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Electing for Surgery in the Management of BCC


Experts provide insight on when patients may not be surgical candidates and potential complications that can follow surgery when approaching treatment of basal cell carcinoma.


Omid Hamid, MD: For basal cell carcinoma [BCC], the factors that would indicate a patient is not a good surgical candidate could be morbidity—that’s a patient who cannot tolerate a surgical procedure and has a contraindication, whether it be due to cardiopulmonary function or otherwise. This could be one who can’t travel enough to get surgery. Or it can also be an area where surgery is contraindicated because it would cause deformity or loss of function. Historically that’s been near the eyelid or near the mouth where it would cause functional deficiencies.

Also, there could be areas where there have been local recurrences, where doing another surgical procedure would be a difficulty. Those are the patients where we consider other therapeutic approaches. Again, some basal cell carcinomas are fixed to underlying structures, or have evidence of local advancement or metastatic advancement. Therefore, those definitely would not be looked at as surgical candidates, and they would need to have an evaluation for systemic therapies.

Morgana Freeman, MD: With the exception of Gorlin syndrome, basal cell carcinoma is again a cancer that typically happens in older patients, especially when we’re talking about more advanced disease. In cases where you have a very large primary tumor or tumor that may be deeply invading local structures, such as bone, or muscle, or fascia, it may not be appropriate to take that patient through a big debulking surgery. There’s a case I can think of that I saw very recently of a woman who had a basal cell carcinoma that was superficially invading most of the anterior chest. In that case, based on anatomy alone, not surgically feasible. There also may be comorbid medical conditions that one would have to consider, including concurrent heart disease, diabetes, or perhaps something that would make them a set up for poor wound healing. In other cases, this may be where it’s a recurrent BCC that may have happened in a primary surgical or radiation field. All those things should be considered and often are considered in the surgical management and determination of eligibility for surgery.

Omid Hamid, MD: The majority of times the recovery from surgery for basal cell carcinoma is short with minimal morbidity. There’s always a risk of dehiscence or infection, although those are minimal. In the hands of the appropriate Mohs micrographic surgeon, there should be really no complications and no recurrence.

After appropriate resection, it’s appropriate to review the pathology to evaluate for skip lesions, positive margins, and the deep margin to ensure that a complete resection has been done.

Morgana Freeman, MD: There are a lot of surgical considerations to keep in mind, and that’s why I oftentimes will ask patients to meet with a surgical oncologist, in particular, who is skilled and deft at handling perhaps some of these more aggressive or large or potentially comorbid types of situations. In the case of head and neck, for example, that patient may be facing a rhinectomy, or that patient may be facing an orbital exenteration. Or they may have a lesion that’s involving the parotid that can result in a facial nerve paralysis. When we’re talking about an area that has a lot of vulnerable real estate, there can certainly be surgical complications and potentially irreversible complications from surgical management.

The other thing to keep in mind is patient preference. They oftentimes do have desires around cosmesis. Oftentimes, these patients have had multiple surgical excisions, not only for basal cell carcinoma but for other skin cancers as well. If they are facing a potentially disfiguring surgery, as I mentioned—in the case of a rhinectomy, an auriculectomy, or an orbital exenteration—they may not want to go through all of that in terms of their management, especially if they know that there may be other options available to them.

Omid Hamid, MD: Usually there are very minimal complications, if any, from a surgical resection for basal cell carcinoma. Unfortunately, at times there can be wound dehiscence, infection in the area, which would require an evaluation. There are certain patients who may form keloids around the area; that’s rare. Usually you see patients with scars, and therefore, it’s important to evaluate with wound care. There are specific manipulations that can decrease the incidence of scarring. In the majority of patients, the surgical procedure renders them free of disease with a very low risk of recurrence. At this time, an initial surgical evaluation is considered the standard first-line treatment for basal cell carcinoma.

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