Institution based audit on non-melanoma

skin cancer excision margins in maxillofacial

out-patient department- YGC
by
Nuwan Rajapaksha
Viji Kamisetty
 Introduction
• Non-Melanoma Skin cancer encompasses basal cell
carcinoma (BCC) and cutaneous squamous cell
carcinoma (cSCC)
• They are the commonest cancers worldwide
• Account for 20% of all new malignancies in the UK
• It is projected to rise due to increased reporting and
historic exposure to ultraviolet radiation
• In 2020, skin cancer is estimated to cost the NHS
over £180 million per annum.
 Importance of excision margins
• The mainstay of treatment is complete surgical
excision
• The likelihood of recurrence is directly related to
achieving tumour-free margins
• Just 1% of BCCs recur where margins are clear,
compared with 31–41% when margins are involved
• The same data for cSCC is lacking, however given its
metastatic potential which is reported at 5-47%,
complete excision is desirable
• Incomplete excisions may require further surgery or
increased surveillance which burdens patients and
healthcare systems
 Recommendations
• British Association of Dermatology (BAD)
recommendations for BCC
• 4 to 5mm peripheral margins for low-risk BCC
• Greater than 5mm peripheral margins for high-risk BCC
• Deep margins are recommended to reach the level of
subcutaneous fat.
 Recommendations
• British Association of Dermatology
(BAD) recommendations for cSCC
• 4mm peripheral margin for low-risk cSCC
• At least 6mm peripheral margin for high-risk cSCC
• The deep margin should extend to the hypodermis,
avoiding the aponeurosis, perichondrium, and periosetum
if unaffected by the tumour extension
 The Current Standards
• NICE standard- estimated margin risk- 5%
• A meta-analysis of 110 non-Mohs clinical studies comprising
53 796 patients with 106 832 BCCs and 21 569 cSCCs,
established the proportion of incomplete excisions for BCC
was 11·0% [95% confidence interval (CI) 9·7-12·4] and for
SCC 9·4% (95% CI 7·6-11·4)
(Nolan GS, Kiely AL, Totty JP, Wormald JCR, Wade RG, Arbyn M et al. Incomplete surgical excision of
keratinocyte skin cancers: a systematic review and meta-analysis. Br J Dermatol 2021;184: 1033–
1044)

• As such, our set standards were portion of incomplete

excision for
BCC- 11.0%
cSCC- 9.4%
 Materials and Methods
• Audit period- 6 months (from April to October-
2023)
• Data collected retrospectively
• Used QOMS- NMSC audit data collection form
with a data collection form used previously
• Histology data set was collected from excision
biopsy reports
• Statistical analysis was done with Microsoft Excel
 Objectives
• Primary objective was to assess the risk of
incomplete surgical excision in adults with NMSC
in the setting of maxillofacial out-patient
department in Glan Clywd Hospital
• Secondarily, we aimed to determine if other factors
were associated with the risk of incomplete excision
 Inclusion and exclusion criteria
• Inclusion Criteria
o all patients with a preoperative diagnosis (either
histological or clinical) of BCC or cSCC undergoing
surgical excision were eligible for inclusion
• Exclusion Criteria
o Biopsies expected to have incomplete margins (incision,
shave or punch biopsies) were excluded
o Excisions turned out to diagnosis other than NMSC were
also excluded
o Re-excisions
• A total of 68 patients undergoing 80 excisions met
the eligibility criteria
• 87.5% of suspected BCCs were excised without a
preoperative tissue diagnosis
• 33.33% of excised cSCCs were biopsy-proven in
advance
• All biospy proven NMSCs were referred by
dermatologists
GENDER DISTRIBUTION

32.4

67.6

F M
AGE DISTRIBUTION

6
6

46

43

20-39 40-59 60-79 80-99

 REFERRALS

29.0

47.0

24.0

OMFS GP Dermatology
Referal to Clinic Waiting Time (in weeks)

7.4

23.5
52.9

16.2

<2 weeks 2-6 weeks 6-12 weeks >12 weeks

CLINICAL DIAGNOSIS

11.8

17.6

70.6

BCC cSCC Unsure

RESPONSIBLE CONSULTANT

26.5 22.1

14.7 20.6

16.2

CJL HBJ EJW MI AKK

 MEDICAL HISTORY

9.0
3.0
27.0
20.0

41.0

Healthy Hypertension Diabetes

Steroids Anticogulants
 SITE DISTRIBUTION
30

25
25

20 21

15 16

10 10
7
5
4 4 4
3 3
0 1
ar p d w le r e in k n k
l al a o p a os k he
e hi ec
o cu Sc
e he e br em
E N p
s
C C N
er
i
Fo
r
E y T Li
P
 Largest Tumour Diameter (mm)
20
18
18
16
16
14
12
12
10
10
8 9

6
4 5
4 4
2
2
0
(1-5) (6-10) (11-15) (16-20) (21-25) (26-30) (31-35) (36-40) Missing
Data
 Clinical Excision Margin (mm)
50.0
45.0 45.6
40.0
35.0 36.8

30.0
25.0
20.0
15.0 16.2
10.0
5.0
0.0 1.5
3 4 5 Missing Data
Method of Reconstruction

1.5
17.6

14.7
66.2

Primary Closure Local Flap

Skin Graft Secondary Healing
NON MELANOMA SKIN CANCERS

27.5

72.5

BCC cSCC
 TYPES OF BCC

94

Nodular BCC Infiltrative BCC

 TYPES OF cSCC

10
25

65

Well Dif SCC Moderate Dif SCC Poorly Dif SCC

 DOI

5.9
26.5

67.6

Clark I-II Clark III-IV Clark V

 Excision Margins
NMSC No of Peripheral No of Deep No of margin
Margin involved Margin involved involved on either
way

BCC 3/58 (5.2%) 2/58 (3.4%) 4/58

(6.9%)**

cSCC 2/22 (9.1%) 0/22 (0%) 2/22 (9.1%)

**One case had both peripheral and deep involved margins. Therefore, it was
considered as one case
 Discussion
• This audit shows that the risk of involved excision
margins of BCCs and cSCCs are 6.9% and 9.1%, and are
below the set standards of 11.0% and 9.4%, respectively.
• Dermatologists had the lowest proportion of incomplete
excisions (6·2% BCCs, 4·7% SCCs) and general
practitioners had the highest proportion (20·4% BCCs,
19·9% SCCs). (Nolan et al., 2020)
• Plastic surgeons had a slightly higher proportion of
incomplete excisions than dermatologists (9·4% BCCs,
8·2% SCCs) (Nolan et al., 2020)
• No enough evidence/statistics available in
the literature regarding maxillofacial surgeons
• Incomplete excision risk of cSCC in our setting
(9.1%) is higher than that of plastic surgeons (8.2%)
• However, plastic surgeons do excisions in low-risk
sites as well.
• Maxillofacial surgeons perform excision of NMSCs
located only on head and neck region
• Head and neck NMSC is carries higher risk
of incomplete margins due to anatomical
complexity and aesthetic concerns. (Nahhas et al,.2017)
• The judgement of where a tumour ends and when
a deep plane is ‘clean’ can be complicated by local
anatomy of head and neck region
• Common examples of this include the ear, nose,
eyelid and cheek where excisions are more likely
to be incomplete in an attempt to preserve
underlying vital anatomical structures (cartilage,
facial nerve) (Khan et al., 2013)
• All the incomplete excsion sites of the present
study are the ear, nose and cheek
Outpatient maxillofacial department at Glan Clywd
hospital has managed to maintain its quality of care
by maintaining the incomplete excision rates of
NMSC at a well below level compared to global
standards even with challenges associated with head
and neck NMSC management

BCC cSCC
Global Standards 11.0% 9.4%
YGC Standards 6.9% 9.1%
 Limitations

• Majority of the cases managed at outpatient

department were T1 or T2 lesions
• More complex cases are excised by consultants or
registrars themselves at the theatre
• This audit did not account those complex cases
 Action Plan
• Run the same audit on NMSC excision cases done
at the setting of theatre
• Calculate amalgamated risk rates to give a fare
image of quality of care
• Nolan GS, Dunne JA, Lee AE, Wade RG, Kiely AL, Pritchard Jones RO, Gardiner MD; NMSC:
PlastUK Collaborative; Jain A. National audit of non-melanoma skin cancer excisions performed
by plastic surgery in the UK. Br J Surg. 2022 Oct 14;109(11):1040-1043. doi:
10.1093/bjs/znac232. PMID: 35891582.
• Nolan GS, Wormald JCR, Kiely AL, Totty JP, Jain A. Global incidence of incomplete surgical
excision in adult patients with non-melanoma skin cancer: study protocol for a systematic review
and meta-analysis of observational studies. Syst Rev 2020;9(1):83. doi:10.1186/s13643-020-
01350-5
• Khan, A.A., Potter, M., Cubitt, J.J., B.J. Khoda, Smith, J., Wright, E.H., Scerri, G., Crick, A.,
Cassell, O.C. and Budny, P.G. (2013). Guidelines for the excision of cutaneous squamous cell
cancers in the United Kingdom: The best cut is the deepest. PubMed, 66(4), pp.467–471.
doi:https://doi.org/10.1016/j.bjps.2012.12.016.
• Nahhas AF, Scarbrough CA, Trotter S. A Review of the Global Guidelines on Surgical Margins
for Nonmelanoma Skin Cancers. J Clin Aesthet Dermatol. 2017 Apr;10(4):37-46. PMID:
28458773; PMCID: PMC5404779.
• Ranjan R, Singh L, Arava SK, Singh MK. Margins in skin excision biopsies: principles and
guidelines. Indian J Dermatol. 2014 Nov;59(6):567-70. doi: 10.4103/0019-5154.143514. PMID:
25484385; PMCID: PMC4248492.
THANK YOU.!