High-risk Basal Cell Carcinoma Research Articles

GATA3 Positively Correlates with BCL2 Expression in Indolent and Aggressive Histological Types of Cutaneous Basal Cell Carcinoma.

Some histological basal cell carcinoma (BCC) types demonstrate more aggressive behavior than others. They are known as high-risk BCC and are more challenging in therapy, contrary to indolent (low-risk) BCC types. Identifying novel protein markers to predict aggressiveness and potential therapeutic targets in challenging cases is recommended. GATA3 is a transcription factor critical for epithelial and lymphocytic differentiation. This study investigated the immunohistochemical expression of GATA3 in indolent and aggressive BCC and its association with BCL2 expression. Retrospectively collected indolent and aggressive BCC groups (24 cases each) were immunohistochemically stained with anti-GATA3 and BCL2 antibodies. The mean expression score (by area percentage) and TIL counts were determined and compared using ImageJ analysis. Stromal tumor-infiltrating lymphocytes (TIL) were counted per high-power field (HPF) on hematoxylin and eosin (H&E) staining. GATA3 and BCL2 expressions were significantly higher in the indolent group than in the aggressive group. GATA3 expression significantly correlated with BCL2 score and TIL counts. Higher GATA3 expression was significantly associated with a more indolent BCC histological type, higher BCL2 expression, and higher TIL count. GATA3 is a possible target for immunomodulation experiments to improve BCC immunotherapy outcomes.

[Artículo traducido]]Revisión del rol de la cirugía micrográfica con cortes en parafina en el tratamiento de tumores cutáneos

Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal-cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.

Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors

Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.

MOHS MICROGRAPHIC SURGERY FOR BASAL CELL CARCINOMA: A REVIEW OF TREATMENT RESULTS

Objectives: To evaluate the results of Mohs Micrography Surgery (MMS) in the treatment of basal cell carcinoma (BCC). Materials and methods: We used the database of PUBMED and EMBASE to evaluate the results of MMS in treatment of BCC. Results: Nine studies with the total number of 5845 BCC cases were included in this review, the follow-up time varied from 12 to 42 months. The overall cumulative probabilities of recurrence after MMS were 2.4%. The cumulative probability of recurrence for the primary BCC group and the recurrent BCC group was 2.9% and 7.2%, respectively. In the recurrent BCC group, the cumulative probability of recurrence after MMS was lower than after standard surgical excision (SSE) (3.9% vs 13.5%, p < 0.05). In MMS group, 52% of patients required one round of excision to achieve complete removal of BCC, 34% needed two rounds and 14% needed three rounds. The size of final skin defect after MMS was 1.34 times larger than that of the primary tumor (p < 0.05). Conclusion: MMS is superior to SSE in BCC treatment, with lower recurrence rate and better normal skin-sparing. Therefore, MMS is strongly recommended for surgical treatment of BCC, especially in high-risk BCC. Received 28 June 2023Revised 26 September 2023Accepted 29 November 2023

Efficacy of micrographic surgery versus conventional excision in reducing recurrence for basal cell carcinoma and squamous cell carcinoma: A systematic review and meta-analysis.

The standard of care for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) involves excision by conventional surgery (CS) with a predefined safety margin of resection or micrographic surgery (MS) with microscopic margin control. Previous studies have reported the superiority of MS in reducing recurrences for high-risk BCC and SCC. This systematic review aimed to assess MS and CS recurrence rates by including randomized clinical trials (RCTs) and cohort studies. A systematic review and meta-analysis were conducted for related studies in PubMed, LILACS, Embase, Scopus, Web of Science, CINHAL and Cochrane until May 2023. RCTs and cohorts involving patients with BCC or SCC submitted to MS and CS were included. Risk of bias assessment followed Cochrane-recommended tools for RCTs and cohorts, and certainty of evidence followed the GRADE approach. Pooled estimates were used to determine the relative risk (RR) and absolute risk difference (RD) using a random-effects model. Seventeen studies were included, two RCTs and fifteen cohorts. There were 82 recurrences in 3050 tumours submitted to MS, with an overall recurrence rate of 3.1% (95% CI 2.0%-4.7%). For CS, there were 209 recurrences in 3453 tumours, with a recurrence rate of 5.3% (95% CI 2.9%-9.3%). The combined estimate of RR was 0.48 (95% CI 0.36-0.63), without heterogeneity nor evidence of publication bias (p > 0.3). The RD resulted in 2.9% (95% CI 1.0%-4.9%; NNT = 35). Regarding subgroup analysis, the RR for BBC was 0.37 (95% CI 0.25-0.54), and RD was 3.7% (95% CI 0.8%-6.5%; NNT = 28). For SCC, RR was 0.57 (95% CI 0.29-1.13), and RD was 1.9% (95% CI 0.8%-4.7%; NNT = 53). Among primary tumours, RR was 0.39 (95% CI 0.28-0.54), and for recurrent tumours was 0.67 (95% CI 0.30-1.50). There is moderate evidence based on two RCTs, and low evidence based on 15 cohort studies that MS is superior to CS in reducing recurrences of BCCs and primary tumours. The development of protocols that maximize the cost-effectiveness of each method in different clinical scenarios is paramount.

Preoperative evaluation of high-risk basal cell carcinoma with line-field confocal optical coherence tomography (LC-OCT) reduces Mohs micrographic surgery stage number: A case-control study

BackgroundMohs micrographic surgery (MMS) is the preferred surgical approach for high-risk basal cell carcinoma (BCC). Pre-surgical tumor margins delineation with line field confocal optical coherence tomography (LC-OCT) is expected to reduce MMS stages number. Objectiveto investigate the effectiveness of LC-OCT preoperative evaluation of high-risk BCC margins in reducing the number of MMS stages to achieve tumor clearance. Patients and methodshigh-risk BCC patients undergoing MMS at Policlinico A. Gemelli Foundation, IRCCS – Rome during January 2018 – December 2022. The LC-OCT group included patients undergoing preoperative lateral tumor margin demarcation by clinical, dermoscopic, and LC-OCT examination; patients in the control group underwent preoperative lateral tumor margin demarcation by clinical and dermoscopic examination only. LC-OCT imaging was compared to MMS histopathological sections. Results63 facial high-risk BCCs from 60 patients, mean age of 68.3 years (SD 11.9). The LC-OCT and the control group included 22 and 41 BCCs, respectively. LC-OCT imaging showed almost perfect agreement with histopathology for low- versus high-risk of recurrence BCC histopathological subtypes discrimination (Cohen’s kappa 0.88). We reported a significant difference in the mean number of MMS stages between the LC-OCT and the control group (1.23 ± 0.43 SD, and 1.89 ± 1.05 SD, respectively; p-value =0.007). At univariate regression analysis, LC-OCT preoperative mapping of BCC tumor margins significantly reduced patients’ risk of undergoing >1 MMS stage (crude odds ratio [ORc]: 0.3 95% CI 0.1–0.8, p-value =0.032). ConclusionLC-OCT preoperative evaluation of high-risk BCC margins significantly reduced the number of MMS stages to achieve tumor clearance.

Optically Guided High-Frequency Ultrasound to Differentiate High-Risk Basal Cell Carcinoma Subtypes: A Single-Centre Prospective Study.

Basal cell carcinoma (BCC) is the most common type of skin cancer in the Caucasian population. Currently, invasive biopsy is the only way of establishing the histological subtype (HST) that determines the treatment options. Our study aimed to evaluate whether optically guided high-frequency ultrasound (OG-HFUS) imaging could differentiate aggressive HST BCCs from low-risk tumors. We conducted prospective clinical and dermoscopic examinations of BCCs, followed by 33 MHz OG-HFUS imaging, surgical excision, and a histological analysis. We enrolled 75 patients with 78 BCCs. In total, 63 BCCs were utilized to establish a novel OG-HFUS risk classification algorithm, while 15 were employed for the validation of this algorithm. The mean age of the patients was 72.9 ± 11.2 years. Histology identified 16 lesions as aggressive HST (infiltrative or micronodular subtypes) and 47 as low-risk HST (superficial or nodular subtypes). To assess the data, we used a one-sided Fisher's exact test for a categorical analysis and a Receiver Operating Characteristic (ROC) curve analysis to evaluate the diagnostic accuracy. OG-HFUS distinguished aggressive BCC HSTs by their irregular shape (p < 0.0001), ill-defined margins (p < 0.0001), and non-homogeneous internal echoes (p = 0.004). We developed a risk-categorizing algorithm that differentiated aggressive HSTs from low-risk HSTs with a higher sensitivity (82.4%) and specificity (91.3%) than a combined macroscopic and dermoscopic evaluation (sensitivity: 40.1% and specificity: 73.1%). The positive and negative predictive values (PPV and NPV, respectively) for dermoscopy were 30.2% and 76.8%, respectively. In comparison, the OG-HFUS-based algorithm demonstrated a PPV of 94.7% and an NPV of 78.6%. We verified the algorithm using an independent image set, n = 15, including 12 low-risk and 3 high-risk (high-risk) with two blinded evaluators, where we found a sensitivity of 83.33% and specificity of 91.66%. Our study shows that OG-HFUS can identify aggressive BCC HSTs based on easily identifiable morphological parameters, supporting early therapeutic decision making.

The Importance of Basal Cell Carcinoma Risk Stratification and Potential Future Pathways.

Basal cell carcinoma (BCC) is the most common human cancer. Although there are surgical and topical treatments available, surgery remains the mainstay of treatment, leading to higher costs. What is needed is an accurate risk assessment of BCC so that treatments can be planned in a patient-centered manner. In this study, we will review the literature about guidelines for the management of BCC and analyze the potential indicators of high-risk BCC. Using this risk assessment approach, we will propose pathways that will be able to optimize treatments more efficiently. This paper presents a perspective from a skin cancer expert and clinic involved in the treatment of both simple and complex cases of BCC. It addresses the key challenges associated with accurate risk stratification prior to any treatment or procedure. Different immunohistochemical and angiogenic markers for high-risk BCC were reviewed in this study. The expression of interleukin-6, vascular endothelial growth factor, and mast cells within BCC correlates with its aggressiveness. Other immunohistochemical markers, such as Cyclin D1 and Bcl-2, also play a significant role-Cyclin D1 is higher in the aggressive BCC, while Bcl-2 is lower in the aggressive BCC, compared to the nonaggressive variants. Based on our research, we will conclude that using immunohistochemical and angiogenic markers for risk assessment and stratification of BCC can help optimize treatment, ensuring that surgical procedures are used only when necessary.

Benefit of skin surgical revision in high-risk basal cell carcinoma according tohistopathological margins.

This article investigated the impact of histological margins on recurrence for high-risk basal cell carcinomas and analysed the existence of a benefit of surgical revision in the case of inframillimetric margins.

Histologic pattern analysis of cutaneous basal cell carcinoma at a tertiary care hospital in South India

Basal cell carcinoma (BCC) is one of the common malignant disease of the skin worldwide. An attempt at a simplified, accurate histologic classification of BCC based on histologic growth patterns is done in this study. This paved way to the concept of risk typing BCC into low and high-risk types. This is a retrospective descriptive study of skin biopsies diagnosed as BCC between 2010 and 2018 in the Department of Pathology in a tertiary care teaching hospital in Karnataka. H&amp;E stained sections were reviewed, histopathologically subtyped and further categorized into high and low risk types. IHC for BerEP4 was done in ten diagnostically challenging cases. The patients were followed up for six months after the study period. 79 cases of BCC were studied with majority of them being classified as high risk BCC (83.54%), with nodular type (51.89%) being the most common histological subtype. BCCs were seen predominantly in patients in the sixth decade with a female preponderance in both high and low risk BCCs. Majority of the patients with genetic predispositions were of young age and included xeroderma pigmentosa and oculocutaneous albinism. IHC for BerEP4 showed strong and diffuse membranous staining in all ten cases. Recurrence was noted in two cases and metastasis following three recurrences was noted in one case. An accurate histologic classification of BCC based on growth pattern is of great significance as it reflects the biological behaviour of the tumour. Risk typing BCC into high and low risk types further guides the management of BCC. High risk categories mandate more aggressive and decisive treatment to prevent recurrences and also helps predict the prognosis for the patient.

Basal Cell Carcinoma After High Dose Rate Brachytherapy: Medium-term Dermoscopic Evaluation of Cancer's Response.

Basal cell carcinoma of the facial region remains a challenge for contemporary oncology due to the presence of aesthetic regions and critical organs. Surgery is not always the optimal solution, and high dose rate (HDR) brachytherapy has emerged as an organ-sparing treatment method whose effectiveness has been proven by a growing number of publications. Dermoscopy is a diagnostic tool that bridges clinical and pathological examination of skin lesions. It is routinely used for diagnosis, monitoring of treatment, and post-treatment evaluation; however, the literature lacks data concerning changes in dermoscopic patterns of skin cancers during and after irradiation. Our team conducted a prospective non-randomized trial of 39 patients with high-risk basal cell carcinomas (BCCs), mostly localized within the high-risk zone (H-zone) of the facial region, and who qualified for HDR brachytherapy. HDR contact brachytherapy with custom-made surface molds was introduced, delivering a dose of 45Gy in 9 fractions prescribed to the tumor. Every patient was observed clinically and dermoscopically at three observational points: before treatment, at the end of treatment (3rd week), and 24weeks after the end of therapy. The evolution of clinical and dermoscopic patterns was observed by two independent dermoscopists using current diagnostic criteria. A database of 12,088 photographic observations was evaluated. Univariate logistic regression proved that brachytherapy decreases the number of clinical and dermoscopic patterns typical for basal cell carcinoma, as well as dermoscopic features not related to BCC, presumably due to the formation of scar tissue. In addition, univariate logistic regression with random effects proved a positive correlation between tumor size and presence of various dermoscopic patterns typical for BCC. Dermoscopy is proven to be easy to perform and an adequate monitoring tool for patients with BCCs undergoing HDR brachytherapy.

Basal Cell Carcinoma Perineural Invasion and Suggestive Signs of Perineural Invasion-Findings and Perspectives.

Basal cell carcinoma (BCC) is a malignant tumor with a rising incidence and is the beneficiary of several innovative evaluation techniques. Histopathology remains the gold standard for assessment, having the possibility of addressing multiple high-risk factors such as perineural invasion (PNI). The current study included a number of 244 BCC patients and targeted the identification of positive PNI and its suggestive signs, and whether they correlated or not with other high-risk tumor signs. PNI was found in 20.1% of patients, with 30.7% of patients having perineural chronic inflammation (PCI), which is a suggestive sign of PNI. PNI was also found in larger tumors, with deeper Clark levels, in high-risk BCCs and high-grade tumors. PNI and PCI are both important for pathology reporting, aiding in treatment choice and further patient management, with possibly positive outcomes concerning morbidity and mortality.

Clinicopathological Factors Influencing Resection Margin Involvement During Mohs Micrographic Surgery for Skin Tumors.

Mohs micrographic surgery (MMS) is a specialized procedure for removing skin tumors. Intraoperative assessment of the resection margin (RM) status using frozen section examination is a crucial component of MMS. This study aimed to identify significant clinicopathological characteristics that could help surgeons determine the optimal surgical extent. One hundred and fifty-one patients with primary skin tumors were included. The relationship between RM involvement and the clinico-pathological characteristics was analyzed for each histological type. Basal cell carcinoma (BCC) was significantly more likely to exhibit positive RMs and required additional excision during MMS compared to squamous cell carcinoma. In addition, the probability of RM involvement was significantly higher in high-risk BCC subtypes. When planning MMS, considering the histological type and presence of high-risk morphology may help surgeons perform more effective procedures.

FACIAL BASAL CELL CARCINOMA- CLINICAL VARIANTS, MANAGEMENT AND CLINICAL OUTCOME EXPERIENCE AT OUR CENTRE

Background: Basal cell carcinoma (BCC) is the most common type of skin cancer and it constitutes more than three quarters of skin cancers of the face. Any lesion in the face above the line joining the tragus and the angle of mouth are considered as high risk lesions for recurrence. The gold standard surgical treatment is Mohs micrographic surgery (MMS) or surgical excision with intraoperative histological and margin assessment. Radiation therapy (RT) has always played an essential role in the management of BCC. To retrospectively analyse the presentation, risk Aim: factors, most common histopathology variant, margin status, ap reconstruction, need for adjuvant RT and recurrence of BCC in the face in a tertiary centre. Methods: Retrospective analysis of 16 cases of BCC over the face treated at out centre was done from 2018 to 2020.All were BCC above the line joining tragus to angle of mandible. All cases presented bet Results: ween the age 34 to 67, mean age of 54. Of the total 16 cases, 12 were males and 4 females. 12 cases were primary and 4 were recurrent operated outside. All lesions excised with 2-4mm margin and reconstructed with local faciocutaneous aps in rst setting. All aps healed well with no complictaions except for 2 which had minor wound breakdown. Post op Radiation given in 5 cases (4 recurrent and 1 primary). All patient had acceptable cosmesis after the completion of treatment. All patients were followed up for 2 years. In our experience high risk BCC in the face can be excised wit Conclusion: h negative margins using intraoperative frozen section and ap reconstruction can be done in rst setting only. Those that are recurrent and with high risk features , adjuvant therapy has to be given

Biopsy type does not affect the number of stages during Mohs micrographic surgery: a retrospective study.

Mohs micrographic surgery (MMS) is the treatment of choice for high-risk basal cell carcinoma (BCC). However, there are no evidence-based recommendations regarding which biopsy type is more appropriate to obtain tumour samples prior to MMS. Shave or punch biopsies are performed depending on the clinical characteristics of the tumour, surgeon experience and local protocols. However, biopsy type might result in difficult histopathological interpretation and influence the practical implementation of MMS. We performed a retrospective study on 208 consecutive BCCs treated with MMS. Of the 208 BCC biopsies, 42 (20.2%) were obtained by the shave method and 166 (79.8%) via punch. Those obtained with the shave technique had a mean of 1.64 stages vs. 1.69 stages with the punch technique (P = 0.130). These findings suggest biopsy type does not affect Mohs surgery performance. The biopsy type of choice is the one deemed adequate for each specific case to obtain a diagnosis and tumour subtyping.

Comparison of the Basal Cell Carcinoma (BCC) Tumour Microenvironment to Other Solid Malignancies

Basal cell carcinoma (BCC) is the most common form of skin cancer, contributing to nearly a third of new cancer cases in Western countries. Most BCCs are considered low risk "routine" lesions that can either be excised through surgery or treated with chemotherapeutic agents. However, around 1-2% of BCC cases are locally aggressive, present a high risk of metastasis, and often develop chemoresistance, termed advanced BCC. There currently exists no animal model or cell line that can recapitulate advanced BCC, let alone intermediate-risk and high-risk early BCC. We previously found that aggressive BCC tumours presented a Th2 cytokine inflammation profile, mesenchymal stem cell properties, and macrophage-induced tumoral inflammation. In this study, we aimed to identify potential BCC "relatives" among solid-organ malignancies who present similar immune cell proportions in their microenvironment compositions. Using immune cell type deconvolution by CIBERSORTx, and cell type enrichment by xCell, we determined three cancers with the most similar tumour microenvironments as compared to BCC. Specifically, chromophobe renal cell carcinoma, sarcoma, and skin cutaneous melanoma presented significance in multiple cell types, namely in CD4+ T lymphocytes, gammadelta T lymphocytes, and NK cell populations. Consequently, further literature analysis was conducted to understand similarities between BCC and its "relatives", as well as investigating novel treatment targets. By identifying cancers most like BCC, we hope to propose prospective druggable pathways, as well as to gain insight on developing a reliable animal or cell line model to represent advanced BCC.

Diagnosis and management of basal cell carcinoma: interdisciplinary consensus statements of Jose R. Reyes Memorial Medical Center, a Department of Health Tertiary Hospital in Manila, Philippines.

Basal cell carcinoma (BCC) is the most common cutaneous malignancy. Multiple risk factors are associated in the development of BCC, with ultraviolet light and genetics playing major roles. The departments of dermatology, medical oncology, ophthalmology, otorhinolaryngology, head and neck surgery, plastic surgery, and radiation oncology of the Jose R. Reyes Memorial Medical Center, Manila, Philippines, have convened and formulated consensus statements on the diagnosis and management of BCC patients seen in the institution. The summary of the recommendations is: (1) Surgery is the treatment of choice for BCC. The range of margins (2-4 mm) depends on the type of BCC. (2) Mohs micrographic surgery (MMS) is indicated for high risk BCC. (3) Topical treatment with imiquimod or 5-flourouracil (5-FU) may be used for superficial BCC. (4) Destructive methods (cryotherapy, curettage and electrodessication, photodynamic therapy) may be used for low risk BCC. (5) Medical and/or radiation therapy is advised for cases where surgery is contraindicated or tumor is not amenable to surgery. Metastasis of this malignancy is rare. Follow-up, which may continue up until 2 years, is recommended for high risk BCC.

MSS08 Presentation Time: 4:20 PM: Dermoscopic Evaluation of Basal Cell Carcinomas During and After Brachytherapy

<h3>Introduction Objectives</h3> Basal cell carcinoma(BCC) is the most common malignancy of the Caucasian population. Dermoscopy is a diagnostic method that provides the bridge between clinical and pathological examination. Surface skin High Dose Rate (HDR) brachytherapy is an organ sparing treatment method used for non-surgical candidates in contemporary management of skin cancers. Literature lacks data reporting observations of dermoscopic patterns of non-melanoma skin cancers (NMSC) undergoing HDR brachytherapy. <h3>Materials and Methods</h3> Single center prospective study was conducted. Twenty three patients with high risk BCC's of facial region were treated with contact, 3D planned HDR brachytherapy with 9 fractions of 5Gy, 3 times a week. Custom made polyacrylamide surface moulds were used. Clinical and dermoscopic images were obtained before treatment and before every fraction and 6 months after treatment. 603 macroscopic and dermoscopic photographs were obtained. In every macroscopic picture 12 clinical features typical for BCC's were analyzed Dermoscopic images were searched for 61 dermoscopic neoplastic features and 31 dermoscopic non-neoplastic features. In total database of 21526 observations was analyzed by two independent dermoscopists using current diagnostic criteria. <h3>Results</h3> Univariate logistic regression showed decreasing number of clinical and pathological features with each fraction of brachytherapy. Correlation was more expressed for features typical for BCC. Older patients showed more pronounced response to treatment. After 6 months number of clinical and dermoscopic patterns typical for BCC as well as number of non neoplastic dermoscopic features is reduced, presumably due to formation of scar (Figure 1). <h3>Conclusions</h3> HDR brachytherapy decreases number of clinical and dermoscopic Basal Cell Carcinoma features. Effect is more pronounced in older patients. Medium time observation shows that effect is persistent after 6 months.

The development and validation of a decision aid to facilitate patient choice of surgery versus radiotherapy for high-risk basal cell carcinoma.

Basal cell carcinoma (BCC) is an increasingly common cancer. For high-risk BCCs, there are several treatment options, with similar efficacies. The current best practice in deciding upon a particular treatment is for a patient-centred approach. At present, there are few resources available for patients to assist their choice. This reduces patient autonomy and increases the burden on clinicians within clinic. Patient decision aids (PDAs) have been shown to increase patient autonomy and facilitate shared decision-making. Currently, there is no published PDA designed to facilitate the decision between surgical management or radiotherapy in high-risk BCCs. We developed a novel decision aid designed along the International Patient Decision Aid Standards to fill this clinical need, and evaluated its acceptance by both patients and clinicians. We describe the challenges faced at initial alpha and subsequent beta testing, and go on to validate our PDA with both the Decisional Conflict Scale and the nine-item Shared Decision Making Questionnaire (SDMQ9). We include an example of the PDA and encourage other units to modify the PDA for their own use.

A review of the evidence for Mohs micrographic surgery. Part 2: basal cell carcinoma.

Mohs micrographic surgery (MMS) is considered the gold-standard treatment for basal cell carcinoma (BCC) particularly for sites with a high-risk of incomplete excision such as the central face, for tumours with an aggressive growth pattern and consequent unpredictable subclinical extension and for recurrent tumours. However, the process is more time-consuming than for standard excision (SE), and the magnitude of benefit is uncertain. This article aims to provide a more complete picture of current evidence, including a review of cosmetic outcomes, tissue-sparing ability and cost-effectiveness of MMS. Although robust evidence is lacking, there is a large volume of observational data supporting a low recurrence rate after MMS. The risk of incomplete excision and higher recurrence rate of standard excision favours the use of MMS at high-risk sites. There is some low-certainty evidence that MMS results in a smaller defect size compared with SE, and that incomplete excision with SE results in larger defects. Larger defects may affect cosmetic outcome but there is no direct evidence that MMS improves cosmetic outcome compared with SE. There is conflicting evidence regarding the cost of MMS compared with SE, as some studies consider MMS less expensive than SE and others consider it more expensive, which may reflect the healthcare setting. A multicentre 10-year randomized controlled trial comparing MMS and SE in the treatment of high-risk BCC would be desirable, but is unlikely to be feasible or ethical. Collection of robust registry data capturing both MMS and SE outcomes would provide additional long-term outcomes.