Review of outcomes of 500 consecutive cases of non-melanoma skin cancer of the head and neck managed in an oral and maxillofacial surgical unit in a District General Hospital

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Abstract

We provide a non-melanoma skin cancer (NMSC) service for skin cancers of the head and neck in the south-west of England. We hypothesised that certain anatomical sites such as the nose and eyelid would have a higher incidence of close or involved margins than others, and that the choice of repair might influence the excised margins. We therefore retrospectively analysed the data of 500 consecutive NMSC that were operated on in the oral and maxillofacial surgery unit of Taunton and Somerset NHS Trust. The database reports were crosschecked against the Trust’s own pathology reporting system to ensure that they were accurate. Data collected included clinical and personal details of patients, anatomical sites, type of reconstruction, histopathological diagnosis, excision margins, and complications. Of the 500 patients reviewed 362 (72%) were basal cell carcinomas (BCC) and 138 (28%) squamous cell carcinomas (SCC). The outcomes of 243 patients treated by primary closure, 134 treated by reconstruction with local flaps, and 123 treated by skin grafts, were reviewed with particular attention paid to the anatomical site and excision margins. There was an overall incomplete excision rate of 10.8% (n = 54) and 29 patients developed complications (5.8%). We confirmed that rates of close or incomplete margins are more likely in certain anatomical sites such as the nose, forehead, and ear. The rate of involved margins was unaffected by choice of surgical technique.

Introduction

Basal cell carcinoma (BCC) is the most common non-melanoma skin cancer (NMSC) among white-skinned people,1, 2 and the incidence has increased in recent years as a result of excessive exposure to ultraviolet (UV) radiation, in particular short-wave UV B radiation.3 It is more prevalent in men and is more common with increasing age.

BCC are known as rodent ulcers as they are locally invasive. They rarely metastasise, and local recurrence has been reported as <2% when the tumour has been completely excised.4 In cases with involved margins, however, the recurrence rate can be as high as 30%–40%.5 Many effective treatments are available, such as excision, topical immune-modulating creams, cryotherapy, radiotherapy, cauterisation, and photodynamic treatment.

Squamous cell carcinoma (SCC) is the second most common form of skin cancer, and arises from uncontrolled growth within the squamous cells of the epidermis. It is mainly caused by cumulative UV exposure over a patient’s lifetime, and is usually found on areas often exposed to the sun, such as the head and neck, arms, back, and legs. People who habitually use indoor tanning beds are at a higher risk of developing SCC, and these patients often present at a younger age.6

The total cost of skin cancer to the National Health Service (NHS) is projected to be about £180 million by 2020.7 The National Institute for Health and Care Excellence (NICE) has recommended that all suspicious skin lesions, except low-risk BCC, should be referred on the “two-track cancer pathway”,8 because of concerns that insufficient training is given to non-specialist operators. Reports have shown that there are higher rates of incomplete excision in patients whose tumours were excised in primary care.9

Management of NMSC in the UK is carried out in multidisciplinary settings including specialists from dermatology, oral and maxillofacial surgery (OMFS), plastic surgery, and ENT. The OMFS unit based at Musgrove Park Hospital, Taunton and Somerset NHS Trust, is the main service provider for NMSC of the head and neck in the south-west of England, and about 650 affected patients are treated at the unit each year.

Section snippets

Patients and methods

We used the Trust’s 3S Reporting™ (3S Reporting Ltd) database the data to analyse the data on 500 consecutive patients with NMSC. All patients included had had NMSC of the head and neck excised over a 12 month period (2014–15). Patients with incomplete data and those given adjuvant treatment were excluded. The patients studied were entered into an electronic database at the time of first consultation, which recorded clinical diagnosis, measurement of the lesion, anatomical site, and personal and

Results

All patients were seen and treated by one of four OMFS consultants. There were more men (n = 325, 65%) than women (n = 175, 35%). Overall, 385 (77%) were over 70 years old, 83 (16.5%) between 61–70 years, and 32 (6.5%) under 60.

Most referrals were from the dermatology unit in the same Trust (n = 170, 34%). A total of 125 were tertiary referrals from general practitioners with a special interest in dermatology (25%), 85 (17%) were from local general practitioners, five (1%) from local dentists, and 115

Discussion

We have presented our data of 500 consecutive cases of NMSC of the head and neck with reported rates of incomplete excision of 12.4% (45/362) for BCC and 6.5% (9/138) for SCC, respectively. Most of the large published series relate to BCC on the whole body, and have recorded incomplete excision rates that vary from 0.7% to 50%.11, 12, 13, 14 A five-year retrospective review of 1832 BCC of the whole body treated by primary excision reported an overall rate of incomplete excision of 14%, with the

Conclusion

The findings of this 12-month retrospective review of 500 cases of NMSC support one of our hypotheses, which is that the anatomical site does influence the excision margins. We thought that lesions on the nose and eyelid would be high-risk areas because of the lack of available tissue and, given the risk of disfigurement, a more conservative margin is likely to be taken and this increases the risk of close or involved margins. We found that the rate of involved margins was unaffected by choice

Conflict of interest

We have no conflicts of interest.

Ethics statement/confirmation of patients’ permission

Not applicable.

References (20)

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