Deep Resection Margin Research Articles

Do basal cell carcinomas recur after complete conventional surgical excision?

For 1378 patients treated in the 11 years 1988-1998 by conventional excision of 1635 basal cell carcinomas, 1516 first index lesions were histologically completely excised. All patients having more than one BCC excised were identified from the data base from 1988 to 2003 to give minimum 5 years follow for last treated primary lesions in 1998. Measured clearance margins around the initial lesions at or near sites of presumptive recurrent lesions were noted and the lesions recorded photographically. All incompletely excised lesions whether or not re-excised were excluded. The median age for all patients was 70 years. Over minimum 5 years follow up, six patients developed nine subsequent lesions contiguous with the scar or graft repair of primary index lesion excision site (probable recurrences). The median interval to recurrence was 41 months (4 months-8 years 10 months), with median lateral clearance margin around the primary tumour of 2 mm (0.3-6.8 mm). A further nine patients developed 11 new lesions near (within 1cm of) the scar or graft of primary index lesion excision site (possible recurrences). The median interval to recurrence was 59 months (1 year-8 years 6 months). The median lateral clearance margin around the primary tumour was 4.1 mm (0.8-5.8 mm). For the two groups combined the maximum recurrence rate expressed as a percentage of index lesions was 1.3% (20/1516). Two thirds of possible and probable recurrences occurred in the temple and forehead, although these sites represented only 22% of all lesions, which may rather suggest new lesions in an area of field change as opposed to residual disease. The measured clearance margins reported here perhaps suggest that some original lesions may well have been completely excised primarily and many 'recurrences' were new primaries. These figures indicate there is a low order of probability for the incidence of recurrent basal cell carcinoma during minimum 5 years follow period after conventional surgical excision and conventional histological assessment of tumour resection margins.

Audit of clinical and histological prognostic factors in primary invasivesquamous cell carcinoma of the skin: assessment in a minimum 5 year follow-up study after conventional excisional surgery

In an attempt to evaluate the prognostic factors for primary squamous cell carcinoma of the skin treated by conventional surgery, a 6 year (1990-1995) cohort comprising 171 patients was analysed. Of these 171 patients, 157 were confirmed as having been treated for invasive squamous cell carcinoma, of whom 64 (41%) died within 5 years of treatment from causes other than squamous cell carcinoma, and were therefore defined as indeterminate. The remaining 93 patients were determinate patients; 85 lived without recurrence or metastasis for at least 5 years after treatment, and eight died of their disease. Comparing the groups who were alive or had died of disease at 5 year follow-up, the tumour diameter and tumour thickness were significantly greater in the eight patients who died (P = 0.02 and P = 0.0057, respectively) but there were no significant differences between the two groups with regard to age, deep resection margin clearance, lateral epidermal resection margin clearance, lymphocyte response or degree of tumour differentiation. This study defines the 5 year follow-up outcome following conventional surgery for squamous cell carcinoma of the skin, related to histological parameters, which, if routinely reported, would allow valid comparisons to be made between differing primary therapies.

Mohs micrographic surgery for facial skin cancer.

Although it is well established that conventional treatment modalities generally result in high cure rates for non-melanoma skin cancer, it has been demonstrated over recent decades that the highest overall cure rates are achieved using Mohs micrographic surgery. The key to Mohs surgery is the excision and control of complete peripheral and deep resection margins in one plane, allowing orientation, mapping and re-excision of microscopic tumour extension. These extensions can be followed without sacrificing inappropriate amounts of normal tissue, yielding high cure rates and maximum preservation of tissue. These qualities make Mohs surgery an important and reliable treatment for skin cancer of the face, in particular when it concerns large, aggressive or recurrent carcinoma in cosmetic and functionally important areas. In an 8-year study period, 369 basal cell carcinomas (BCCs) and 56 squamous cell carcinomas (SCCs) of the face were treated in our department using Mohs surgery. With a follow-up ranging from 3 months to 99 months (mean 33 months), none of the BCCs recurred and only one (2%) of the SCCs recurred a few months postoperatively. These favourable cure rates using the modality of Mohs surgery are the reason for highlighting this technique in the current review.

Mohs micrographic surgery for facial skin cancer.

Although it is well established that conventional treatment modalities generally result in high cure rates for non-melanoma skin cancer, it has been demonstrated over recent decades that the highest overall cure rates are achieved using Mohs micrographic surgery. The key to Mohs surgery is the excision and control of complete peripheral and deep resection margins in one plane, allowing orientation, mapping and re-excision of microscopic tumour extension. These extensions can be followed without sacrificing inappropriate amounts of normal tissue, yielding high cure rates and maximum preservation of tissue. These qualities make Mohs surgery an important and reliable treatment for skin cancer of the face, in particular when it concerns large, aggressive or recurrent carcinoma in cosmetic and functionally important areas. In an 8-year study period, 369 basal cell carcinomas (BCCs) and 56 squamous cell carcinomas (SCCs) of the face were treated in our department using Mohs surgery. With a follow-up ranging from 3 months to 99 months (mean 33 months), none of the BCCs recurred and only one (2%) of the SCCs recurred a few months postoperatively. These favourable cure rates using the modality of Mohs surgery are the reason for highlighting this technique in the current review.

A close or positive margin after mastectomy is not an indication for chest wall irradiation except in women aged fifty or younger

Introduction: Indications for postmastectomy radiation include primary tumor size ≥5 cm and/or ≥4 positive axillary nodes. In clinical practice, patients with a close or positive margin after mastectomy are also often treated with postmastectomy radiation. However, there is little data regarding the risk of a chest wall recurrence in patients with close or positive margins who otherwise would be considered low risk (tumor size <5 cm and/or 0–3 positive nodes). To address this issue, we assessed the risk of a chest wall recurrence in women with Stage I–II breast cancer who underwent mastectomy and were found to have primary tumor size <5 cm and 0–3 positive nodes with a close or positive deep margin. Methods and Materials: The pathologic reports from 789 patients treated by mastectomy between 1985 and 1994 at our institution were retrospectively reviewed. Of these, 136 (17%) had tumor within 1 cm of the deep resection margin. The study population consists of 34 of these patients with close or positive margins whose primary tumor size was <5 cm with 0–3 positive axillary nodes and who received no postoperative radiation. The median age was 43 years (range 29–76). Of these, 44% had T1 tumors and 56% T2 tumors. Pathologic axillary nodal status was negative in 65% and positive in 35%. The median number of positive nodes was 1. The deep margin was positive in 2 patients, ≤2 mm in 17 patients, 2.1–4 mm in 7 patients and 4.1–6 mm in 8 patients. Of the 34 patients, 67% received adjuvant chemotherapy ± tamoxifen and 21% received tamoxifen alone. The median follow-up was 59 months (range 7–143). Results: There were 5 chest wall recurrences at a median interval of 26 months (range 7–127). One was an isolated first failure, one occurred concurrent with an axillary recurrence, and three were associated with distant metastases. The 5- and 8-year cumulative incidences of a chest wall recurrence were 9% and 18%. Patient age correlated with the cumulative incidence of chest wall recurrence at 8 years; age ≤50 years had a rate of 28% vs. 0% for age >50 ( p = 0.04). There was no correlation with chest wall failure and number of positive nodes, ER status, lymphovascular invasion, location of primary, grade, family history, or type of tumor close to the margin. Of 5 chest wall failures, 4 were in patients who had received adjuvant systemic chemotherapy ± tamoxifen. Chest wall failures occurred in 1 patient with a positive deep margin, 3 patients with margins within 2 mm, and 1 patient with a margin of 5 mm. The estimated cumulative incidence probability of chest wall recurrence at 8 years by margin proximity was 24% ≤ 2 mm vs. 7% 2.1–6 mm ( p = 0.36), and by clinical size 24% for T2 tumors vs. 7% for T1 ( p = 0.98). Conclusions: A close or positive margin is uncommon (≤5%) after mastectomy in patients with tumor size <5 cm and 0–3 positive axillary nodes but, when present, it appears to be in a younger patient population. The subgroup of patients aged 50 or younger with clinical T1–T2 tumor size and 0–3 positive nodes who have a close (≤5 mm) or positive mastectomy margin are at high risk (28% at 8 years) for chest wall recurrence regardless of adjuvant systemic therapy and, therefore, should be considered for postmastectomy radiation.

Laser Microsurgery for Superficial TI–T2 Basal Cell Carcinoma of the Eyelid Margins

Basal cell carcinoma (BCC), the most common malignancy of the eyelid margins, poses therapeutic problems. Surgery, radiation therapy, and cryotherapy are the currently accepted methods for the treatment of this affliction. To verify the technical and clinical effectiveness of the surgical laser method, a specific approach was developed by performing laser-combined procedures under microscopic control. A series of 26 patients underwent carbon dioxide (CO2) laser microsurgical excision of 27 primary superficial BCCs of the eyelid margins. Eighteen tumors were T1 and 9 were T2. The lesions were located at the lid margins in 18 and at the canthus in 9 cases. The eyelash line was involved in all cases, whereas intermarginal space was involved in 17 cases, without extension to the conjunctival border. Six lesions were in the lacrimal region. Median linear extent of the lesion was 5 mm (range, 4-10 mm). Treatment was performed with the patient under local anesthesia in a Day Hospital regimen. The authors used the microscope-mounted CO2 laser as a scalpel to excise the tumor mass, thus obtaining the specimen for histologic evaluation. The authors treated the deep and lateral resection margins with laser vaporization and left the wound bed to heal by secondary intention. No significant complications were observed. As full-thickness eyelid resections were avoided, the authors noted conservation of lid function and cosmetic aspect in all patients. With a median follow-up of 73 months (range, 18-118), only one patient had tumor recurrence after 22 months. This tumor, located at the outer canthus, had a second microsurgical laser excision, and the patient is disease free 51 months after the last treatment. Laser microsurgery appears to be a safe and effective treatment method for primary superficial T1 and T2 BCC of the eyelid margins without conjunctival extension.

Phonomicrosurgical treatment of early glottic cancer and carcinoma in situ

In recent years, transoral resection of early glottic cancer has developed into a phonomicrosurgical approach that resulted from the convergence of microlaryngoscopic surgical technique theory with body cover mucosal wave theory of voice production. The vocal outcome from these procedures has improved by minimizing the deep resection margin and thereby maximizing the preservation of the vocal folds' normal layered microstructure (laminae propria and epithelium). Recurrence and cure rates from this narrow-margin approach were examined. The phonomicrosurgical resection approach is composed of four basic procedures in which there is an increasing depth of resection to accommodate a narrow-field deep cancer margin. This approach was employed to treat 13 T1 cancers and 7 with carcinoma in situ (CIS). No patients who underwent a cancer resection developed a recurrence. Minimum follow-up on these patients was 2 years and the mean follow-up was 42 months. In the group with CIS, 2 patients developed microinvasive carcinoma despite en bloc excision of the CIS. Both were successfully treated; 1 was resected transorally and the other underwent radiation therapy. This study indicates that the phonomicrosurgical approach, which incorporates a narrow deep cancer margin to enhance the postoperative vocal outcome, resulted in standard control and cure of early glottic neoplasia.

Nasal Glioma

Nasal gliomas are rare, benign, congenital masses more accurately referred to a sequestered glial tissue. Seven patients with nasal glioma treated by Hugh G. Thomson over the last 28 years are presented with special reference to tumor recurrence after excision and associated naso-ocular cleft. Three of our patients had an associated ipsilateral naso-ocular cleft, and three similar cases have been reported. This association is probably more frequent because a naso-ocular cleft can exist as a forme fruste and be easily overlooked. The first two tumors resected in our series recurred within 10 months; however, no recurrences were seen after a new treatment protocol was initiated in 1972. This consisted of total excision of the skin overlying the tumor if the skin adhered to the mass or if glial elements were seen within the dermis on frozen section. Deep resection margin was also assessed by frozen section of the nasal mucosa or fibrous stalk of the tumor. Accordingly, unnecessary intracranial procedures were avoided without increasing the risk of recurrence.