Histographic Surgery: Accuracy of Visual Assessment of the Margins of Basal‐Cell Epithelioma

Burg, Günter; Hirsch, Rolf D.; Konz, Birger; Braun‐Falco, Otto

doi:10.1111/j.1524-4725.1975.tb00089.x

Cited by 149 publications

(79 citation statements)

References 11 publications

(12 reference statements)

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“…3 The clinically visible tumor surface may only represent one fifth of its local microscopic invasion. 4 Therefore, identification of high-risk lesions with extensive subclinical spread can help determine optimal treatment and can significantly reduce morbidity and cost.…”

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confidence: 99%

Predictors of Extensive Subclinical Spread in Nonmelanoma Skin Cancer Treated With Mohs Micrographic Surgery

Batra¹

2002

Arch Dermatol

158

130

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Background: In nonmelanoma skin cancer, the clinically visible portion may represent a small fraction of microscopic tumor spread. Previous studies have examined individual risk factors for subclinical spread based on patient and tumor characteristics. However, these risk factors have not been prioritized or studied in combination.Objective: To identify the most predictive risk factors for extensive subclinical tumor spread.Design: Retrospective analysis of 1131 Mohs micrographic surgical cases. Variables analyzed included patient age, sex, and immune status and lesion size, location, histologic subtype, and recurrence. Logistic regression was applied to identify important combinations of tumor characteristics and to quantify relative odds of spread.Setting: Academic referral center.Patients: Consecutive sample of all referred patients treated by a single Mohs micrographic surgeon in a 3-year period.Main Outcome Measure: Number of Mohs micrographic surgical layers required to clear a tumor, with 3 or more layers defined as extensive subclinical spread.Results: The highest-risk tumors, with odds ratios greater than 6.0, were basosquamous and morpheaform basal cell carcinoma (BCC) on the nose, morpheaform BCC on the cheek, and those with a preoperative size greater than 25 mm. Other important risk factors were recurrent and nodular BCC on the nose; location on the eyelid, temple, or ear helix; neck tumors and recurrent BCC in men; and tumor size greater than 10 mm. Patients younger than 35 years were at lower risk. Increasing age and immunocompromise were not significant predictors. Conclusion:Identification of lesions likely to exhibit extensive subclinical spread can help guide management to ensure complete tumor eradication and thereby reduce the risk of recurrence and its associated morbidity and cost.

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confidence: 99%

Predictors of Extensive Subclinical Spread in Nonmelanoma Skin Cancer Treated With Mohs Micrographic Surgery

Batra¹

2002

Arch Dermatol

158

130

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“…This technique assumes tumour growth only follows a perfectly spherical or elliptical pattern and may lead to false-negative results ( Figure 5). Research data from studies examining subclinical extension using microscopic control of complete lateral and deep margins has shown that an asymmetrical subclinical growth pattern with one or multiple extensions appears to characterize the majority of BCCs (24)(25)(26). Standard frozen section techniques have been found to be accurate in only 72% of cases (27).…”

Section: Discussionmentioning

confidence: 99%

A reliable frozen section technique for basal cell carcinomas of the head and neck

Menesi¹,

Buchel²,

Hayakawa³

2014

CAN J PLAST SURG

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Basal cell carcinoma (BCC) is the most common skin cancer worldwide and represents 75% of cutaneous malignancies (1). The mortality rate from BCCs is <1% and metastases rarely occur (0.0028% to 0.5%) (2-6). Achieving clear margins, particularly with the more aggressive histological subtypes of BCC and in recurrent tumours, can prove challenging. In these scenarios, the visible clinical margin frequently underestimates the true extent of the tumour. This phenomenon is often referred to as subclinical tumour growth with fingerlike extensions. It is particularly common in the danger zone of the face (H zone), where BCCs often behave more aggressively and recur more frequently (7,8).Before reconstruction, it is imperative that the entire BCC be removed with negative pathological margins. Incomplete resection of primary and recurrent tumours can lead to substantial morbidity and even mortality (9). The majority of BCCs can be treated using standard techniques including conventional surgical excision, curettage, cryotherapy and radiotherapy. The recurrence rates for each of these techniques has been reported to be 3% to 42% following surgical excision (10-12), 3% to 9% with curettage (13,14), 4% to 17% following cryotherapy (10) and 7% to 10% after radiation (15).Mohs micrographic surgery (MMS) or frozen section have been recommended for difficult tumours such as recurrent tumours, tumours located in anatomically sensitive areas, aggressive histological subtypes, perineural invasion or large tumours >2 cm in size (7). Cure rates with MMS has proven better than with other treatment modalities, with low overall five-year recurrence rates of 0.6% to 3% for primary BCC, and 6% to 10% for recurrent . Disadvantages of MMS include the fact that it can be very time consuming, expensive and the reconstruction may be deferred if the Mohs surgeon is not comfortable with more involved reconstructive procedures.We evaluated the effectiveness of a surgeon-directed 'en face' frozen section technique that immediately evaluates the entire peripheral and deep margins during BCC resection and potentially offers a more efficient and equally effective alternative to MMS. METHODS PatientsThe study group comprised 50 patients who were treated by a single plastic surgeon (TH) in a tertiary centre. Fifty-three BCCs were evaluated. All tumours excised from the face over a five-year period (2002 to 2006) were retrospectively reviewed. The indications for 'en face' frozen section were recurrent tumours, tumours located in anatomically sensitive areas, aggressive histological subtypes, perineural invasion or large tumours >2 cm. The 'en face' method is a technique that permits examination of the entire tumour margin (20). The sections for the 'en face' method are cut very thin to enable maximal tissue preservation. Basal cell carcinomas (BCCs) of the head and neck treated by conventional techniques of surgical excision, curettage, cryotherapy and radiation therapy have recurrence rates of up to 42%. Mohs micrographic surgery (MMS) decreases the r...

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“…In our study, excisions were performed 1 mm beyond the 3-mm margin of treatment, and all excisional margins were negative, so a 4-mm margin of treatment beyond the lesion would have been sufficient for all skin cancers in our series. Larger BCCs and SCCs (Ͼ2 cm) are likely to have a greater radius of subclinical extension, 31,33,36 and greater treatment margins are recommended.…”

Section: Commentmentioning

confidence: 99%

“…Current recommendations for excisional margins for primary nonmorphea-form BCC range from 2 to 5 mm. [30][31][32][33][34][35][36] Wolf and Zitelli 33 demonstrated subclinical extension that was sufficiently excised using 4-mm margins in 95% of BCCs smaller than 2 cm. No data specifically address subclinical extension in superficial BCC.…”

Section: Commentmentioning

confidence: 99%

Treatment of Superficial Basal Cell Carcinoma and Squamous Cell Carcinoma In Situ With a High-Energy Pulsed Carbon Dioxide Laser

Humphreys¹,

Malhotra²,

Scharf³

et al. 1998

Arch Dermatol

106

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Histographic Surgery: Accuracy of Visual Assessment of the Margins of Basal‐Cell Epithelioma

Cited by 149 publications

References 11 publications

Predictors of Extensive Subclinical Spread in Nonmelanoma Skin Cancer Treated With Mohs Micrographic Surgery

Predictors of Extensive Subclinical Spread in Nonmelanoma Skin Cancer Treated With Mohs Micrographic Surgery

A reliable frozen section technique for basal cell carcinomas of the head and neck

Treatment of Superficial Basal Cell Carcinoma and Squamous Cell Carcinoma In Situ With a High-Energy Pulsed Carbon Dioxide Laser

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