Dermoscopic Findings in the Presurgical Evaluation of Basal Cell Carcinoma. A Prospective Study

Exploring the role of surgical margins and reoperation in basal cell carcinoma recurrence: a study of 3036 cases

INTRODUCTION

Basal cell carcinoma (BCC) is the most common type of skin cancer globally, with its prevalence increasing due to chronic ultraviolet (UV) radiation exposure. Although surgical excision remains the cornerstone of treatment, achieving optimal outcomes requires a careful balance between complete tumor removal and the preservation of cosmetic appearance.

OBJECTIVE

This study aims to investigate the relationship between excision margins, reoperation rates, and BCC recurrence through a retrospective analysis of 3036 surgical excisions.

METHODS

Conducted at the Department of Plastic Surgery in Trieste, Italy, this study includes data from 2037 patients treated between 2014 and 2018. Excision procedures adhered to standardized hospital protocols. Tumor characteristics, excision margins, and involved anatomical sites were analyzed.

RESULTS

The study demonstrated an equal gender distribution (51.02% women), with the nodular subtype (45.85%) being the most common. The head was the most frequently affected site (54.74%). A complete excision rate of 93.3% was achieved, but incomplete excisions were more common in head and neck locations and certain histological subtypes. Surgical reinterventions were primarily performed for high-risk BCCs, significantly reducing recurrence rates (0.52%).

CONCLUSION

Reoperation, especially for high-risk BCCs, should be prioritized over conservative management to minimize recurrence. Narrow excision margins were associated with higher recurrence rates, highlighting the importance of adequate margin clearance. This study enhances understanding of the complex interplay between excision techniques, reoperation, and long-term outcomes in BCC management.

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.

European consensus-based interdisciplinary guideline for diagnosis and treatment of basal cell carcinoma-update 2023

Basal cell carcinoma (BCC) is the most common malignant tumour in white populations. Multidisciplinary experts from European Association of Dermato-Oncology (EADO), European Dermatology Forum, European Society for Radiotherapy and Oncology (ESTRO), Union Européenne des Médecins Spécialistes, and the European Academy of Dermatology and Venereology developed updated recommendations on diagnosis and treatment of BCC. BCCs were categorised into 'easy-to-treat' (common) and 'difficult-to-treat' according to the new EADO clinical classification. Diagnosis is based on clinico-dermatoscopic features, although histopathological confirmation is mandatory in equivocal lesions. The first-line treatment of BCC is complete surgery. Micrographically controlled surgery shall be offered in high-risk and recurrent BCC, and BCC located on critical anatomical sites. Topical therapies and destructive approaches can be considered in patients with low-risk superficial BCC. Photodynamic therapy is an effective treatment for superficial and low-risk nodular BCCs. Management of 'difficult-to-treat' BCCs should be discussed by a multidisciplinary tumour board. Hedgehog inhibitors (HHIs), vismodegib or sonidegib, should be offered to patients with locally advanced and metastatic BCC. Immunotherapy with anti-PD1 antibodies (cemiplimab) is a second-line treatment in patients with a progression of disease, contraindication, or intolerance to HHI therapy. Radiotherapy represents a valid alternative in patients who are not candidates for or decline surgery, especially elderly patients. Electrochemotherapy may be offered when surgery or radiotherapy is contraindicated. In Gorlin patients, regular skin examinations are required to diagnose and treat BCCs at an early stage. Long-term follow-up is recommended in patients with high-risk BCC, multiple BCCs, and Gorlin syndrome.

Non-invasive imaging techniques in presurgical margin assessment of basal cell carcinoma: Current evidence

BACKGROUND

The diagnosis of basal cell carcinoma (BCC) is based on clinical and dermoscopical features. In uncertain cases, innovative imaging techniques, such as reflectance confocal microscopy (RCM) and optical coherence tomography (OCT), have been used. The main limitation of these techniques is the inability to study deep margins. HFUS (high-frequency ultrasound) and the most recent UHFUS (ultra-high-frequency ultrasound) have been used in various applications in dermatology, but they are not yet routinely used in the diagnosis of BCC. A key point in clinical practice is to find an imaging technique that can help to reduce post-surgical recurrences with a careful presurgical assessment of the lesional margins. This technique should show high sensitivity, specificity, reproducibility and simplicity of execution. This concept is very important for the optimal management of patients who are often elderly and have many comorbidities. The aim of the paper is to analyse the characteristics of current imaging techniques and the studies in the literature on this topic.

MATERIALS AND METHODS

The authors independently searched the MEDLINE, PubMed, Embase, Scopus, ScienceDirect and Cochrane Library databases for studies looking for non-invasive imaging techniques for the presurgical margin assessment of BCC.

RESULTS

Preoperative study of the BCC subtype can help to obtain a complete excision with free margins. Different non-invasive imaging techniques have been studied for in vivo evaluation of tumour margins, comparing the histologic evaluation with a radical surgery. The possibility to study the lateral and deep margins would allow a reduction of recurrences and sparing of healthy tissue.

CONCLUSION

HFUS and UHFUS represent the most promising, non-invasive techniques for the pre-operative study of BCC facilitating the characterization of vascularization, deep lateral margins and high-risk subtypes, although they are limited by insufficient literature unlike RCM and OCT.

Design and Validation of a Handheld Optical Polarization Imager for Preoperative Delineation of Basal Cell Carcinoma

Simple Summary

Skin cancer is the most common malignancy in humans. The goal of this study was to design, implement, and clinically test a novel handheld optical polarization imaging (OPI) system for rapid and noninvasive detection of basal cell carcinoma (BCC) margins. The device is compact, lightweight, and can be operated with minimal training. To validate the handheld imager, 10 subjects with biopsy-confirmed BCC were imaged prior to Mohs surgery. The optical images were processed using a spectral encoding method to increase the accuracy of the tumor boundary delineation. Preoperative margin assessment results from the OPI were compared to the surgeon’s clinical evaluation and to the gold standard of histopathology. Our findings indicate that OPI may be a valuable tool for optimizing surgical treatment of skin cancer.

Abstract

Background: Accurate removal of basal cell carcinoma (BCC) is challenging due to the subtle contrast between cancerous and normal skin. A method aiding with preoperative delineation of BCC margins would be valuable. The aim of this study was to implement and clinically validate a novel handheld optical polarization imaging (OPI) device for rapid, noninvasive, in vivo assessment of skin cancer margins. Methods: The handheld imager was designed, built, and tested. For clinical validation, 10 subjects with biopsy-confirmed BCC were imaged. Presumable cancer margins were marked by the study surgeon. The optical images were spectrally encoded to mitigate the impact of endogenous skin chromophores. The results of OPI and of the surgeon’s preoperative visual assessment were compared to clinical intraoperative histopathology. Results: As compared to the previous prototype, the handheld imager incorporates automated image processing and has 10-times shorter acquisition times. It is twice as light and provides twice as large a field of view. Clinical validation demonstrated that margin assessments using OPI were more accurate than visual assessment by the surgeon. The images were in good correlation with histology in 9 out of 10 cases. Conclusions: Handheld OPI could improve the outcomes of skin cancer treatments without impairing clinical workflows.

Basal Cell Carcinoma Treated with High Dose Rate (HDR) Brachytherapy-Early Evaluation of Clinical and Dermoscopic Patterns during Irradiation

Simple Summary

Basal cell carcinoma (BCC) is the most frequent malignancy of the Caucasian population. High dose rate (HDR) brachytherapy is a re-emerging treatment method for various skin cancers. Dermoscopy is an acknowledged and widely used diagnostic tool providing the bridge between histopathology and clinical examination. Current literature lacks data reporting on the dermoscopic observation of basal cell carcinomas undergoing brachytherapy. In this article, the authors describe clinical and dermoscopic patterns of basal cell carcinomas from 23 patients treated with HDR brachytherapy, and analyse the evolution of BCC structures.

Abstract

Basal cell carcinoma (BCC) is the most frequent malignancy of the Caucasian population. Dermoscopy is an established diagnostic method providing 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. This prospective study aimed to observe clinical and dermoscopic features and their evolution in 23 patients with pathologically confirmed BCC that have been treated with HDR brachytherapy. In all cases, custom-made surface moulds were used. HDR brachytherapy was performed with 192Ir, dose 45Gy was delivered to the tumour in nine fractions of 5Gy, three times a week. The evolution of clinical and dermoscopic features was followed up at the beginning of treatment, and on the day of every fraction (t1–t9). Dermoscopic evaluation of neoplastic and non-neoplastic structures was based on current diagnostic criteria according to current literature. Univariate logistic regression showed a decreasing number of clinical and pathological features of basal cell carcinoma with every treatment fraction. The effect was more strongly pronounced for cancer-related dermoscopic structures compared with non-neoplastic features. We used multivariate ordinal logistic regression with random effects to prove that the patients’ age corresponds with the tumour’s response to radiation—which may implicate a better response to treatment among older patients. High dose rate brachytherapy decreases the number of clinical and dermoscopic features typical for basal cell carcinoma. The effect is more pronounced among older patients.