Excision Of Nonmelanoma Skin Cancer Research Articles

68. Frailty as an indicator of post-operative complications following surgical excision of non-melanoma skin cancer on the head and neck

Non-melanoma skin cancer (NMSC) predominantly affects those aged over 90 years with 85% of lesions arising on the head and neck. Frailty is a measure of physiologic age and can be used as a predictor of adverse treatment outcomes. The aim of this study was to determine if the Rockwood Frailty Index is predictive of complications following excision of NMSC.

Frailty as an indicator of postoperative complications following surgical excision of non-melanoma skin cancer on the head and neck.

Non-melanoma skin cancer (NMSC) predominantly affects those aged over 90years, with 85% of lesions arising on the head and neck, where surgical excision remains the treatment of choice. Frailty is a measure of physiologic age and can be used as a predictor of adverse treatment outcomes. The aim of this study was to determine if the Rockwood Frailty Index is predictive of complications following excision of NMSC. Data were collected prospectively for patients who underwent an excision of a suspected NMSC from the head or neck across a two-month period. Details of the patient, lesion and procedure were recorded alongside ASA grade and Rockwood's Frailty score. Postoperative complications were recorded four weeks later. There was a total of 125 patients: 74 (60%) male, 51 (40%) female; mean age was 78 (±9.8) years. Of the excised sites, 61% were closed primarily, 26% with a full thickness skin graft (FTSG), 13% with a local flap. Frailty ranged from 1 to 7 (median = 4). ASA ranged from 1 to 4 (median = 3). A total of 21 (17%) patients reported postoperative complications. Within this group, the median frailty and ASA grades were 5 and 3. Both frailty and ASA were positively significantly associated with age (p ≤ 0.001). There was no significant difference between the frailty or ASA grades of patients that experienced complications and those who did not. Patients who had a FTSG were significantly more likely to experience complications (p ≤ 0.05). Frailty is not predictive of postoperative complications following excision of NMSC on the head and neck. Postoperative complications are significantly more associated with FTSG.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK.

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

The impact of treatment delay on skin cancer in COVID-19 era: a case-control study

BackgroundThe outbreak of COVID-19 pandemic led to a 2-month lockdown in Europe. Elective surgeries, including skin cancer excisions, were postponed. The purpose of this prospective case-control study was to assess the impact of the treatment delay on patients with non-melanoma skin cancer (NMSC) or melanoma operated in the first post-lockdown period.MethodsA comparative study of skin cancer operations performed in a 4-month period either in 2020 or in 2019 was conducted. All data were collected from a prospectively maintained clinic database and the pathological reports. Continuous variables were compared with t test or Mann-Whitney U test according to their distribution. Categorical variables were compared with Fisher exact test. Odds ratio (OR) with 95% confidence interval (95% CI) was used to assess the risk of excising high-risk NMSC in 2020 compared with 2019.ResultsSkin cancer excision was performed in 158 cases in 2020 compared to 125 cases in 2019 (26.4% increase). Significantly, more SCC were excised in 2020 (p = 0.024). No significant difference for several clinical parameters regarding BCC, SCC, and melanoma was identified. However, the reconstructive method applied, following NMSC excision, was significantly different, requiring frequently either skin grafting or a flap.ConclusionThese results indicate that skin cancer treatment delay, due to COVID-19 pandemic, is related to an increased incidence of SCC and more complicated methods of reconstruction. Considering the relapsing COVID-19 waves, significant skin cancer treatment delays should be avoided.Trial registrationThe study adhered to the STROBE statement for case-control studies.

Surgical excision of non-melanoma skin cancer: no end in site?

Non-melanoma skin cancer (NMSC) is the most common type of cancer in the UK and Ireland, accounting for approximately 20% of all new malignancies recorded, with evidence of increasing incidence. Surgical excision is regarded as the gold standard treatment for such lesions; however, incomplete excision incurs both physical and financial strain on patients and the healthcare service. Our aim is to identify which anatomical regions of the head and neck pose greater risk of incomplete excision and raise awareness for future surgical practice. Manual data collection was carried out on all patients admitted to the OMFS department for surgical excision of NMSCs between January 2016 and December 2017. Information collected included clinical notes and MDT outcomes. NMSCs excised via Mohs surgery. All tumours incompletely excised and requiring further treatment were noted with particular emphasis on the site of the lesion within the head and neck region, and the location of the positive margin on the specimen itself. A total of 506 NMSCs were excised (307 BCC, 199 SCC). Of these, 7.8% (n=24) and 6.0% (n=12), respectively, required further treatment due to incomplete excision. The incompletely exised lesions were predominately located on the nose (13.3%), temple (15.0%), and ear (12.8%). Our results demonstrate that our department is successfully excising NMSCs with minimal cases requiring further management. This study has identified anatomical profiles posing a higher risk of incomplete removal. Alongside the conventionally challenging sites of the nose and ear, we have highlighted additional risk within the temporal region. We therefore propose that Mohs surgery or a two-stage procedure should be considered as management for the temple at future MDTs.

Audit of the excision of non-melanoma skin cancers (NMSCs) of the head and neck

Audit of the excision of non-melanoma skin cancers (NMSCs) of the head and neck

13943 Factors influencing rates of complete excision of basal cell carcinomas and melanomas

Skin cancer, composed of both melanoma and nonmelanoma skin cancer (NMSC), can be treated with myriad modalities, including surgical excision. The primary end point for surgical excision of melanoma-in-situs (MIS) and NMSC is tumor clearance rate, determined postoperatively by the presence of tumor-free resection margins in the excised sample. This study explored which factors impacted the success of a MIS or NMSC excision. We conducted a retrospective study of 5800 standard excisions of MIS and basal cell carcinomas (BCC) performed by dermatologists, general surgeons, otolaryngologists, and plastic surgeons from 13 different Kaiser Permanente centers.

33% hydrogen peroxide as a Neoadjuvant treatment in the surgical excision of non-melanoma skin cancers: a case series

BackgroundHydrogen peroxide (H2O2) is a product of respiration in mitochondria and an important oxidizing agent in biological systems. Previous investigations have shown the efficacy of H2O2 in treating skin conditions such as seborrheic keratosis and actinic keratosis. In an area like the face, reconstruction of excision defects and ultimately aesthetic outcomes are of utmost importance. Hydrogen peroxide may represent a simple yet effective method at shrinking non-melanoma skin cancers (NMSC) of the head and neck before they are excised.MethodsEleven consecutive patients presenting to our cutaneous malignancy clinic had their skin lesions evaluated by the senior author for participation in the study. Lesion length and width was measured. Hydrogen peroxide formulated at a concentration of 33% was rubbed into the lesion until blanching was observed. Lesions were re-measured at follow up. Excisional biopsy was then performed and histopathological diagnosis was obtained. Statistical analyses compared pre- and post-treatment lesion dimensions.ResultsSeventeen biopsy-proven NMSC lesions were included in this investigation. Statistically significant reductions in the length (p < 0.001) and width (p < 0.001) were observed with H2O2 treatment. For some lesions, H2O2 was the sole treatment required, with post-treatment biopsy demonstrating no evidence of malignancy. Patients endured minimal discomfort during treatment and no long-term side effects were observed. Follow up at 6 months revealed no recurrences.ConclusionsWe have demonstrated a significant reduction in the size of multiple lesions after application of 33% hydrogen peroxide, simplifying definitive excision and reconstruction. Hydrogen peroxide demonstrated an ability to successfully treat non-melanoma skin cancers as well.

Surgical excision of non-melanoma skin cancer: no end in site?

Surgical excision of non-melanoma skin cancer: no end in site?

Presurgical Curettage Improves Accuracy for Nonmelanoma Skin Cancer Excision.

Presurgical curettage before nonmelanoma skin cancer surgery may help delineate tumor subclinical extensions. To determine histologically whether presurgical curettage appropriately or inappropriately changes excision specimen size. One hundred fifty consecutive nonmelanoma skin cancers treated with Mohs micrographic surgery. The clinical margin (CM) was marked. Presurgical curettage was then performed and the resultant presurgical curettage margin (PCM) marked. Frozen section analysis of the CM and PCM revealed whether the curettage-induced margin change was appropriate or unnecessary. Presurgical curettage appropriately increased the surgical margin in 9.3% of cases, reducing the number of Mohs stages from 2 to 1. It appropriately decreased the surgical margin in 17.3% thereby conserving normal skin. In 19.4% of cases the curettage increased the margin in situations where the CM had underestimated the size of the tumor; however, in these cases, the curettage did not increase the margin sufficiently to clear the tumor. In 44.0% of cases the PCM did not change the size of the stage I specimen compared to the CM and confirmed the CM. In 10.0% of cases, preoperative curettage reduced margin accuracy by removing healthy tissue (8.0%) or underestimating tumor (2.0%). These errors were associated with eyelid location, severe background photodamage, and morpheiform/infiltrating/sclerosing basal cell carcinomas. Presurgical curettage can improve tumor excision accuracy and efficiency. Careful tumor selection is important to optimize curette utility.

Intraoperative Frozen Section Analysis for the Excision of Nonmelanoma Skin Cancer: A Single-center Experience

INTRODUCTION: Recurrence rates for nonmelanoma skin cancers (NMSCs) following Mohs’ micrographic surgery (MMS) are consistently lower than standard surgical excision. However, variations in the availability of MMS, waiting times, and costs continue to affect patient preference between treatment modalities. Furthermore, MMS commonly requires delayed reconstruction leading to additional surgeries that increases the risk of adverse outcomes. To achieve curative resection while ensuring optimal cosmetic outcomes, plastic surgeons may utilize intraoperative frozen section-guided excision to forego extensive or delayed reconstruction. METHODS: Patients presenting with NMSCs undergoing wide local excision using intraoperative frozen section margin analysis (IFSA) at our institution from October 2008 to November 2016 were retrospectively reviewed. Analyzed data included IFSA results, final permanent section histopathology, number of resections required for clear margins, and recurrence rates. Excisions were performed by 1 of 3 plastic surgeons and analyzed by 1 of 8 pathologists. RESULTS: A total of 171 patients and 204 lesions were included in the study. Mean patient age was 72 years. Operative reports demonstrated that 79.9% of margins were clear after one excision. The remaining 20.1% of cases with residual positive margins after primary excision were identified using IFSA and were re-excised until negative margins were achieved. Of the 20.1%, a total of 11.8% required a second excision and 8.3% required ≥3 excisions. Intraoperative frozen section results revealed 1 false-positive case representing a rate of 0.49% and 5 false-negative results leading to a rate of 2.45%. Fifteen patients had local recurrence; a rate of 7.35%. Frozen section sensitivity was 89.79% and specificity was 99.35%. The positive predictive value was 97.78% with a negative predictive value of 96.85%. Patients had a mean follow-up of 39 months. CONCLUSION: The resection results and recurrence rate of NMSCs excised at our institution are comparable to national trends using standard surgical excision. The findings suggest that standard surgical excision using intraoperative frozen section analysis is a safe and effective alternative to MMS.

Reconstruction of nasal supratip defect using vertical alar groove tissue

Background: Several local flaps have been introduced for the reconstruction of small-to-medium-sized nasal supratip defects.Objective: To evaluate the outcome of reconstructing supratip defects using tangential advancement flaps from the vertical alar groove tissue.Methods and materials: Medical records of 20 patients who underwent supratip reconstruction using this flap between January 2012 and July 2018 were retrospectively analyzed. The postoperative photographs were assessed by three dermatologists using a four-scale investigator’s global assessment.Results: The male-to-female ratio was 9:11, with a mean age of 72.6 years (range, 56–89 years). In all 20 cases, defects were caused by a wide local excision of non-melanoma skin cancer on the nose. The mean diameter of the defects was 1.20 cm (ranging from 0.5 to 1.9 cm). The mean follow-up period was 14.0 months (ranging from 0.5 to 48 months). Excellent or good surgical outcome was reported in 95% of patients.Conclusions: Creating a tangential advancement flap using the vertical alar groove tissue is a simple, single-stage procedure with excellent surgical outcome. It may be useful in the reconstruction of supratip defects with a diameter of less than 2 cm.

Retalho “em Machado” de Emmett

INTRODUÇÃO: O retalho “em machado” de Emmett é um retalho cutâneo local, triangular (unilateral ou bilateral) e predominantemente de rotação que permite encerrar defeitos de pequenas, médias e grandes dimensões em diversas áreas cutâneas.MATERIAL E MÉTODOS: Quatro homens com idade média de 78,8 anos foram submetidos à exérese alargada de cancro cutâneo não melanoma (um carcinoma basocelular da face e do couro cabeludo, um porocarcinoma da face e um fibroxantoma atípico do couro cabeludo), sob anestesia local, seguido de reconstrução com o retalho “em machado” de Emmett.RESULTADOS: O diâmetro médio dos defeitos cirúrgicos foi de 30 mm. O retalho "em machado” de Emmett de triângulo bilateral foi usado num e o de triângulo unilateral nos restantes três casos. Não se registaram complicações pós-operatórias. Os resultados funcionais e estéticos foram muito aceitáveis. Os doentes não apresentavam recidiva aos 12 meses de seguimento.CONCLUSÃO: O retalho "em machado” de Emmett mostrou ser um procedimento alternativo versátil, seguro e eficaz nos quatro doentes.

Reconstructive Approaches to Nasal Defects

Nasal reconstruction is commonly performed for treatment of defects arising from excision of nonmelanoma skin cancers, although other tumors, trauma, or infection may also result in significant nasal deformities necessitating corrective surgery. Patients being evaluated for nasal reconstruction should have a functional assessment of airflow through both the internal and external nasal valves to determine the need for reconstructive maneuvers that will maintain or improve the nasal airway. Aesthetic considerations relate to which nasal subunits are missing and how local, regional, and sometimes free tissue transfer can be used to optimize the final appearance of the nose. Reconstruction must incorporate a plan for reestablishing nasal lining, support, and cover depending on which elements are missing. Postoperative considerations include the need for nasal splints and interventions to optimize nasal scarring and contour such as scar massage, steroid injection, and laser treatments. Patients who are not good candidates for autologous nasal reconstruction may be considered for prosthetic reconstruction. This review contains 13 figures and 67 references Key words: Nasal reconstruction, Nasal airway, Mohs surgery, Skin cancer, Nasal aesthetic subunits, Facial flaps, Skin graft, Forehead flap, Nasal cover, Nasal lining, Nasal support, Prosthetic rehabilitation

Reconstructive Approaches to Nasal Defects

Nasal reconstruction is commonly performed for treatment of defects arising from excision of nonmelanoma skin cancers, although other tumors, trauma, or infection may also result in significant nasal deformities necessitating corrective surgery. Patients being evaluated for nasal reconstruction should have a functional assessment of airflow through both the internal and external nasal valves to determine the need for reconstructive maneuvers that will maintain or improve the nasal airway. Aesthetic considerations relate to which nasal subunits are missing and how local, regional, and sometimes free tissue transfer can be used to optimize the final appearance of the nose. Reconstruction must incorporate a plan for reestablishing nasal lining, support, and cover depending on which elements are missing. Postoperative considerations include the need for nasal splints and interventions to optimize nasal scarring and contour such as scar massage, steroid injection, and laser treatments. Patients who are not good candidates for autologous nasal reconstruction may be considered for prosthetic reconstruction. This review contains 13 figures and 67 references Key words: Nasal reconstruction, Nasal airway, Mohs surgery, Skin cancer, Nasal aesthetic subunits, Facial flaps, Skin graft, Forehead flap, Nasal cover, Nasal lining, Nasal support, Prosthetic rehabilitation

Reverdin pinch grafts for surgical closure after removal of nonmelanoma skin cancer lesions of the leg

Background: Surgical closure after removal of nonmelanoma skin cancer on the leg can be challenging. Objective: Reverdin pinch grafting is an old skin transplant approach to treat leg ulcers. We present our experience using Reverdin pinch graft to close leg surgical defects following excision of nonmelanoma skin cancers. Patients and Methods: This was a retrospective study of 35 patients with medium-large sized defects with a median ± standard deviation of 20 ± 2.7 mm. Pinch grafts harvested from the thigh were used to cover the surgical leg defects with a 6-year follow-up period. Results: The average healing time after pinch grafting was 4 weeks ± 1.12 weeks. Ten patients (28.6%) had a failure of one or two single pinch grafts. There was no hypertrophic or keloid scarring in any grafted patients. Wound infection occurred in two patients (5.7%) and postoperative hemorrhage in only one patient (2.8%). Basal cell carcinoma arose in one patient (2.8%). Conclusion: Reverdin pinch graft technique is an easy and effective closure option for medium-large surgical defects of the leg after nonmelanoma skin cancer excision.

British Association of Dermatologists’ national audit on nonmelanoma skin cancer excision, 2014

Diagnosis and management of nonmelanoma skin cancer (NMSC) represents a large part of the dermatology workload, and complete excision is a required surgical standard for treatment. To conduct an audit of the surgical practice for the treatment of NMSC by dermatologists in the UK. Data on 10 consecutive nonmicrographic excisions of nonmelanoma skin cancer by UK dermatologists. Data collected included site, preoperative diagnosis, histological diagnosis, proximity to previous scars, and histological deep and peripheral margins. A total of 227 responses from 135 centres reported 2739 excisions. Excisions on the head and neck accounted for 58.3% of cases. Tumour diameter (mean±SD) was 10.61±6.9mm (maximum 130mm), and 96.7% of cases were primary excisions, with 3.3% being re-excisions. Basal cell carcinomas (BCCs) accounted for 79.1% (n=2167) of the total cases and squamous cell carcinomas (SCCs) for 17.9% n=491). Of the suspected BCCs and SCCS, 94.4% (n=2045) and 66.8% (328), respectively, were confirmed histologically to be the respective carcinomas. Similar proportions of BCC and SCC cases were within 10mm of a previous excision. Lateral and deep margins were clear in 98.3% and 99.2% of BCC cases, respectively, and in 98.4% and 97.1% of SCC cases, respectively. Reported surgical complication rate in the audit was 3.4%. The majority of excisions for NMSC are for BCC and SCC. Our figures for diagnostic accuracy are at the upper range of previously published figures. Most patients were not followed up in secondary care, hence complication rates may be under-reported.

False-negative rate of intraoperative frozen section margin analysis for complex head and neck nonmelanoma skin cancer excisions.

Intraoperative frozen section analysis (IFSA) is traditionally performed for complex and high-risk non-melanoma skin cancer (NMSC) resections, particularly when surgery under a general anaesthetic and a complex reconstruction is required, and where Mohs micrographic surgery (MMS) is not available. A retrospective audit of 253 cases between 1999 and 2009 was undertaken, investigating the accuracy and efficacy of IFSA for the treatment of NMSC in our tertiary skin tumour unit based in a university hospital setting. The combined incomplete and very narrow (<1 mm) excision margin rates were 28.7% and 27.5% for basal cell and squamous cell carcinoma, respectively. Unrepresentative sampling of the excision margins intraoperatively was the overwhelming cause of error (94%). After a thorough audit of our data, IFSA has been abandoned for the treatment of NMSC in our unit. MMS is practised intraoperatively, even in advanced cases. We believe that IFSA no longer has any role in our complex, multidisciplinary skin cancer practice.

Assessment of Patients Who Underwent Nasal Reconstruction After Non-Melanoma Skin Cancer Excision

Basal and squamous cell carcinomas are the most common malignant cutaneous lesions affecting the nose. With the rising incidence of skin cancers, plastic surgeons increasingly face nasal reconstruction challenges. Although multiple options exist, optimal results are obtained when "like is used to repair like". We aimed to introduce a simple algorithm for the reconstruction of nasal defects with local flaps, realizing that there is always more than one option for reconstruction. We retrospectively reviewed 163 patients who underwent nasal reconstruction after excision of non-melanoma skin cancer between March 2011 and April 2014. We analyzed the location of the defects and correlated them with the techniques used to reconstruct them. There were 66 males and 97 females (age, 21-98 years). Basal cell carcinoma was diagnosed in 121 patients and squamous cell carcinoma in 42. After tumor excision, all the defects were immediately closed by either primary closure or local flap options such as Limberg, Miter, glabellar, bilobed, nasolabial, V-Y advancement, and forehead flaps. Obtaining tumor-free borders and a pleasing aesthetic result are major concerns in nasal reconstruction. Defect reconstruction and cosmesis are as important as rapid recovery and quick return to normal daily activities, and these should be considered before performing any procedure, particularly in elderly patients.

Engineered autologous cartilage tissue for nasal reconstruction after tumour resection: an observational first-in-human trial

Autologous native cartilage from the nasal septum, ear, or rib is the standard material for surgical reconstruction of the nasal alar lobule after two-layer excision of non-melanoma skin cancer. We assessed whether engineered autologous cartilage grafts allow safe and functional alar lobule restoration. In a first-in-human trial, we recruited five patients at the University Hospital Basel (Basel, Switzerland). To be eligible, patients had to be aged at least 18 years and have a two-layer defect (≥50% size of alar subunit) after excision of non-melanoma skin cancer on the alar lobule. Chondrocytes (isolated from a 6 mm cartilage biopsy sample from the nasal septum harvested under local anaesthesia during collection of tumour biopsy sample) were expanded, seeded, and cultured with autologous serum onto collagen type I and type III membranes in the course of 4 weeks. The resulting engineered cartilage grafts (25 mm × 25 mm × 2 mm) were shaped intra-operatively and implanted after tumour excision under paramedian forehead or nasolabial flaps, as in standard reconstruction with native cartilage. During flap refinement after 6 months, we took biopsy samples of repair tissues and histologically analysed them. The primary outcomes were safety and feasibility of the procedure, assessed 12 months after reconstruction. At least 1 year after implantation, when reconstruction is typically stabilised, we assessed patient satisfaction and functional outcomes (alar cutaneous sensibility, structural stability, and respiratory flow rate). Between Dec 13, 2010, and Feb 6, 2012, we enrolled two women and three men aged 76-88 years. All engineered grafts contained a mixed hyaline and fibrous cartilage matrix. 6 months after implantation, reconstructed tissues displayed fibromuscular fatty structures typical of the alar lobule. After 1 year, all patients were satisfied with the aesthetic and functional outcomes and no adverse events had been recorded. Cutaneous sensibility and structural stability of the reconstructed area were clinically satisfactory, with adequate respiratory function. Autologous nasal cartilage tissues can be engineered and clinically used for functional restoration of alar lobules. Engineered cartilage should now be assessed for other challenging facial reconstructions. Foundation of the Department of Surgery, University Hospital Basel; and Krebsliga beider Basel.