7.3 Optimal surgical technique for the treatment of basal cell carcinoma

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Systematic review evidence

What factors need to be considered when determining the optimal surgical technique for those with basal cell carcinoma?

A systematic review was undertaken to answer this clinical question. The search strategy, inclusion and exclusion criteria, and quality assessment are described in detail in the Technical report.

A total of 24 studies were identified that reported on outcomes of surgical treatment for basal cell carcinoma (BCC) according to various risk factors. These included one randomised controlled trial (RCT),[1][2] two case control studies,[3][4] one prospective cohort study,[5][6][7] five retrospective cohort studies[8][9][10][11][12] and 15 case series.[13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]

One prospective cohort study[7] and two retrospective cohort studies[12][17] had a moderate risk of bias. Both RCTs[1][2] and all remaining studies had a high risk of bias.

Surgical techniques included surgical excision, Mohs micrographic surgery (MMS), and electrodessication and curettage.

Reported outcomes included completeness of excision, recurrence rates, and cure rates.

Recurrence rates

Studies reported recurrence rates for BCC according to the following treatment-related factors:

Studies also reported recurrence rates for BCC according to a range of tumour-related factors:

No RCT investigated the relationship between excision margins and recurrence rates. However, some studies found associations between recurrence rate and histologic subtype or tumour location, which suggest that wider surgical margins and more judicious follow-up may be necessary when excising BCCs with higher-risk features such as aggressive histological subtype, the presence of pigment, unfavourable anatomical sites (e.g. H-zonethe area of the face that includes the central face, eyelids, eyebrows, periorbital, nose, lips, chin, mandible, preauricular and postauricular skin and sulci, temple, and ear of the face).

Surgical margins of 3mm were used in the RCT comparing surgical excision with Mohs micrographic surgery (MMS) for BCCs of the face.[1][2] For primary BCCs, this study reported 10-year recurrence rates of 4.4% after MMS and 12.2% after surgical excision (statistically nonsignificant difference).[van Loo et al 2014] All recurrences appeared on the H-zonethe area of the face that includes the central face, eyelids, eyebrows, periorbital, nose, lips, chin, mandible, preauricular and postauricular skin and sulci, temple, and ear, and a high proportion (56%) of recurrences occurred after more than 5 years.

Overall aggressive histologic subtypes were found to be more likely to recur than non-aggressive types.[8][2][3][7][12][14][21][23][25][27] Tumours on the nose eyes lips and ears were more likely to recur than elsewhere on the face or body.[8][5][1][7][14][19][20][6]

Based on weak evidence (small non-randomised studies with inconsistent results), completeness of excision appears to be related to tumour histology[9][10][13][18][21][22] and to location.[9][10][16][17][21][22][26]

Evidence from studies examining the relationship between excision margins and recurrence rate was inconsistent and of poor quality,[4][17][18][24] as was evidence from studies examining the relationship between closure technique and recurrence rate.[9]

Evidence summary and recommendations

Evidence summary Level References
Basal cell carcinoma subtypes significantly associated with recurrence were aggressive, sclerodermiform and non-pigmented subtypes as well as those with infiltrative, metatypic-basaloid squamous cell-pleomorphic patterns, compared with less aggressive, nodular, adenoid, superficial and pigmented subtypes and subtypes with pilar differentiation. II, III-2, III-3, IV [2], [3], [7], [8], [12], [14], [21], [23], [25], [27]
Basal cell carcinomas on the face and H-zonethe area of the face that includes the central face, eyelids, eyebrows, periorbital, nose, lips, chin, mandible, preauricular and postauricular skin and sulci, temple, and ear of the face were generally more likely to recur after surgical excision than those on the rest of the body, forehead, cheek and temple. However, only tumours located on the nose, lips, eyes and superior eyelid were found to have significantly higher rates of recurrence than those on the forehead, check, temple, medial and lateral canthus and lower eyelid. II, III-2, III-3, IV [1], [5], [6], [7], [11], [8], [14], [19], [20]
There were no difference in recurrence rates between surgical margins 3,4 and ≥5mm on the nose. However, excision sizes >1.75cm2 were associated with significantly higher recurrence than excision sizes <1.75cm2 on the eyelid. IV [15], [18]
No significant difference was found in the mean size of tumours which did and did not recur. II, III-3 [8], [5]
BCCs that had invaded deep structures were more likely to recur than BCCs that had invaded into the reticular dermis, hypodermis and papillary dermis. IV [25]
Incomplete excision was generally found to be greater on the face and head than the rest of the body (trunk, legs and arms), and on the nose, eyelid and ears than the rest of the face and head. III-2, III-3, IV [9], [10], [16], [17], [21], [22], [26]
Rates of incomplete excisions were found to be higher with undefined and mixed histology, fibrosing, adenoid, and non-pigmented BCCs than pigmented and superficial BCCs.

Rates of incomplete excision for nodular and infiltrative BCCs were mixed.

No significant difference in rates of incomplete excision was found between groups with some aggressive types of BCC (morpheaform [sclerosingscar-like (morphoeic)], infiltrative, nodulo-infiltrative) and non-aggressive (nodular, superficial, pagetoid) BCCs.

III-2, III-3, IV [9], [10], [13], [18], [21], [22]
There was no significant association between completeness of excision for BCCs when comparing margin widths of ≤2mm, 3mm, 4mm, and ≥5mm.

There was no significant association between completeness of excision comparing BCCs excised with 2mm and 4mm margins versus inspected healthy margins.

Numerically higher rates of complete excision were reported for BCCs with 4-mm margins versus 3-mm and 5-mm margins, but these results were not statistically analysed.

III-2, IV [4], [17], [18], [24]
BCCs that stopped before the reticular dermis had significantly higher rates of complete excision than those that had spread to the hypodermis, muscle, cartilage, bone and nerve. III-3 [9]
There was no significant associated between mean diameter of tumours which were completely excised versus incompletely excised. However tumour size >3cm was associated with more complete excisions than <0.5cm. III-2, III-3 [9], [10]
The 5-year cure rate was over 97% for BCCs surgically excised on the face in areas such as the nose, eyelid, temple, forehead, and cheek. IV [19], [27]
Evidence-based recommendationQuestion mark transparent.png Grade
EBR 7.3.1. Patients with high-risk recurrent facial basal cell carcinomas should be offered wide surgical excision or Mohs micrographic surgery. Regular follow-up should be provided.
C
Evidence-based recommendationQuestion mark transparent.png Grade
EBR 7.3.2. Non-surgical treatment modalities can be considered for patients with basal cell carcinomas assessed to have a low risk of recurrence based on favourable histological type (e.g. superficial or nodular types) and favourable anatomic locations (away from unique structures).
C

Notes on the recommendations

Follow-up of patients after treatment is individually tailored according to patient factors, tumour factors, anatomic site and the perceived adequacy of treatment.

Current literature supports the use of wide surgical excision or Mohs surgery for primary high-risk facial BCCs.[1][2] The RCT[1][2] reported no significant difference between 10-year recurrence rates for primary BCCs treated by MMS or surgical excision. For recurrent BCCs, however, MMS achieved higher 10-year cure rates than surgical excision.[2]

Recent US guidelines for the management of BCC[Bichakjian et al 2018] recommend surgical excision for low-risk primary BCCs and selected high-risk BCCs, but make a stronger recommendation for MMS in high-risk tumours (defined according to National Comprehensive Cancer Network stratification[ref] to include all H-zonethe area of the face that includes the central face, eyelids, eyebrows, periorbital, nose, lips, chin, mandible, preauricular and postauricular skin and sulci, temple, and ear facial tumours as well as tumours that are large, poorly defined, recurrent, showing aggressive growth pattern or perineural invasion, at radiation therapy sites, or in immunosuppressed patients). The US working group based its recommendation for MMS in both primary and recurrent BCC mainly on the only available RCT,[1][2] but noted that ‘these findings cannot necessarily be extrapolated beyond the scope of the study population with facial BCC.’ The US working group further noted that the lack of availability of tissue blocks for molecular testing or further histological examination is a limitation of MMS, and suggested that this limitation should be minimised by careful selection of MMS candidates based on initial biopsy results.

Our recommendation was made after considering these same limitations, as well as the availability of MMS in Australia. MMS has a statistically significant advantage for high risk recurrent facial BCC, but not for primary at this stage.[2]

See also: Criteria for choosing Mohs micrographic surgery in preference to other surgical techniques.


Appendices

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References

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