Homan, F. (Femke) (2014) Surgical excision with primary closure vs ‘delayed closure’ for basal cell carcinoma on the face: a retrospective study. thesis, Medicine.
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Abstract
Background: Basal cell carcinoma (BCC) is the most common type of skin cancer worldwide. The incidence is still increasing. Conventional surgical excision with primary closure (PC) remains the standard of treatment for BCC. Alternatively secondary closure after histological confirmation of radical resection can be performed, the ‘delayed closure’ technique (DC). Studies to compare both treatments modalities are not previously described. Objective: To record clearance outcomes, cure-rates and recurrence rates as well as patient-reported cosmetic outcomes in patients treated with conventional surgical excision or with the ‘delayed closure’ technique. Method: We retrospectively reviewed the pathology and medical records of patients diagnosed with ≥1 BCC, located in the H-zone. BCCs treated with either surgical excision and DC (n=156), or PC (n=164) from January 2005 and December 2011 were included. Patient-reported cosmetic and functional outcome for (sub)total nasal defects following radical tumor resection were measured with the Facial Skin Index Score and the Nasal Appearance and Function Evaluation Questionnaire. The statistical methods included a descriptive analysis of clinical and pathologic variables, standard statistical analyses, and multivariate logistic regression. Ultimately, Kaplan-Meier survival analysis was performed to compare tumor free interval between different treatments. Results: A total of 156 basal cell carcinomas from 140 patients, with a mean age of 70.7 ± 12.7 years (SD) were included for analysis in the delayed closure group. Lesions treated with PC occurred in 143 patients with a mean age of 71.2 ± 13.1 years (SD). Clearance was achieved in 144 BCCs (92.3%) after DC and in 148 BCCs (90.2%) after PC, with a mean of 1.53 stages and 1.26 stages respectively (P<0∙009). Incomplete excisions after first attempt were 43.7% in the DC group and 23.0% in PC group. Those BCCs located on the nose were related to a higher change for incomplete excision. Logistic regression analysis showed that BCC located on the nose (P 0∙016) was associated with a higher incomplete resection rate. After further excision of incompletely excised tumors, in one-third no residual tumor was found. The mean interval between first excision and complete excision in the DC group was 6.13 days (range 0-183 days). The mean interval between clearance and defect closure was 12.56 (range 0-93 days). Recurrence occurred in 5.1% BCCs after DC and in 5.5% after PC giving a cure-rate of 97.4% and 97.0% after a mean follow-up of 4.7 years. Conclusion: Incomplete excision rate after first excision in both treatment groups was high compared to other studies. The most frequent location for incomplete excision was the nose, regardless of histologic subtype. The results of our study suggest that the margins we use for excision in delicate locations are generally too small. Therefore we emphasize the use of larger margins of at least 3 mm in non-aggressive BCCs and 5 mm in aggressive BCCs, even in delicate zones according to the guidelines. Considered that wider margins are taken into account, we think the delayed closure technique is still an accurate treatment option for aggressive BCCs and/or located in anatomic delicate and aesthetic areas of the face even though they acquire more excision stages. The clinician needs to be aware of the manner how the margins are checked (only 5%) and needs to consider that we cannot always relay on pathology reports of biopsy alone. Therefore we advise that the biologic aspects of the tumor are considered as well when choosing the size of the surgical margin. Alternatively, (slow)Mohs’ micrographic surgery should be considered in H-zones or poorly defined lesions.
| Item Type: | Thesis (Thesis) |
|---|---|
| Supervisor name: | Zöphel, Dr. O.T. |
| Supervisor name: | Rakhorst, Dr. H.A. and Department of Plastic Surgery and Medical Spectrum Twente |
| Faculty: | Medical Sciences |
| Date Deposited: | 25 Jun 2020 11:04 |
| Last Modified: | 25 Jun 2020 11:04 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/2382 |
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