subtypes of BCC present) (17%), andnodular (9.8%).

Analysis of incomplete excisions revealed that thehistological subtypes were not reported by the histopa-thologist in 82 (33%) lesions, representing the largest group.The other major subtypes noted were mixed pattern (i.e. �2 subtypes of BCC present) in 27%, sclerosing (9.3%),nodular (8%), and infiltrative (7.5%). Table 2 details histo-logical subtypes for overall lesions and incompletelyexcised basal cell carcinomas.

Margin involvement of incomplete excision

The incidence of incomplete excision was 251 (14%). Themost commonly involved margin was the lateral margin 135(54%), followed by the deep margin 48 (19%). In 41 (16%)lesions, the lateral and deep margins were both involved. Inthe remaining 27 lesions the histology report failed toidentify which margin was incompletely excised.

2060 V. Malik et al.

Management of incomplete excisions

Out of 251 incompletely excised lesions, (a) 130 (52%)lesions had further surgical intervention, (b) 104 (41%)lesions had no surgical intervention, and in (c) 17 (7%)lesions the exact outcome could not be obtained fromhospital notes. Figure 1 demonstrates treatment intent forincompletely excised BCC’s.

(a) Incomplete excision e Further surgical intervention:

Surgical re-excision was considered for 130 lesions, whichwere initially incompletely excised. Ninety-two (71%) lesionswere completely excised after one further re-excision. Nine(7%) lesions required two further re-excisions to achievecomplete tumour removal. Twenty (15%) lesions were stillincompletely excised after multiple re-excisions, of which 15lesions were then observed in follow up out patient clinics.Two lesions were referred for Mohs’ micrographic surgery.Two lesions were referred for radiotherapy and in one lesionthe patient refused further re-excision. Five (4%) incom-pletely excised lesions, which were initially observed atfollow up outpatient clinics were re-excised as they hadrecurred during the study. Four (3%) lesions were awaitingfurther surgical intervention. (Figure 1)

(b) Incomplete excision e No surgical intervention:

In 104 of the lesions, which were initially incompletelyexcised, no surgical intervention was performed. Thelargest groups of 86 (83%) of these lesions were observed in

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Figure 1 Demonstrates treatment int

follow up out-patient clinics. Fourteen (14%) lesions wereconsidered for surgery but non surgical intervention waschosen in 6 lesions due to patient co-morbidities, in 5lesions patients refused further re-excisions and in 3 lesionssurgery was deferred due to age. Two (1.8%) of theremaining 4 lesions were excised by non surgical interven-tions and two (1.8%) lesions were lost to follow up.(Figure 1)

Table 3 details management of all incompletely excisedlesions.

Residual tumour

A total of 121 lesions of the 130 lesions considered forsurgical intervention underwent further re-excision(excluding lesions awaiting surgery and those which re-occurred while being observed). Ninety-two out of the 121lesions were completely excised after re-excision while 9lesions were found to have residual tumour and requireda further re-excision to be completely excised. Theremaining 20 of the 121 lesions were found to have residualtumour after multiple re-excisions and their respectivemanagement is detailed in Table 3. Residual tumour wasfound in 62 (51%) of the 121 re-excised lesions with notumour being observed in the remaining 59 (49%) of lesions.

Discussion

Eradication of basal cell carcinomas can be accomplishedby surgical and non surgical interventions.18 Excision of

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ent for incompletely excised BCC’s.

Table 3 Management of incomplete excisions

Outcome of lesions No of lesions %

Completely excisedafter re-excision

92 37

Lesion observed at follow upclinics for recurrence

86 34

Incompletely excised afterre-excisions, lesion observed

15 6.0

Unknown outcome 17 6.8Completely excised after

multiple re-excisions9 3.6

Surgery deferred due toco-morbidities

6 2.4

Patient refusing furtherre-excisions

5 2.0

Recurrence while being observed 5 2.0Awaiting surgery 4 1.5Surgery deferred due to age 3 1.1Lost to follow up 2 0.8Incompletely excised after re-excision

Pt referred for Moh’s 2 0.8Pt referred for radiotherapy 2 0.8Pt refused further treatment 1 0.4

Excised by pulsed dye laser 1 0.4Excised by CO2 vaporisation & biopsy 1 0.4

Total 251 100

Table 4 Comparison of published incomplete excisionrates 1981e2007

Author Years No of lesions Incompleteexcision rate

Emmett, AJ. et al 16 1981 1411 10 (0.7%)Hauben, DJ. et al 26 1982 188 39 (20.7%)Griffths, R.W. et al 24 1999 1392 99 (7%)Kumkar, P. et al 22 2000 879 41 (4.7%)Kumkar, P. et al 27 2002 757 34 (4.5%)Hallock & Lutz et al 28 2001 415 65 (15.7%)Flesisher et al 21 2001 1459 243 (16.6%)Dieu, M. et al 29 2002 3558 223 (6.3%)Hussain, M. et al 30 2003 126 10 (8%)Berzovsky et al 31 2004 1478 159 (10.8%)Wilson, w. et al 32 2004 3795 235 (6.2%)Griffths, R.W. et al 33 2005 1635 119 (7%)Griffths, R.W. et al 34 2007 1539 134 (8.4%)Malik et al 2008 1832 251 (13.7%)

Median: 7%

Risk and outcome analysis 2061

BCC’s by conventional surgical excision should be under-taken with the sacrifice of minimal normal tissue, yetachieving complete excision of the tumour. Cure rates aftersuccessful surgical excisions have been reported in theregion of 95e99%.12,15,19,20

Reported incidences of incomplete excisions of BCC’svary anywhere from 0.7%16 to 50%.17 In addition to thepotential of tumour recurrence and the tissue destructionthat can accompany a progressive tumour, the effect ofincompletely excised BCC’s on patient anxiety levels andoverall treatment costs must be considered.

In this study a retrospective analysis of the clinicalpractise in the management of BCC’s in a single plasticsurgery unit was performed. An aim of this retrospectiveaudit was to help set up a database which would serve asa tool to assess clinical outcomes and be instrumental in thesubsequent implementation of changes applied to ourclinical practise. It is hoped that this will help improve thequality of care provided to our patients with BCC’s.

The head and neck were the most common anatomicalsites for BCC’s followed by the trunk and the limbs(Table 1). This would be in keeping with establishedaccepted high risk factors for BCC’s due to excessive sunexposure to certain parts of the body. Incompletely excisedlesions were prominent in the region of the head and neckwhile being very low on the trunk and the limbs alsoconcurring with published literature.12,14,21,22 It has beenagreed by many authors 17,20,22,23 that a higher rate ofincomplete excision of the mid face is expected as smallerexcisions are performed due to a deficit of available skin inthese areas.

The senior house officers had the lowest rate of incom-plete excisions, as compared to senior staff. This could beattributed to senior house officers excising smaller lesions,operating in areas of relative skin surplus, using simplermethods of closure and possibly under senior supervision.The reverse would be true for senior staff who would beexcising the larger lesions, in areas with skin deficits, andusing either grafts or flaps for closure.

The most commonly encountered positive marginfollowing tumour excision was the lateral margin which is inkeeping with previous reports.12,13,22,24,25 The mean age ofpatients was 67.7-years with incomplete excision, higherthan the mean age of 64.8-years for patients with completeexcisions. Kumar et al 22 reported similar findings.

The incomplete excision rate from our analysis is 14%which is comparable to the range of 0.7%16e 50%17 in pub-lished literature. Exclusion of patients treated by Moh’ssurgical techniques and the fact that resource limitation inthe unit excluded the routine use of frozen section evalu-ations contribute significantly to overall incomplete exci-sion rate which lies above the median of 7% for comparablestudies. Table 4 details incomplete excision rates forcompared published series over the past 26-years.

The analysis revealed surgical intervention was mostsought for incompletely excised lesions (Figure 1). Patientsbeing observed had a mean age of 70.9-years (range: 4e90-years), which was higher than the mean age of 62.4-years(range: 34e92-years) for patients undergoing furthersurgical excision.

Researching the management of incompletely excisedBCC’s reveals a divided view on this topic with some authorsfavouring re-excision12,13,15,16,20,24,35,36 and others optingfor a more conservative approach.6,14,25,26,37 Our reviewshowed a more conservative approach when dealing witholder patients with incompletely excised lesions. Eachunsuccessful excision is assessed on a case by case basistaking into account site of location, availability ofsurrounding tissue, patient’s age and co-morbidities, the

Table 5 Comparison of published series with incomplete excision rates, re-excision rates, and residual tumour

Author Years No of lesions Incomplete excision rate Re-excision rate Residual tumor

Griffths, R.W. et al 24 1999 1392 99 (7%) 74/99 (75%) 40/74 (54%)Kumar, P. et al 22 2000 879 41 (4.7%) 14/41 (34%) 2/14 (14%)Dieu, M. et al 29 2002 3558 223 (6.3%) 125/223 (56%) 74/125 (59%)Berzovsky et al 31 2004 1478 159 (10.8%) 100/159 (62.8%) 28/100 (28%)Griffths, R.W. et al 33 2005 1635 119 (7%) 91/119 (76%) 48/91 (53%)Griffths, R.W. et al 34 2007 1539 134 (8.4%) 80/134 (59.7%) 30/80 (37.5%)Malik et al 2008 1832 251 (13.7%) 121/251 (48.2%) 62/121 (51.2%)

2062 V. Malik et al.

follow up care and visits to out-patient clinics that wouldentail. Treatment options are discussed with patients andthe choices they make are respected. The incidence ofobservation in the non surgical intervention group of 83%concurs with reported series quoting incidences of 66e100%13,14,22,25 but this is higher than the observation incidenceof 39.5% reported by Dieu et al. 29

Comparable with many published series (43%e76%),13,24,29,31,33,34,38,39 the rate of re-excision from the analysisfor incompletely excised BCC’s was 52%. We are aware ofsome others reporting lower averages for re-excisions ofincompletely excised lesions.22,25 Residual tumour wasfound in 51% of cases which is higher than some reports(7e28%) 22,31,39 but similar to other series reporting inci-dences of residual tumour.13,16,24,26,29,33 Table 5 detailsrecently published series with incomplete excision rates,re-excision rates, and residual tumour.

Residual tumour was found more often in lesions of thenose, cheek, temple, forehead and pre-auricular area onre-excision. The opposite was noted on re-excision of theeyelid, ear, medial and lateral canthus. The lip, trunk andneck had an equal incidence of finding residual tumour tonot noting any remnant tumour. Review of published liter-ature has not shown such findings.

Initial histology reports have indicated that the presenceof lateral margin involvement does increase the likelihoodof finding a residual tumour at re-excision. The same wasalso noted if both lateral and deep margins were involved.However, no increase in residual tumour was noted whereinitial reports indicated only deep margin involvement. Asimilar finding in respect to residual tumour rates and thespecific positive margins involved has been reported byGriffith et al. 24

Our recurrence rate of 4% is lower than reportedrecurrence rates for incomplete excisions. This could beattributed to only a small number of patients (n Z 5) havingrecurrence of BCC during our analysis. We are unaware ofrecurrences that could have occurred since the terminationof the study.

Basal cell carcinomas have been shown to either progressor regress after excision. 40 It is imperative that one bears inmind the ability of BCC’s to regress when considering treat-ment modalities. 33 We consider our own incomplete excisionrate of 14% as high and feel a better success rate can beattained but would presume that many units, even with largeskin cancer practises, probably underestimate their ownincomplete excision rates and don’t formally audit theirpractises. Performed retrospectively this study has beenunable to identify BCC’s with a high risk of incomplete exci-sion. Maintaining of a database would enable us in the future

to perform prospective analysis of incomplete excisions moreaccurately and allow for comparative analysis with otherplastic surgical units. Since completing this study, a multidis-ciplinary team to assess further management of all skinmalignancies has been established in our unit involvinga consultant dermatologist, a consultant skin pathologist andconsultant plastic surgeon. In addition a Moh’s surgeryprogram is now available in our unit. It is hoped that in thefuture a comparison of the management of all BCC’s over thesubsequent 5-years to this study since the establishment ofthe database, the new Moh’s surgery service and a multidis-ciplinary approach will show improved results.

Acknowledgements

We would like to extend our gratitude to the consultantplastic surgeons in our department for allowing us to reviewtheir patient records.

The authors would also like to thank Dr. MaureenMcMenamin, consultant histopathologist for her valuablecontribution and advice. We are also thankful to the staff ofthe chart room in St James Hospital, especially TommyKavanagh for assisting us with the location of patientcharts.

Conflict of interest statement

None.

Funding

None.

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