There is still debate about whether re-excision or close follow-up without surgery should be performed in patients revealing positive surgical margins upon pathologic examination. Most authors suggest that close follow-up is the most appropriate treatment for an inadequately excised BCC if it is histologically not aggressive type[6]. According to this suggestion, all patients having positive surgical margins were taken into a clinical follow-up program in our clinic. The aim of this study is to evaluate our clinical protocol for the patients with positive surgical margins after primary excision and to define the morphologic characteristics and anatomical location of the recurrent tumor when it occurred.

According to our clinical protocol, tumors smaller than and larger than 2 cm in diameter were excised with a surgical margin of 3-5 mm and 10 mm, respectively. Patients with positive surgical margins were included into a clinical follow-up program with monthly controls for the first 3 months, then controls with 3 month intervals until the end of second year and with 6 month intervals afterwards. In the case of a clinical suspicion for a tumor recurrence, re-excision was performed in the follow-ups. A retrospective analysis of patients with positive surgical margins and recurrences were performed. The histological type of the primary and recurrent tumor, and anatomical localization and size of the primary and recurrent tumor were noted. The time intervals between the primary and the recurrent excisions were designated.

Table 1: Patients with positive surgical margins

Re-excision was performed in 7 patients with a suspicion of recurrence during follow-ups and 5 of them (21%) were diagnosed as tumor recurrence. For the remaining 2 cases the pathologic examination revealed chronic inflammation. Histological subtyping of 5 recurrent tumors was as follows: 4 (80%) were sclerosing type, 1 was superficial spreading BCC. Two of the recurrent tumors were located in the alar region, 1 in medial canthal region, 1 in lower eyelid and 1 in frontal region. The time interval between the primary excision and recurrence ranged from 2 months to 12 months with a mean period of 6 months.

Histological examination of recurrent tumors revealed that tumors were composed of atypical basaloid cells with a uniform palisadic arrangement. Additionally 5 of them were designated to have lymphocytic infiltration and one had squamous differentiation upon pathologic examination. None of the patients with lymphocytic infiltration has recurrence in clinical follow-ups.

Table 2: The histologic subtype-recurrence time relationship in patients operated for recurrent tumors

In a recent study, 28% of re-excision material due to positive surgical margins revealed scar tissue in histopathological examination. According to “disappearance theory”, tumor cells may be destroyed during the inflammatory and repairing processes[9]. In our study 2 patients with positive surgical margins who were thought to have recurrence, pathologic examination after re-excision displayed “chronic inflammatory event”.

Factors such as the localization (nasal, malar, periorbital or perioral), size (tumors bigger than 2 cm) of the tumor, invasiveness on histological examination (superficial or sclerosing) or a history of radiotherapy were found to increase the risk of inadequate excision. However no relation was found between inadequate excision and age or gender of the patient[6-12]. Nagore et al.[7] asserted that tumor location and histological type specifically related to risk of inadequate excision. Bogdanov-Berezovsky[9] has implied that only squamous differentiation was related to inadequate excision. Dellon et al.[13] showed that age and the gender of the patient, tumor localization and the presence of squamous differentiation had no effect on rate and time of recurrence. In our study, we had one patient whose tumor was excised inadequately and had squamous differentiation upon histological examination. No signs of recurrence have been encountered in this patient on the clinical follow-ups during the 10 month postoperative period.

De Silva and Dellon[8] suggested that host-tumor relationship should be taken into consideration in order to show tumor recurrence risk individually for a patient. They also suggested that metatype, irregularity in palisadic arrangement, spiky appearance of the tumor cords and absence of small lymphocytes were among the factors increasing recurrence risk. Robinson and Fisher[12] also stated that recurrence risk in inadequately excised tumors may be related with lymphocyte infiltration and unfavorable host response. Dellon et al.[13] recommended reexcision in the case of no or low lymphocytic infiltration. Terzioglu et al.[15] reported that the most reliable histopathological prognostic parameter is the irregularity of more than 75% in the periphery of a palisadic array. However, according to the same study, lymphocytic infiltration and ulceration should be considered as secondary prognostic parameters. Terzioğlu et al.[15] thus recommended that histopathological criteria including irregularity in the palisading array, lymphocytic infiltration and ulceration should be taken into account while determining the treatment protocol for inadequately excised BCCs.

The study by Netscher and Spira[5] classified BCC in two groups as limited or diffuse. According to this classification, nodular type BCC was included in the limited subgroup whereas sclerosing and superficial spreading types were in the diffuse subgroup. Netscher and Spira[5] also reported superficial spreading BCC as having the highest risk of recurrence as the tumor extends beyond clinically visible limits. They also implied that the sclerosing type may extend as much as 7 cm beyond the visible margin. In our study, when we classified patients with positive surgical margins according to the classification by Netscher and Spira, 11 out of 23 positive margin lesions were found to be of the limited type and the remaining 12 of the diffuse type. All the recurrent cases were in the diffuse type BCC group. Our follow-up period ranged from 6 months to 63 months in the limited group with no cases of recurrent tumors. In cases classified as diffuse BCC, the recurrent tumors were of the sclerosing type in 4 cases and observed between 2 to 12 months, whereas one case of the superficial spreading type was seen in the second month.

Friedman et al.[4] suggested re-excision if the tumor with positive surgical margins was multicenter in origin or had a sclerosing component. Karaca et al.[16] recommended close follow-up if the tumor was not infiltrative and not histologically aggressive, the host response was strong and tumor formation time was long. They found re-excision more advisable otherwise.

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