Basal Cell Cancer

The excision of small basal cell cancers (BCCAs) of less than 20 mm with well-defined borders and a 3-mm peripheral surgical margin will remove the tumor in 85% of cases. A 4- to 5-mm peripheral margin will increase the clearance rate to approximately 95%. Approximately 5% of small, well-defined BCCAs extend more than 4 mm beyond their apparent clinical margins. Morpheic (morpheaform) and large BCCAs require wider surgical margins to maximize the chance of complete histologic removal. On initial removal of morpheic lesions, the rate of complete excision with a 3-mm margin is 66%; 5-mm margin, 82%; and 13- to 15-mm margin, over 95% (Telfer et al., 2008).

Standard vertical-section processing of excision specimens allows the pathologist only to examine representative areas of the peripheral and deep surgical margins, and at best an estimated 44% of the entire margin can be examined in this manner. Therefore, tumors that appear fully excised occasionally recur (Telfer et al., 2008). If the BCCA is on an area with little excisable tissue, consider Mohs microscopic surgery to obtain adequate margins and minimize tissue removal.

If the BCCA lesion is completely excised, the recurrence rate is about 1%. If not completely excised, BCCAs have recurrence rates of 17% to 35% for lateral-margin positivity and 33% for deep-margin positivity. Only a third of positive-margin BCCA lesions recur, so the physician might reexcise the margins or consider reexcision only if a recurrence develops, with the following exceptions: lesions of long duration, size greater than 2 cm, previous recurrence, and aggressive histologic features, including perineural and perivascular invasion and infiltrative, morpheaform, or micronodular appearance. If marginal positivity is detected in such cases after excision, reexcision and removal of the residual tumor is advised over watchful observance (Unlu et al., 2009). (See Tuggy Video: Basal Cell Curettage and Cautery.)

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