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PRACTICE: Dean E Boyce and Kayvan Shokrollahi Reconstructive surgery BMJ 2006; 332: 710-712 [Full text]

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Surgical margins for basal cell carcinoma: What’s a millimetre between friends?

Sandeep Varma, John English   (31 March 2006)

Surgical margins for basal cell carcinoma: What’s a millimetre between friends? 31 March 2006
Sandeep Varma, Consultant Dermatologist and Dermatological Surgeon Department of Dermatology, Queens Medical Centre, Nottingham, NG7 2UH, John English Send response to journal: Re: Surgical margins for basal cell carcinoma: What’s a millimetre between friends?	Dear Sir We have enjoyed reading the highly informative series on wound healing, in particular the most recent article on reconstructive surgery [1]. However, as basal cell carcinoma (BCC) is the commonest cancer of humans with an estimated 60,000 occurring in the UK each year, we feel it important to highlight a potential error. Boyce and Shokrollahi state that 3mm is a suitable margin which they typically take for the excision of BCCs [1]. We did not want other surgeons, especially those who are less experienced in the management of BCCs to be left with this misconception. Margins of 1-3mm are inadequate for BCC, even those with a small diameter [2]. Wolf and Zitelli using horizontal frozen sectioning (Mohs micrographic surgery) showed that for well-defined previously untreated BCCs on the face which measure less than 20mm in diameter, a minimum margin of 4mm is necessary to totally eradicate the tumour in more than 95% of cases [3]. They inspected BCCs under bright theatre lights and palpated the BCC to define the margins and reported that 3mm margins removed the tumour in only 85% of cases. Even for small BCCs measuring on average 6x5mm, excision margins of 1,2 or 3mm result in positive margins of 16%, 24% and 13%, respectively [2]. Of course, we accept that there may be inter-operator variability in what constitutes 3mm. Boyce and Shokrollahi may mark out at 3mm and excise around the outside of these markings thereby effectively taking 4mm or more. A less experienced surgeon, perhaps concerned about the subsequent repair of a large defect on the face, may be tempted to mark out 3mm around a BCC and excise inside or on the marking line thereby taking a true 3mm margin which will inevitably result in greater incomplete excision rates. Most dermatologists in the UK follow the guidelines set out by the British Association of Dermatologists and take 4mm around a BCC where possible [4]. References: 1. Boyce DE, Shokrollahi K. Reconstructive surgery. BMJ 2006; 332: 710-12. 2. Asadi-Kimyai A, Alam M, Goldberg L et al. Efficacy of narrow-margin excision of well-demarcated primary facial basal cell carcinomas. J Am Acad Dermatol 2005; 53: 464-8. 3. Wolf DJ, Zitelli JA. Surgical margins for basal cell carcinoma. Arch Dermatol 1987; 123: 340-4. 4. Telfer NR, Colver GB, Bowers PW. Guidelines for the management of basal cell carcinoma. Br J Dermatol 1999; 141: 415-23. Competing interests: None declared