Types of surgical approaches in locally advanced forms of basal cell carcinoma of the scalp in elderly patients

Abstract

Background. Basal cell cancer is the most common type of skin cancer in fair-skinned adults older than 50 years. The incidence rate of this disease is growing around the world. Basal cell carcinomas (BCC) are heterogeneous: from superficial or nodular lesions with benign prognosis to large lesions which are very difficult to cure. The prognosis of treatment is connected with the risk of recurrence of basal cell cancer or its local destructive ability. Hedgehog pathway activation is a distinctive molecular event in these tumors, which has allowed Hedgehog inhibitors for lesions that are difficult to cure to be developed, and which are also beyond the reach of surgical treatment or radiation therapy. Immunotherapy may be offered for the treatment of tumors with a high mutational load which leads to tumor resistance to Hedgehog inhibitors. Surgical intervention is a standard treatment method for most BCCs because it allows excision margins to be controlled and it shows a low risk of recurrence. The issue of removal of locally advanced forms with simultaneous reparative stage in elderly patients remains challenging.
 Purpose – to prove the high effectiveness of the surgical approach with simultaneous plastic surgery in locally advanced forms of BCC of the scalp in elderly patients.
 Materials and methods. Clinical observation of female patient A., 87 years old, who was receiving treatment in the Department of Surgical Oncology regarding multiple advanced BCC of facial skin, and patient V., 91 years old, who was undergoing treatment in the Department of Surgical Oncology regarding advanced basal cell skin carcinoma of the left pinna. Observation and treatment were performed in the State Organization «Grigoriev Institute for Medical Radiology and Oncology of the National Academy of Medical Sciences of Ukraine».
 Results. Clinical cases of locally advanced basal cell skin cancer in 2 elderly patients (87 and 91 years old) are presented. The effectiveness of the surgical approach with broad excision of the tumor and simultaneous reparative stage has been proven: in one case – a free split-skin autoplastic graft, in the other one – a full-thickness musculo-subcutaneous flap with axial blood circulation. In both cases there was no rejection of transplants; the scalp defects were completely covered, and a good cosmetic appearance was successfully achieved. In both cases, there were no significant complications observed. These examples have proven that the patients’ age of more than 90 years is not a counterindication to broad resections with simultaneous reparative stage in locally advanced BCC of the scalp.
 Conclusions. Thus, modern methods of diagnostics and treatment of BCC allow the disease to be controlled in most cases. It is also possible to cure locally advanced BCCs in patients older than 85 years surgically with a simultaneous reconstructive stage, given the reasonable selection of the patients.