JEADV
LETTERS TO THE EDITOR
Standard surgical excision and reconstruction of giant basal cell carcinoma of the face: may be an alternative to the Mohs micrographic surgery Editor Giant basal cell carcinoma (BCC) defined as a tumour 5 cm or greater in diameter, is very rare skin malignancy that accounts for less than 1% of all basal cell tumours.1 Due to the rare entity of these giant BCC, few case series have been reported on the resection and reconstruction method of such lesions, and most of the reported articles focused on the Mohs Micrographic Surgery (MMS) because of its tissue sparing properties, which may result in less complex and more successful aesthetic reconstructions.2,3 The aim of this study was not only to present our experience with surgical management of giant BCC of the face but also to emphasis the application of standard surgical excision as an alternative to the MMS in the treatment of large facial BCC in terms of immediate reconstruction. From January 2000 to December 2012, a total of 17 patients with giant BCC of the facial region were surgically excised and reconstructed at our hospital. The lesion was at the scalp and forehead in three cases (17.7%), the eyelid in four cases (23.5%), the tempro-auricular region in two cases (11.8%), the nasal–cheek region in four cases (23.5%) and lips–chin–cervical in four cases (23.5%). The greatest diameter of lesion ranged from 5 cm to 11 cm with 5–6 cm being the most common size of lesion at the time of presentation. Because of the large size of tumour, all lesions were resected with >1 cm surgical margins to acquire a free clear margin as validated by intraoperative frozen
(a)
(b)
sections. The resulting defects were reconstructed immediately using local or free flap depending on the extension of the tumour (Fig. 1 and 2). All patients were followed up for at least 2 years on regular basis, and only two patients presented local recurrence (Both are single) at 3- and 2-year follow-up, reaching average cure rates 90–91%. Despite the surgical challenge in the treatment of these large tumours, we have managed to resect and reconstruct our patients in single-stage procedure using standard surgical technique without causing any severe postoperative complications. In this study, we did not employed MMS because it is reserved for high-risk cutaneous tumours for which standard excision is not sufficient to define complete tumour margins.4 Not all the tumours in our study are in the high-risk areas, at embryonic fusion planes or near high-recurrence areas near the nose and ears.5 In addition to this, MMS is used to treat nonmelanoma skin cancer (NMSCs) of a size and anatomic location amenable to local anaesthesia.4 The average size of lesion in our study is 7.2 cm, and all resulting defects should be reconstructed under general anaesthesia. Because MMS is time consuming and labour intensive, this surgical technique incurs a high cost.6 But most of the cases in this study are farmers who come from remote rural areas of our country where public health awareness and economic status are quite low. Aside from those, the average age of our patients is 60.1 years and most of them have systematic diseases, for these reasons we have chosen surgical excision instead of MMS on the basis of age and comorbidity. The last reason why we consider surgical resection as an alternative to the Mohs surgery for very large BCC is that the postoperative sloughing of the fixed tissue caused by MMS, however, postponed immediate reconstruction of the wound, as a result requiring multiple office visits for delayed reconstruction.7
(c)
Figure 1 (a) A 76-year-old male patient with giant nodular basal cell carcinoma (BCC) of the nose; (b) the lesion was resected and reconstructed using bilateral nasolabial advancement flap in single-stage procedure; (c) the patient presented a mild nasal deformity with minimal surgical scar at 2-year follow-up.
JEADV 2014, 28, 1572–1578
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
(a)
1573
(b)
(c)
(d)
Figure 2 (a) A 63-year-old female patient with a 8 cm 9 4 cm nodular basal cell carcinoma (BCC) of the entire upper lip extending into right ala and upper cheek; (b) intraoperative soft tissue defect after resection of this giant lesion; (c) reconstruction after with bilateral nasolabial advancement flap and rotational cheek flap; (d) postoperative 2 weeks view showed favourable morphology of the upper lip with insignificant scar.
Based on our experience in the treatment of giant BBC, we can conclude that large BCC of the face can be successfully treated using standard surgical excision with high cure rate and low postoperative complication. To obtain conclusive results, additional studies with larger sample sizes should be conducted for more accurately assess the treatment superiority of standard surgical excision vs. MMS. M. Tuerdi,1,2 A. Yarbag,3 A. Maimaiti,1,2 A. Mijiti,1,2 A. Moming1,2,* 1
Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China, 2Stomatological Research Institute of Xinjiang Uyghur Autonomous Region, Urumqi, China, 3 Marmara Eye Center, Sakarya, Turkey *Correspondence: A. Moming. E-mail: [email protected]
References 1 Zoccali G, Pajand R, Papa P, Orsini G, Lomartire N, Giuliani M. Giant basal cell carcinoma of the skin: literature review and personal experience. J Eur Acad Dermatol Venereol 2012; 26: 942–952. 2 Wood LD, Ammirati CT. An overview of mohs micrographic surgery for the treatment of basal cell carcinoma. Dermatol Clin 2011; 29: 153–160. 3 Netscher DT, Spira M. Basal cell carcinoma: an overview of tumor biology and treatment. Plast Reconstr Surg 2004; 113: 74e–94e. 4 Cumberland L, Dana A, Liegeois N. Mohs micrographic surgery for the management of nonmelanoma skin cancers. Facial Plast Surg Clin N Am 2009; 17: 325–335. 5 Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basal cell carcinoma treated with Mohs surgery in Australia II. Outcome at 5-year follow-up. J Am Acad Dermatol 2005; 53: 452–457. 6 Essers BA, Dirksen CD, Nieman FH et al. Cost-eff ectiveness of Mohs micrographic surgery vs. surgical excision for basal cell carcinoma of the face. Arch Dermatol 2006; 142: 187–194. 7 Mosterd K, Krekels GA, Nieman FH. Surgical excision versus Mohs’ micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years’ followup. Lancet Oncol 2008; 9: 1149–1156. DOI: 10.1111/jdv.12360
JEADV 2014, 28, 1572–1578
A rare case of multiple Becker’s nevi in a checkerboard mosaic pattern Editor Becker’s nevus is an epidermal melanosis, considered to be a cutaneous hamartoma, which characteristically manifests as a localized, unilateral hyperpigmented patch covered with terminal hairs.1 It is five times more frequent in males, and usually involves the upper trunk. Although it is a common finding, affecting approximately 0.5% of young men,2 multiple lesions are extremely rare. Here, we report a very rare form of the disorder, manifesting as multiple lesions with a checkerboard pattern of cutaneous mosaicism. A 39-year-old man presented with multiple brown plaques on his skin. Since the age of 12, the patient noticed a change in colour of the left upper back, extending to his arm, and on his right chest and right lower back. Gradually, he noted darkening of the lesions and increased growth of hair. The lesions were asymptomatic. His medical history was unremarkable, except for mild hypercholesterolemia, and family history was negative for similar cutaneous lesions. Clinical examination revealed three light brown plaques on the right upper chest (Fig. 1a), left upper back (Fig. 1b) and right lower back (Fig. 1c). The patch on the back extended to his left arm and forearm, and was accompanied by scattered skin tags in the axilla. The patches were covered with thick black hairs, and there were sharp anterior and posterior midline borders. His left leg was 1.25 cm shorter than his right leg. Histopathological examination of a punch biopsy taken from the plaque on the right upper chest showed acanthosis with widening of the tips of the rete ridges accompanied by increased melanin, consistent with the diagnosis of Becker’s nevus (Fig. 1d). X-ray of the cervical, thoracic and lumbar spine revealed narrowing of the intervertebral spaces between
© 2014 European Academy of Dermatology and Venereology
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
LETTERS TO THE EDITOR
Standard surgical excision and reconstruction of giant basal cell carcinoma of the face: may be an alternative to the Mohs micrographic surgery Editor Giant basal cell carcinoma (BCC) defined as a tumour 5 cm or greater in diameter, is very rare skin malignancy that accounts for less than 1% of all basal cell tumours.1 Due to the rare entity of these giant BCC, few case series have been reported on the resection and reconstruction method of such lesions, and most of the reported articles focused on the Mohs Micrographic Surgery (MMS) because of its tissue sparing properties, which may result in less complex and more successful aesthetic reconstructions.2,3 The aim of this study was not only to present our experience with surgical management of giant BCC of the face but also to emphasis the application of standard surgical excision as an alternative to the MMS in the treatment of large facial BCC in terms of immediate reconstruction. From January 2000 to December 2012, a total of 17 patients with giant BCC of the facial region were surgically excised and reconstructed at our hospital. The lesion was at the scalp and forehead in three cases (17.7%), the eyelid in four cases (23.5%), the tempro-auricular region in two cases (11.8%), the nasal–cheek region in four cases (23.5%) and lips–chin–cervical in four cases (23.5%). The greatest diameter of lesion ranged from 5 cm to 11 cm with 5–6 cm being the most common size of lesion at the time of presentation. Because of the large size of tumour, all lesions were resected with >1 cm surgical margins to acquire a free clear margin as validated by intraoperative frozen
(a)
(b)
sections. The resulting defects were reconstructed immediately using local or free flap depending on the extension of the tumour (Fig. 1 and 2). All patients were followed up for at least 2 years on regular basis, and only two patients presented local recurrence (Both are single) at 3- and 2-year follow-up, reaching average cure rates 90–91%. Despite the surgical challenge in the treatment of these large tumours, we have managed to resect and reconstruct our patients in single-stage procedure using standard surgical technique without causing any severe postoperative complications. In this study, we did not employed MMS because it is reserved for high-risk cutaneous tumours for which standard excision is not sufficient to define complete tumour margins.4 Not all the tumours in our study are in the high-risk areas, at embryonic fusion planes or near high-recurrence areas near the nose and ears.5 In addition to this, MMS is used to treat nonmelanoma skin cancer (NMSCs) of a size and anatomic location amenable to local anaesthesia.4 The average size of lesion in our study is 7.2 cm, and all resulting defects should be reconstructed under general anaesthesia. Because MMS is time consuming and labour intensive, this surgical technique incurs a high cost.6 But most of the cases in this study are farmers who come from remote rural areas of our country where public health awareness and economic status are quite low. Aside from those, the average age of our patients is 60.1 years and most of them have systematic diseases, for these reasons we have chosen surgical excision instead of MMS on the basis of age and comorbidity. The last reason why we consider surgical resection as an alternative to the Mohs surgery for very large BCC is that the postoperative sloughing of the fixed tissue caused by MMS, however, postponed immediate reconstruction of the wound, as a result requiring multiple office visits for delayed reconstruction.7
(c)
Figure 1 (a) A 76-year-old male patient with giant nodular basal cell carcinoma (BCC) of the nose; (b) the lesion was resected and reconstructed using bilateral nasolabial advancement flap in single-stage procedure; (c) the patient presented a mild nasal deformity with minimal surgical scar at 2-year follow-up.
JEADV 2014, 28, 1572–1578
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
(a)
1573
(b)
(c)
(d)
Figure 2 (a) A 63-year-old female patient with a 8 cm 9 4 cm nodular basal cell carcinoma (BCC) of the entire upper lip extending into right ala and upper cheek; (b) intraoperative soft tissue defect after resection of this giant lesion; (c) reconstruction after with bilateral nasolabial advancement flap and rotational cheek flap; (d) postoperative 2 weeks view showed favourable morphology of the upper lip with insignificant scar.
Based on our experience in the treatment of giant BBC, we can conclude that large BCC of the face can be successfully treated using standard surgical excision with high cure rate and low postoperative complication. To obtain conclusive results, additional studies with larger sample sizes should be conducted for more accurately assess the treatment superiority of standard surgical excision vs. MMS. M. Tuerdi,1,2 A. Yarbag,3 A. Maimaiti,1,2 A. Mijiti,1,2 A. Moming1,2,* 1
Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China, 2Stomatological Research Institute of Xinjiang Uyghur Autonomous Region, Urumqi, China, 3 Marmara Eye Center, Sakarya, Turkey *Correspondence: A. Moming. E-mail: [email protected]
References 1 Zoccali G, Pajand R, Papa P, Orsini G, Lomartire N, Giuliani M. Giant basal cell carcinoma of the skin: literature review and personal experience. J Eur Acad Dermatol Venereol 2012; 26: 942–952. 2 Wood LD, Ammirati CT. An overview of mohs micrographic surgery for the treatment of basal cell carcinoma. Dermatol Clin 2011; 29: 153–160. 3 Netscher DT, Spira M. Basal cell carcinoma: an overview of tumor biology and treatment. Plast Reconstr Surg 2004; 113: 74e–94e. 4 Cumberland L, Dana A, Liegeois N. Mohs micrographic surgery for the management of nonmelanoma skin cancers. Facial Plast Surg Clin N Am 2009; 17: 325–335. 5 Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basal cell carcinoma treated with Mohs surgery in Australia II. Outcome at 5-year follow-up. J Am Acad Dermatol 2005; 53: 452–457. 6 Essers BA, Dirksen CD, Nieman FH et al. Cost-eff ectiveness of Mohs micrographic surgery vs. surgical excision for basal cell carcinoma of the face. Arch Dermatol 2006; 142: 187–194. 7 Mosterd K, Krekels GA, Nieman FH. Surgical excision versus Mohs’ micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years’ followup. Lancet Oncol 2008; 9: 1149–1156. DOI: 10.1111/jdv.12360
JEADV 2014, 28, 1572–1578
A rare case of multiple Becker’s nevi in a checkerboard mosaic pattern Editor Becker’s nevus is an epidermal melanosis, considered to be a cutaneous hamartoma, which characteristically manifests as a localized, unilateral hyperpigmented patch covered with terminal hairs.1 It is five times more frequent in males, and usually involves the upper trunk. Although it is a common finding, affecting approximately 0.5% of young men,2 multiple lesions are extremely rare. Here, we report a very rare form of the disorder, manifesting as multiple lesions with a checkerboard pattern of cutaneous mosaicism. A 39-year-old man presented with multiple brown plaques on his skin. Since the age of 12, the patient noticed a change in colour of the left upper back, extending to his arm, and on his right chest and right lower back. Gradually, he noted darkening of the lesions and increased growth of hair. The lesions were asymptomatic. His medical history was unremarkable, except for mild hypercholesterolemia, and family history was negative for similar cutaneous lesions. Clinical examination revealed three light brown plaques on the right upper chest (Fig. 1a), left upper back (Fig. 1b) and right lower back (Fig. 1c). The patch on the back extended to his left arm and forearm, and was accompanied by scattered skin tags in the axilla. The patches were covered with thick black hairs, and there were sharp anterior and posterior midline borders. His left leg was 1.25 cm shorter than his right leg. Histopathological examination of a punch biopsy taken from the plaque on the right upper chest showed acanthosis with widening of the tips of the rete ridges accompanied by increased melanin, consistent with the diagnosis of Becker’s nevus (Fig. 1d). X-ray of the cervical, thoracic and lumbar spine revealed narrowing of the intervertebral spaces between
© 2014 European Academy of Dermatology and Venereology
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
