Surgery For Basal Cell Carcinoma Research Articles

Diagnostic accuracy of autofluorescence-Raman spectroscopy for surgical margin assessment during Mohs micrographic surgery of basal cell carcinoma.

Autofluorescence (AF) - Raman spectroscopy is a technology that can detect residual basal cell carcinoma (BCC) on the resection margin of fresh surgically excised tissue specimens. The technology does not require tissue fixation, staining, labelling, or sectioning, and provides quantitative diagnosis maps of the surgical margins in 30 minutes. To determine the accuracy of the AF-Raman instrument to detect incomplete excisions of BCC during Mohs micrographic surgery, using histology as reference standard. Skin layers from 130 patients undergoing Mohs surgery at the Nottingham University Hospitals NHS Trust (September 2022 to July 2023) were investigated with the AF-Raman instrument. The layers were measured fresh, immediately after excision. The AF-Raman results and the intra-operative assessment by Mohs surgeons were compared to a post-operative consensus-derived reference produced by three dermatopathologists. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. The AF-Raman analysis was successfully completed for 125 out of the 130 layers. The AF-Raman analysis covered 91% of the specimen surface area on average, with the lowest being 87% for eyelid and the highest being 94% for forehead specimens. The AF-Raman instrument identified positive margins in 24 out of 36 BCC-positive cases, resulting in a 67% sensitivity (95% confidence intervals (CI): 49%-82%) and negative margins in 65 out of 89 BCC-negative cases, resulting in a 73% specificity (95% CI 63%-82%). Only one out of the 12 false negative cases was caused by misclassification by the AF-Raman algorithm. The other 11 false negatives cases were produced because no valid Raman signal was recorded at the location of the residual BCC due to either occlusion by blood or poor contact between tissue and cassette window. The intra-operative diagnosis by Mohs surgeons identified positive margins in 31 out of 36 BCC-positive cases, 86% sensitivity (95% CI: 70%-95%), and negative margins in 79 out of 89 BCC-negative cases, 89% specificity (95% CI: 81%-95%). This study shows that the AF-Raman instrument has potential for intra-operative microscopic assessment of surgical margins in surgery of BCC. Further improvements are required for tissue processing to ensure complete coverage of the surgical specimens. ClinicalTrials.gov ID NCT03482622.

Results of Mohs' Micrographic Surgery of Periocular Basal Cell Carcinoma: The Swedish Experience.

The Department of Ophthalmology, Sahlgrenska University Hospital, has until recently been the only eye clinic in the Nordic countries to perform Mohs' micrographic surgery of basal cell carcinoma. This has led to the practice of only the most complicated basal cell carcinomas being operated on with this technique. The purpose of this study was to present the results of these surgeries in patients with at least 5 years of follow-up. A retrospective study of all patients operated upon in 2010-2015 was performed. Data were gathered from their medical charts. Primary outcome was recurrence of basal cell carcinoma. One-hundred and sixty-seven patients were operated on. Mohs' micrographic surgery was used for tumours that were judged as highly aggressive on preoperative biopsy, had ill-defined borders, had recurred after previous surgery, or a combination of these factors. Nine recurrences (5.4% of all radical Mohs' micrographic surgeries) were diagnosed after a mean postoperative time of 37 months (4-84 months). Interestingly, all of these 9 recurrences after Mohs' micrographic surgery were in patients who had such surgery because of a recurrent basal cell carcinoma to start with. Good results can be achieved when operating on the most complicated periocular basal cell carcinomas with Mohs' micrographic surgery but special care has to be taken to ensure radical borders when operating on recurring basal cell carcinomas.

NASAL RECONSTRUCTION AFTER MOHS SURGERY: MANAGEMENT OF DEFECTS ACCCORDING TO ANATOMICAL UNITS AND DIMENSIONS

Objectives: Skin cancer frequently affects the nose, particularly in sun-exposed areas such as the ala, apex, root, and bridge. Even minor nasal lesions can pose aesthetic and psychosocial challenges for patients, necessitating nasal reconstruction tailored to anatomical units and defect size. The primary goal of reconstructive surgery is to restore the original shape, emphasizing three-dimensional space, symmetry, color, and compatibility with surrounding tissue structures. Despite numerous options for post-cancer surgery reconstruction, establishing a gold standard for nasal defect management remains elusive. Materials and Methods: A retrospective study was conducted in 41 patients following Mohs surgery for basal cell carcinoma. Defects are approached based on rhinoplasty principles, considering anatomical units, defect size, and location to select appropriate reconstruction methods. Results: Among the patients, 17 (41.5%) had nasal alar defects, 5 (12.2%) had nasal apex defects, 4 (9.8%) had nasal root defects, 7 (17.1%) had nasal bridge defects, and 9 (22%) had complex defects involving multiple anatomical units. Patients with nasal alar defects <1.5cm underwent reconstruction using the nasolabial flap, while those with larger defects (>1.5cm) underwent forehead flap reconstruction, including auricular cartilage grafts for nasal alar defects. Complex lesions (22%) were reconstructed using a combination of forehead flap and rotation or V-Y flap. Nasal root defects (7.3%) were reconstructed using the glabellar flap. Conclusion: Nasal reconstruction, employing local or regional flaps, consistently yields positive functional and aesthetic outcomes due to the similarity in color and skin flap thickness with adjacent structures. The forehead flap, with its constant blood supply, vitality, and versatile design, is particularly effective for complex nasal lesions. Received 29 June 2023Revised 27 September 2023Accepted 29 November 2023

Хирургическое лечение базалиомы внутреннего угла глазной щели с закрытием дефекта свободным лоскутом. Клинический случай

Basal cell carcinoma is a tumor of the basal layer of the skin epithelium. It occupies an intermediate position between benign and malignant tumors. It develops from atypical basal cells of the epidermis and follicular epithelium. It does not metastasize. The occurrence on the lower eyelid is about 65 %, on the medial canthus about 15 %, on the upper eyelid about 15 % and on the lateral canthus 5 % of cases. Usually the neoplasm is painless, but more invasive basal cell carcinomas with perineural germination into the tissues of the eyelid and orbit can cause pain [1, 3]. The choice method of treatment of this disease is surgical. The operation is performed under a microscope, which allows to remove the altered tissues as much as possible and correctly match the edges of the donor material. To replace the surgical defect, a type of plastic was chosen: plastic with local tissues, free skin plastic. The skin flap was taken from the upper eyelid of the fellow eye [2]. There are several types of basal cell carcinomas: nodular, flat, and superficial. The nodular form is most common. A distinctive feature in most cases is pearl shade and waxy or translucent consistency of the tumor, more noticeable on the raised edges of the neoplasm. A characteristic and important symptom is telangiectasis marked at the edges of the neoplasm [1]. Initially, a painless nodule appears on the skin gradually, the nodule spreads over the area, accompanied by formation of ulcers, due to disturbance of blood supply and turns into ulcerative-nodular form. Ulceration can bleed. Further, basal cell carcinoma turns into a flat plaque with a peeling surface, a node protruding above the surface of the skin, or into a deep ulcer that destroys the underlying tissues. With advanced forms or inadequate treatment, the tumor can grow into the lacrimal pathways, the orbit and occasionally into the cranial cavity. The sprouting of orbital tumor causes diplopia and dislocation of the eyeball. Spontaneous regression is rare [3]. There are the following types of treatment: radiation, surgical, combined, medicinal, cryogenic, laser [4, 5]. Radiation, laser, cryogenic methods of treatment are carried out in a specialized cancer center. The surgical method is based on excision within healthy tissues with the least traumatization or destruction of surrounding tissues. Excision of a part of the eyelid weakens its horizontal tension; this circumstance requires special restorative techniques to prevent scarring. The choice method of the defect closure is the method of lateral displacement, plastic with a free flap or pedicle flap [4, 5]. Key words: basal cell carcinoma; surgery of basal cell carcinoma; plastic surgery with a free flap.

Dermatosurgery - from surgical option to integral part of dermatologic therapy.

Dermatosurgery was long considered an isolated, and not always important, discipline within dermatology. As a therapeutic option, it was considered either the gold standard of first-line therapy, for example in basal cell carcinoma surgery and treatment of early-stage melanoma, or the last option, for instance in the treatment of warts. The fact that a profound change has taken place and that dermatosurgery is now an integral, equal, sometimes leading and always significant component of dermatology will be demonstrated in this review using three examples from geriatric dermatology, the treatment of hidradenitis suppurativa (acne inversa), and melanoma therapy. This review is supplemented by a section on the most important technique in dermatosurgery: microscopic (micrographic) surgery or Mohs Surgery.

The Role of Inflammatory Markers in the Differential Diagnosis of Skin Cancers

Aim: The purpose of this study was to evaluate the role of WBC count, NLR, LMR, PLR, Systemic immune-inflammation index (SII) [(platelet count X neutrophil count) \ lymphocyte count] and platelet count (Plt)×NLR in the differential diagnosis of basal cell carcinoma, squamous cell carcinoma, and malignant melanoma and to determine the effect of tumor type, prediction of lymph node metastasis at initial diagnosis and location on these inflammatory markers. Material and Method: Patients who underwent surgery for basal cell carcinoma, squamous cell carcinoma, or malignant melanoma were retrospectively screened. NLR, LMR, PLR, SII and Plt×NLR were calculated. Relationships between tumor type, prediction of lymph node metastasis at initial diagnosis, tumor localization and the inflammatory and hematological parameters of interest were investigated. Tumor location was classified as head and neck and others. Results: A total of 257 patients were included in the study. No statistically significant differences in WBC, NLR, PLR, LMR, SII or Plt×NLR were detected according to tumor location. The patients with squamous cell carcinoma had higher NLR, PRL, SII and Plt×NLR values than those with basal cell carcinoma. The risk of lymph node metastasis at the time of initial diagnosis was 10.3 times higher in patients with PLR levels of 180.7 and higher. The risk of lymph node metastasis detected at initial diagnosis was 8.9 times higher in patients with Plt×NLR of 747 and higher. The risk of lymph node metastasis detected at initial diagnosis was 7.1 times higher in patients with SII of 414 and higher. Conclusion: Inflammatory markers seem to be useful in the differential diagnosis of skin cancers and determined the risk of lymph node metastasis. However, it does not differ according to tumor localization.

Don't Mess With Tattoos? Mohs Micrographic Surgery for Basal Cell Carcinoma Within the State of Texas: Erratum.

Don't Mess With Tattoos? Mohs Micrographic Surgery for Basal Cell Carcinoma Within the State of Texas: Erratum.

Clinicopathological factors influencing the number of stages of Mohs surgery for basal cell carcinoma

BackgroundMohs Micrographic Surgery (MMS) is commonly used to treat high-risk basal cell carcinoma (BCC). ObjectivesCorrelate clinicopathologic preoperative features with the number of MMS stages (primary endpoint) and margins (secondary endpoint) required for BCC complete excision. MethodsWe retrospectively analyzed BCCs treated by MMS in a 2-year period at the study’s institution. Variables studied included the patient gender, age, immune status, lesion size, location, if it was a primary, recurrent, or persistent tumor, histopathologic characteristics, number of surgical stages, and amount of tissue excised. Results116 BCCs were included. The majority (61.2%, n = 71) required a single-stage surgery for complete clearance, requiring a final margins of 3.11 ± 2.35 mm. Statistically significant differences between locations in different high-risk areas (periocular, perioral, nose, ear) and the number of MMS stages required for complete excision (p = 0.025) were found, with periocular tumours requiring the highest mean of stages (2.29 ± 0.95). An aggressive histopathology significantly influenced the number of MMS stages (p = 0.012). Any significant relation between clinicopathological features and variation in the final surgical margins was found, just certain tendencies (male patients, persistent tumor, periocular location, and high-risk histopathological tumors required larger margins). Neither patient age or tumor dimension correlated significantly with both number of MMS stages and final surgical margins. Study limitationsLimitations of this study include its single-center nature with a small sample size, which limits the value of conclusions. ConclusionMain factors related to a greater number of MMS stages were periocular location and high-risk histopathological subtype of the tumor.

PATIENT AND OBSERVER SCAR ASSESSMENT FOLLOWING BASAL CELL CARCINOMA SURGERY: MULTICENTER QUASI EXPERIMENTAL STUDY

Objective: To assess patient and observer reported scar quality after Basal cell carcinoma surgery of face using the Patient and Observer Scar Assessment Scale (POSAS).
 Study Design: Quasi experimental study.
 Place and Duration of Study: Dermatology Department, Tertiary Care Hospitals at Multan and Karachi and Plastic Surgery Department, Tertiary Care Hospital Multan, from Apr to Sep 2020.
 Methodology: Patients with basal cell carcinoma that full filled inclusion and exclusion criteria were enrolled by consecutive sampling technique at Dermatology and Plastic Surgery Department after informed consent. Surgical excision was followed by reconstruction of defect either by direct closure or by rotation or advancement flap. Surgical scar was assessed independently at 8 weeks by POSAS. Data was analyzed with SPSS-23.
 Results: A total of 27 patients were enrolled in study. There were 11 (37.9%) males and 16 (59.25%) females between ages of 45-70 years. Basal cell carcinoma was located on cheek in 15 (55.5%), nose in 9 (33.3%), temple 2 (7.4%) and forehead 1 (3.7%) cases. Direct closure was performed in 6 (22.2%), rotation flaps in 10 (40.7%), and advancement flaps in 11 (40.7%) cases. Mean score of observer opinion about surgical scar between different surgical techniques was not statistically significant (p=0.191). How-ever, mean score of patient opinion of scar between different surgical techniques was statistically significant (p=0.032).
 Conclusion: POSAS is a valid tool for scar evaluation by patient and observer-reported scar qualities after Basal cell carcinoma surgery.

Combined CO2 and dye laser technique in the treatment of outcomes due to flap necrosis after surgery for basal cell carcinoma on the nose

AbstractBackground and ObjectiveBasal cell carcinoma (BCC) is the most frequent cutaneous cancer worldwide, and the nasal area is the most commonly affected region. Skin flaps are usually performed to achieve radical results, but various adverse events often occur. The necrosis of the skin flap is one of the most frequently observed, resulting in scars and anti‐aesthetic outcomes. Ablative and non‐ablative lasers have been proposed to improve scars resulting from surgical failure and skin flap necrosis.Study Design/Materials and MethodsThis study aims to evaluate a new laser protocol combining ablative CO2‐laser with flashlamp pulsed dye laser for the treatment of nasal scars resulting from the necrosis of flap that occurred after surgery. Twelve patients were enrolled in the study, and a total of five laser sessions were planned, spaced from 14 days to 1 month apart.ResultsSeven out of 12 patients underwent all the five laser sessions planned, while 5/12 patients achieved optimal cosmetic results within the fourth session. Eighty percent of the patients reported good/optimal cosmetic results, and no significant side effects were observed during the study.ConclusionCombining fractionated CO2 laser with flashlamp pulsed dye laser represents a new effective modality for treating skin flap necrosis after BBC removal, representing a valid alternative to other surgical procedures.

Aesthetic Unit-Based Reconstruction of Facial Defects with Local Flaps after Surgical Excision of Basal Cell Carcinoma

Background: Basal cell carcinoma (BCC) represents themost common type of facial skin cancer in Middle East andEgypt. It rarely metastasizes, but because of its locally destructivenature, it can cause high morbidity. Reconstructionby local flap after surgical excision depends on the size ofthe defect and the affected facial aesthetic unit.Aim: To reveal the prevalence of facial BCC, relation ofits site to facial aesthetic units and type of local flaps usedfor reconstruction per units.Patients and Methods: A retrospective study was conductedon 80 patients with facial BCC that admitted to the outpatientclinic, Plastic Surgery Department, Qena University Hospitalfrom June 2018 to May 2020 (2 years duration). Only earlystageand primary tumors were included. Statistical analysis:Data was analyzed using the Statistical Package for SocialSciences (SPSS) version 24. A p-value significant.Results: 80 patients with facial basal cell carcinoma (BCC)were collected from medical records. 45 (56.25%) patientswere males and 35 (43.75%) patients were females (M:F =1.3:1). Ages ranged from 52-78 years old (SD = 65±13).Nodular subtype was the most common clinical type of BCCand presented in 45 (56.25%) patients. Nasal unit was themost common site in 18 (22.5%) patients. The most randomflap applied was the rhomboid (Limberg) flap in 15 cases.The most axial flap used was the nasolabial flap in 9 cases.Complications (6 cases, 7.5%) included: Wound dehiscencein 3 cases, infection in 2 cases and skin slough in 1 case. TheSCAR scale score result ranged from 0-2 score.Conclusion: Facial defects reconstruction after surgeryfor basal cell carcinoma is a complex endeavor that requirescareful consideration. There are many different local flapsavailable depending on the particular facial subunit thatrequires reconstruction. Careful recognition of the principlesof the facial subunits will equip the surgeon to achieve thebest possible functional and aesthetic outcomes.

Cover Image

Cover Illustration: The cover image is based on the Concise Communication Whole-slide margin control through deep learning in Mohs micrographic surgery for basal cell carcinoma by Mike C.M. van Zon et al., https://doi.org/10.1111/exd.14306.

Clinical integration of fast Raman spectroscopy for Mohs micrographic surgery of basal cell carcinoma.

We present the first clinical integration of a prototype device based on integrated auto-fluorescence imaging and Raman spectroscopy (Fast Raman device) for intra-operative assessment of surgical margins during Mohs micrographic surgery of basal cell carcinoma (BCC). Fresh skin specimens from 112 patients were used to optimise the tissue pre-processing and the Fast Raman algorithms to enable an analysis of complete Mohs layers within 30 minutes. The optimisation allowed >95% of the resection surface area to be investigated (including the deep and epidermal margins). The Fast Raman device was then used to analyse skin layers excised from the most relevant anatomical sites (nose, temple, eyelid, cheek, forehead, eyebrow and lip) and to detect the three main types of BCC (nodular, superficial and infiltrative). These results suggest that the Fast Raman technique is a promising tool to provide an objective diagnosis “tumour clear yes/no” during Mohs surgery of BCC. This clinical integration study is a key step towards a larger scale diagnosis test accuracy study to reliably determine the sensitivity and specificity in a clinical setting.

Whole-slide margin control through deep learning in Mohs micrographic surgery for basal cell carcinoma.

Basal cell carcinoma (BCC) is the most common type of skin cancer with incidence rates rising each year. Mohs micrographic surgery (MMS) is most often chosen as treatment for BCC on the face for which each frozen section has to be histologically analysed to ensure complete tumor removal. This causes a heavy burden on health economics. To develop and evaluate a deep learning model for the automated detection of BCC-negative slides and classification of BCC in histopathology slides of MMS based on whole-slide image (WSI). Two deep learning models were developed on the basis of 171 digitized H&E frozen slides from 70 different patients. The first model had a U-Net architecture and was used for the segmentation of BCC. A subsequent convolutional neural network used the segmentation to classify the whole slide as BCC or BCC-negative. Quantitative evaluation over manually labelled ground truth data resulted in a Dice score of 0.66 for the segmentation of BCC and an area under the receiver operating characteristic curve (AUC) of 0.90 for the slide-level classification. This study demonstrates that through WSIs deep learning models may be a feasible option to improve the clinical workflow and reduce costs in histological analysis of BCC in MMS.

Modified cheek advancement flap for medial lower eyelid, nasal sidewall and infraorbital cheek reconstruction: a case series

ABSTRACTAim: To describe and evaluate surgical outcomes of the Modified Cheek Advancement Flap (MCAF) to reconstruct defects involving medial lower eyelid, nasal sidewall and infraorbital cheek following Mohs micrographic surgery for basal cell carcinoma (BCC).Materials and Methods: All patients who underwent MCAF between 2012 and 2018 under the care of a single surgeon (LCA) were identified. The technique described in this report is a significant modification of the traditional cheek advancement flap. The MCAF was undertaken without subciliary or infraorbital incisions, less extensive dissection and use of flap advancement rather than rotation. A retrospective chart review was completed using a pro-forma which included risk factors for flap failure, early and late complications and additional reconstructive procedures. Patient satisfaction was rated using a five-point Likert-type scale.Results: 42 patients underwent the MCAF. Mean follow up was 28.4 months (±19.9 months). Early complications were found in 11.9% of the patients and resolved completely within the first four post-operative weeks. There were no long term complications secondary to the reconstruction. No lower eyelid ectropion was noted. 78.6% of the patients cited they were ‘extremely satisfied’ with the final cosmetic outcome.Conclusion: The MCAF proves a valuable and safe option in periocular reconstructive surgery with excellent cosmetic results and no post-operative ectropion. The necessity for eyelid tightening as part of the reconstructive process should encourage oculoplastic surgeons to use the MCAF when reconstructing defects involving medial lower eyelid, infraorbital cheek and nasal sidewall.

Pull-through inferiorly based island pedicle flap for a conchal bowl defect

A 39-year-old woman underwent Mohs micrographic surgery for basal cell carcinoma in the conchal bowl (Fig 1), saving cartilage and perichondrium. Adequate reconstruction of this area requires preservation of shape, supportive function, and symmetry. Commonly used reconstructive options include second-intention healing, composite grafts, and skin flaps.

Improved cosmesis using optical-coherence tomographic imaging as a means to avoid diagnostic biopsies before Mohs micrographic surgery of basal cell carcinoma: A pilot study

Improved cosmesis using optical-coherence tomographic imaging as a means to avoid diagnostic biopsies before Mohs micrographic surgery of basal cell carcinoma: A pilot study

Nasal reconstruction of multiple nasal subunits skin defect using an “island flap” after oncological surgery for basal cell carcinoma

Nasal reconstruction of multiple nasal subunits skin defect using an “island flap” after oncological surgery for basal cell carcinoma

Utility of Intraoperative Frozen Section for Basal Cell Carcinoma of the Head and Neck for Margin Clearance

Background: Surgical excision is the treatment of choice for basal cell carcinoma. Complete removal is the key to cure.Objective: To determine the utility of intraoperative frozen section in basal cell carcinoma surgery of high risk cases on the head and neck to achieve margin clearance.Study Design: Prospective descriptive study Place and duration of study: MH Rawalpindi, Army Medical College – February 2015 – May 2018.Methodology: All patients of high risk basal cell carcinoma, on the head and neck, undergoing excision and repair after intraoperative frozen section were included in the study. In addition to demographic profile of the patient, site and clinical type of the lesions were recorded. Histopathology report indicating margin clearance was noted.Results: A total of 96 patients with basal cell carcinoma were operated upon with intraoperative frozen section. Five patients had recurrent basal cell carcinoma whereas 91 had primary lesions. Fifty four (56.3%) patients showed all margins clear of tumor on frozen section whereas 42 (43.8%) patients required further excision of one or more margins based on the result of frozen section.Conclusion: Intra operative frozen section helped conserve skin in addition to saving 42 (43.8%) patients from a second surgical procedure.

A Diagnostic Accuracy Comparison Between Tzanck Smear Test and Frozen Section Examination in Basal Cell Carcinoma

Background: Mohs’ micrographic surgery is a suitable treatment and frozen section (FS) examination is the “gold standard” of surgical margins in tumoral skins. This study compared the diagnostic accuracy between the Tzanck smear test (TST) and frozen section (FS) examination for margin control in surgery for basal cell carcinoma (BCC). Methods: Fifty-nine patients with basal cell carcinoma (BCC) were included. The tumor was excised and the Tzanck smear test (TST) was taken for Papanicolaou staining (Pap staining) and reconfirmation of tumoral cells. Then a dermatologist took margins of tumoral mass. TST was taken from the margins and sent to the dermatopathologist for Pap staining. After dying, each marked fragment was sectioned separately with cryostat. Finally, diagnostic accuracy of TST compared with FS examination was analyzed. Results: The sensitivity and specificity of TST for the evaluation of margin were 0.28 and 0.95; whereas positive and negative predictive values were 0.54 and 0.85, respectively. Positive and negative likelihood values were 5.36 and 0.76, respectively. Diagnostic accuracy was 0.82. The kappa coefficient of agreement between the two methods was 0.28 (P < 0.001). Conclusions: Positive likelihood value and specificity of TST for the evaluation of margin were high; therefore, TST can be suitable in the diagnosis of BCC, but due to low sensitivity and kappa coefficient, TST alone cannot be a suitable alternative method compared to the FS examination for margin control in BCC.