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Basal Cell Carcinoma of the Head and Neck Region in Ethnic Chinese

Basal Cell Carcinoma of the Head and Neck Region in Ethnic Chinese Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 890908, 7 pages doi:10.1155/2011/890908 Clinical Study Basal Cell Carcinoma of the Head and Neck Region in Ethnic Chinese Velda Ling Yu Chow, Jimmy Yu Wai Chan, Richie Chiu Lung Chan, Joseph Hon Ping Chung, and William Ignace Wei Division of Head and Neck, Plastic and Reconstructive Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong Correspondence should be addressed to Velda Ling Yu Chow, vlychow@gmail.com Received 1 May 2011; Revised 4 June 2011; Accepted 8 June 2011 Academic Editor: Michael Veness Copyright © 2011 Velda Ling Yu Chow et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. This study aims to report our experience in the management of HNBCC in ethnic Chinese over a 10-year period. Methods. A retrospective review of all ethnic Chinese patients with HNBCC treated in a tertiary centre from 1999 to 2009. Results. From 1999 to 2009, 225 patients underwent surgical excision for HNBCC. Majority were elderly female patients. Commonest presentation was a pigmented (76.2%) ulcer (64.8%) over the nose (31.6%). Median skin margin taken on tumour excision was 2.0 mm; primary skin closure was achieved in 51.8%. Postresection skin margin was clear in 75.4%. Of those with inadequate skin margins, 56.7% opted for further treatment, 43.4% for observation. Recurrence rates were 2.6% and 13.8%, respectively (P = 0.106). Overall recurrence rate was 5.5%. Conclusions. HNBCC commonly presented as pigmented ulcers over the nose of elderly female patients in our locality. Adequate tumour excision ± reconstruction offered the best chance of cure. Reexcision of those with inadequate skin margins improved local tumour control. 1. Introduction electrodessication, cryosurgery have been reported with vari- able treatment outcomes; similarly, topical and intralesional The incidence of skin cancer is increasing worldwide, agents, photodynamic therapy have also been described, possibly arising from an ageing population and increasing again with variable outcomes, warranting careful patient sunlight exposure. Basal cell carcinoma (BCC) is the most selection [11–14]. prevalent. The incidence of which is increasing at 3% per Much has been published regarding BCCs in Caucasian annum [1–7]. populations, but data on ethnic Chinese are less read- BCC most often arise in areas of long-term sun exposure ily available. We herein report the patient demographics, with a high predilection for the head and neck area. Classical tumour characteristics, surgical management, and outcome clinical features include raised and rolled edges, pearly of HNBCCs in ethnic Chinese patients in Hong Kong. central area with telangiectasia. Lesions may be pigmented or nonpigmented; nodular, ulcerative, erythematous patches or even mimic benign lesions. Most BCCs are indolent with 2. Materials and Methods a low incidence of metastasis [8–11]. The mainstay of treatment for BCC of the head and neck A retrospective review of all ethnic Chinese patients with region (HNBCC) is surgical excision with adequate margins. previously untreated HNBCC managed in the Queen Mary Radiotherapy may be advocated as definitive treatment for Hospital, The University of Hong Kong, Hong Kong, a selected group of patients, for those unfit for surgery between 1999 and 2009. Queen Mary Hospital was one or as an adjuvant treatment for those with inadequate of the largest regional hospitals in Hong Kong. It was margins. Other treatment modalities such as curettage and a tertiary and quaternary referral centre for the entire 2 International Journal of Surgical Oncology territory. Outcome measures included patient demographics, tumour characteristics, surgical management, management of patients with inadequate margins, and recurrence rates. Statistical analysis was performed using SPSS 18.0. 3. Results 3.1. Patient Demographics. A total of 226 HNBCC patients of Chinese ethnicity were treated in our centre from 1999 to 2009. Mean age was 73.1 (22–100) years. There were 132 female and 94 male patients with a male to female ratio of (a) 0.7. 25 patients had multiple BCC lesions. There were a total of 273 HNBCC lesions. 3.2. Tumour Characteristics. There were 65 (23.8%) non- pigmented and 208 (76.2%) pigmented lesions. The most common presentation was in the form of an ulcer (64.8%, n = 177), followed by nodule (19.3%, n = 53), erythema (1.1%, n = 3), and lesions that mimic a benign lesion, for example, keratosis (14.7%, n = 40) (Figure 1). Common sites of involvement included the nose (31.6%, n = 86) and cheek (16.5%, n = 45) (Figure 2). (b) 3.3. Management. One patient with solitary HNBCC refused treatment. All others underwent surgical excision. Median skin margin taken on tumour excision was 2.0 (0–20) mm. Primary skin closure was achieved in 51.8% (n = 141). Other patients required reconstruction in the form of skin graft (11.7%, n = 32), local flap (35.3%, n = 96), and free flap (1.1%, n = 3) (Figure 3). 3.4. Treatment Outcomes. Skin margins were uninvolved, (c) involved, and close in 75.4% (n = 205), 15.4% (n = 42), and 9.2% (n = 25), respectively, with close skin margin being Figure 1: Common presentation of HNBCC in ethnic Chinese: defined as a pathological margin of less than one millimeter. pigmented lesion with well-defined borders, rolled ulcer edges, Involved and close skin margins were classified as inadequate central pearly area, and overlying telangiectasia. skin margins. The rate of tumour clearance was increased with an increase in skin margin taken on tumour excision— 25.3% (n = 40) inadequate margins for 2 mm margins versus 16.9% (n = 13) for 3 mm margins (P = 0.089) (Figure 4). 4. Discussion Most patients with involved margins (76.2%, n = 32) underwent reexcision; 4 (9.5%) underwent radiation ther- According to the Hong Kong Hospital Authority statistical apy. One developed local recurrence 2 years after reexcision. report 2007-2008, there was an increasing trend of skin The majority of those with close margins (92.0%, n = cancer in Hong Kong [15]. The rate of increase in skin 23) opted for observation. Four developed local recurrence cancer and BCC incidence in ethnic Chinese and other Asian thereafter. Two patients opted for reexcision, and none countries was less than that of the fair-skinned Caucasian recurred to date (Figure 5). population [16]. Further treatment in the form of reexcision or radiation BCC had a high predilection for the head and neck therapy in those with inadequate skin margins led to a lower region. HNBCC predominantly affected the elderly popu- recurrence rate than those who opted for observation (2.6% lation with a slight female preponderance in our locality. versus 13.8%, P = 0.106) (Figure 6). Follow-upperiodwas Common presentation was in the form of a pigmented ulcer indefinite for all patients. Overall recurrence rate was 5.5% over the nose. (n = 15) over a mean follow-up period of 73.0 (16–195) Our results were similar to those reported by Sng et months. Mean interval to recurrence was 36.6 (9–78) months al., Kikuchi et al., and Cho et al. [6, 17, 18]. This study, (Figure 7). The commonest site of recurrence was over the corroborated by reviews in other Asian countries, showed nose 20% (n = 3). that HNBCC in ethnic Chinese and other Asian populations International Journal of Surgical Oncology 3 1 Nasal ala Cheek 16.5% 2 Nose tip 3 Nasal bridge 1 Nasal ala 13.6% 4 Forehead Nasalbridge9.9% 8 5 Cheek Nasal tip 8.1% 2 6 Upper eyelid 7 Lower eyelid 8 Temple 9 Preauricular 10 Postauricular 11 Medical canthus 12 Lateral canthus 13 Neck 9 14 Upper lip 15 Lower lip 16 Scalp Ear Nasolabial fold 19 Chin 0 5 10 15 20 (%) Figure 2: HNBCC presentation—anatomical sites. The commonest site was on the nose. Free flap 1.1% Primary Local flap closure 51.8% 35.3% Skin graft 11.8% Figure 3: Methods of wound closure. From right to left in a clockwise direction: an 80-year-old lady with a pigmented ulcerative BCC over her left cheek, pathology excised with a 2 mm margins, wound closed primarily; a 60-year-old lady with a pigmented ulcerative BCC over her right preauricular region, the wound was too extensive for primary closure after tumour resection, and yet there was insufficient tissue for local flap reconstruction, hence a full thickness skin graft was harvested from the postauricular region for wound coverage; a 70-year-old lady with a nonpigmented nodular BCC over her nose tip. Excision was performed with a 2 mm margin followed by reconstruction with a bilobed flap; a 50-year-old lady who presented with a pigmented ulcerative BCC over her right auricle which invaded into the superficial and deep lobes of the parotid gland; facial nerve was intact. Wide local excision of tumour with total conservative parotidectomy was performed. The defect was reconstructed with a free anterolateral thigh myocutaneous flap. Site 4 International Journal of Surgical Oncology 2 mm margin 3 mm margin N = 158 N = 77 Involved margins Close margins Involved margin Close margin N = 22 N = 18 N = 7 N = 6 (13.9%) (11.4%) (9.1%) (7.8%) Inadequate margin Inadequate margin N = 40 N = 13 25.3% 16.9% Figure 4: Treatment outcome—the greater the skin margin taken on tumour excision, the better the tumour clearance rate. Involved margin Close margin N = 42 N = 25 Re-excision Radiotherapy Observe Re-excision Observe N = 32 N = 4 N = 6 N = 2 N = 23 (76.2%) (9.5%) (14.3%) (8%) (92%) Recurrence Recurrence No recurrence No recurrence No recurrence N = 1 N = 4 Figure 5: Management of patients with involved and close margins and associated recurrence rates. presented differently compared to the Caucasian population, adequate tumour control and conservation of normal tissue whereby HNBCC commonly presented as nonpigmented in an attempt to achieve acceptable functional and cosmetic nodules in male patients (Table 1)[6, 11, 17–19]. outcome. Excision of HNBCC with a 2 mm skin margin for The difference in trends, rates, and presentation in the well-defined lesions was adequate in most cases, with an two ethnic groups could be accounted for the difference in overall recurrence rate of 5.5%, which was comparable to skin types (Fitzpatrick types III and IV in Chinese versus that of large-scale studies conducted worldwide [20–23]. I and II in Caucasians), geographical latitude, sociocultural As cited in other reviews, our data also showed that the differences, varying occupational and sun exposure, skin nose was the site with the highest incidence of recurrence and protection, and differences in disease awareness and surveil- inadequate margins. This could represent embryonic fusion lance. planes where tumour can spread aggressively or because of There is no consensus as to the amount of skin margin a scarcity of surplus skin tissue which may present technical taken on tumour excision. However, as one would expect, difficulty on skin closure, resulting in a more conservative the greater the skin margin taken on tumour excision, the excision margin [24–27]. better the tumour control. In excising tumour over the For such difficult mid-face lesions, excision under frozen head and neck region, there is always a balance between section guidance or even Mohs micrographic surgery could International Journal of Surgical Oncology 5 Inadequate margin N = 67 Further treatment Observe N = 38 N = 29 Recurrence Recurrence N = 1 N = 4 2.6% 13.8% (P value = 0.106) Figure 6: Treatment outcomes of patients who chose to undergo further treatment versus observation in those with inadequate margins. Table 1: A table comparing our results with other Asian and Caucasian populations. Hong Kong (QMH) Singapore Japan Korea Australia N = 273 N = 292 N = 243 N = 78 N = 6252 Mean age (yrs) 73.1 70.9 59.0 58.2 62.0 M:F 0.70 0.95 0.97 0.90 1.13 Pigmented (76.2%) Pigmented (63%) Pigmented (75%) Pigmented (55%) Nonpigmented (93%) Clinical features Ulcer (64.8%) Ulcer (NA) Nodule (NA) Ulcer (NA) Nodule (50%) Site Nose (32.3%) Nose (37.0%) Nose (NA) Nose (26.9%) Nose (40.6%) In cases of inadequate skin margins, reexcision should be advocated to prevent recurrence and to decrease the chance of more radical surgery in the future; incompletely excised tumour and recurrent tumours are contributing factors to more aggressive tumour behaviour. The presence of scar tissue obscures monitoring and delays clinical detection. Fibrotic scar tissue entraps malignant cells and favours deep extension by preventing upward migration [27, 31, 32]. 5. Conclusions HNBCC commonly presented as pigmented ulcers over the cheek and nose of elderly female patients of Chinese ethnicity in our locality. This corroborated with studies conducted in 0 20406080 100 other Asian countries but contrasted with those of Caucasian Time(months) populations in that HNBCC commonly presented as non- pigmented nodules in the male population. Tumour excision Figure 7: A graph depicting tumour recurrence over time. with a 2 mm skin margin for HNBCC with well-defined margins yielded a tumour control rate comparable with other large-scale studies. Various reconstructive techniques be advocated to enhance complete tumour removal whilst could be adapted in cases where primary skin closure could preserving the maximal amount of normal tissue [11, 19, 23, not be achieved after adequate tumour resection. Reexcision 28–30]. Various reconstructive techniques such as skin graft, of lesions with inadequate margins improved local tumour local flaps, or even free flaps could be used for skin coverage if the defect is too extensive for primary closure. control. Recurrence 6 International Journal of Surgical Oncology Conflict of Interests [16] D. Koh, H. Wang, J. Lee, K. S. Chia, H. P. Lee, and C. L. Goh, “Basal cell carcinoma, squamous cell carcinoma and The authors declare that there is no conflict of interests. melanoma of the skin: analysis of the Singapore Cancer Registry data 1968–97,” British Journal of Dermatology, vol. 148, no. 6, pp. 1161–1166, 2003. [17] A. Kikuchi, H. Shimizu, and T. Nishikawa, “Clinical and References histopathological characteristics of basal cell carcinoma in Japanese patients,” Archives of Dermatology, vol. 132, no. 3, pp. [1] American Cancer Society, “Detailed guide: skin cancer–basal 320–324, 1996. and squamous cell”. [18] S. Cho, M. H. Kim, K. K. Whang, and J. H. 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Hindawi Publishing Corporation
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Copyright © 2011 Velda Ling Yu Chow et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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10.1155/2011/890908
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Abstract

Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 890908, 7 pages doi:10.1155/2011/890908 Clinical Study Basal Cell Carcinoma of the Head and Neck Region in Ethnic Chinese Velda Ling Yu Chow, Jimmy Yu Wai Chan, Richie Chiu Lung Chan, Joseph Hon Ping Chung, and William Ignace Wei Division of Head and Neck, Plastic and Reconstructive Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong Correspondence should be addressed to Velda Ling Yu Chow, vlychow@gmail.com Received 1 May 2011; Revised 4 June 2011; Accepted 8 June 2011 Academic Editor: Michael Veness Copyright © 2011 Velda Ling Yu Chow et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. This study aims to report our experience in the management of HNBCC in ethnic Chinese over a 10-year period. Methods. A retrospective review of all ethnic Chinese patients with HNBCC treated in a tertiary centre from 1999 to 2009. Results. From 1999 to 2009, 225 patients underwent surgical excision for HNBCC. Majority were elderly female patients. Commonest presentation was a pigmented (76.2%) ulcer (64.8%) over the nose (31.6%). Median skin margin taken on tumour excision was 2.0 mm; primary skin closure was achieved in 51.8%. Postresection skin margin was clear in 75.4%. Of those with inadequate skin margins, 56.7% opted for further treatment, 43.4% for observation. Recurrence rates were 2.6% and 13.8%, respectively (P = 0.106). Overall recurrence rate was 5.5%. Conclusions. HNBCC commonly presented as pigmented ulcers over the nose of elderly female patients in our locality. Adequate tumour excision ± reconstruction offered the best chance of cure. Reexcision of those with inadequate skin margins improved local tumour control. 1. Introduction electrodessication, cryosurgery have been reported with vari- able treatment outcomes; similarly, topical and intralesional The incidence of skin cancer is increasing worldwide, agents, photodynamic therapy have also been described, possibly arising from an ageing population and increasing again with variable outcomes, warranting careful patient sunlight exposure. Basal cell carcinoma (BCC) is the most selection [11–14]. prevalent. The incidence of which is increasing at 3% per Much has been published regarding BCCs in Caucasian annum [1–7]. populations, but data on ethnic Chinese are less read- BCC most often arise in areas of long-term sun exposure ily available. We herein report the patient demographics, with a high predilection for the head and neck area. Classical tumour characteristics, surgical management, and outcome clinical features include raised and rolled edges, pearly of HNBCCs in ethnic Chinese patients in Hong Kong. central area with telangiectasia. Lesions may be pigmented or nonpigmented; nodular, ulcerative, erythematous patches or even mimic benign lesions. Most BCCs are indolent with 2. Materials and Methods a low incidence of metastasis [8–11]. The mainstay of treatment for BCC of the head and neck A retrospective review of all ethnic Chinese patients with region (HNBCC) is surgical excision with adequate margins. previously untreated HNBCC managed in the Queen Mary Radiotherapy may be advocated as definitive treatment for Hospital, The University of Hong Kong, Hong Kong, a selected group of patients, for those unfit for surgery between 1999 and 2009. Queen Mary Hospital was one or as an adjuvant treatment for those with inadequate of the largest regional hospitals in Hong Kong. It was margins. Other treatment modalities such as curettage and a tertiary and quaternary referral centre for the entire 2 International Journal of Surgical Oncology territory. Outcome measures included patient demographics, tumour characteristics, surgical management, management of patients with inadequate margins, and recurrence rates. Statistical analysis was performed using SPSS 18.0. 3. Results 3.1. Patient Demographics. A total of 226 HNBCC patients of Chinese ethnicity were treated in our centre from 1999 to 2009. Mean age was 73.1 (22–100) years. There were 132 female and 94 male patients with a male to female ratio of (a) 0.7. 25 patients had multiple BCC lesions. There were a total of 273 HNBCC lesions. 3.2. Tumour Characteristics. There were 65 (23.8%) non- pigmented and 208 (76.2%) pigmented lesions. The most common presentation was in the form of an ulcer (64.8%, n = 177), followed by nodule (19.3%, n = 53), erythema (1.1%, n = 3), and lesions that mimic a benign lesion, for example, keratosis (14.7%, n = 40) (Figure 1). Common sites of involvement included the nose (31.6%, n = 86) and cheek (16.5%, n = 45) (Figure 2). (b) 3.3. Management. One patient with solitary HNBCC refused treatment. All others underwent surgical excision. Median skin margin taken on tumour excision was 2.0 (0–20) mm. Primary skin closure was achieved in 51.8% (n = 141). Other patients required reconstruction in the form of skin graft (11.7%, n = 32), local flap (35.3%, n = 96), and free flap (1.1%, n = 3) (Figure 3). 3.4. Treatment Outcomes. Skin margins were uninvolved, (c) involved, and close in 75.4% (n = 205), 15.4% (n = 42), and 9.2% (n = 25), respectively, with close skin margin being Figure 1: Common presentation of HNBCC in ethnic Chinese: defined as a pathological margin of less than one millimeter. pigmented lesion with well-defined borders, rolled ulcer edges, Involved and close skin margins were classified as inadequate central pearly area, and overlying telangiectasia. skin margins. The rate of tumour clearance was increased with an increase in skin margin taken on tumour excision— 25.3% (n = 40) inadequate margins for 2 mm margins versus 16.9% (n = 13) for 3 mm margins (P = 0.089) (Figure 4). 4. Discussion Most patients with involved margins (76.2%, n = 32) underwent reexcision; 4 (9.5%) underwent radiation ther- According to the Hong Kong Hospital Authority statistical apy. One developed local recurrence 2 years after reexcision. report 2007-2008, there was an increasing trend of skin The majority of those with close margins (92.0%, n = cancer in Hong Kong [15]. The rate of increase in skin 23) opted for observation. Four developed local recurrence cancer and BCC incidence in ethnic Chinese and other Asian thereafter. Two patients opted for reexcision, and none countries was less than that of the fair-skinned Caucasian recurred to date (Figure 5). population [16]. Further treatment in the form of reexcision or radiation BCC had a high predilection for the head and neck therapy in those with inadequate skin margins led to a lower region. HNBCC predominantly affected the elderly popu- recurrence rate than those who opted for observation (2.6% lation with a slight female preponderance in our locality. versus 13.8%, P = 0.106) (Figure 6). Follow-upperiodwas Common presentation was in the form of a pigmented ulcer indefinite for all patients. Overall recurrence rate was 5.5% over the nose. (n = 15) over a mean follow-up period of 73.0 (16–195) Our results were similar to those reported by Sng et months. Mean interval to recurrence was 36.6 (9–78) months al., Kikuchi et al., and Cho et al. [6, 17, 18]. This study, (Figure 7). The commonest site of recurrence was over the corroborated by reviews in other Asian countries, showed nose 20% (n = 3). that HNBCC in ethnic Chinese and other Asian populations International Journal of Surgical Oncology 3 1 Nasal ala Cheek 16.5% 2 Nose tip 3 Nasal bridge 1 Nasal ala 13.6% 4 Forehead Nasalbridge9.9% 8 5 Cheek Nasal tip 8.1% 2 6 Upper eyelid 7 Lower eyelid 8 Temple 9 Preauricular 10 Postauricular 11 Medical canthus 12 Lateral canthus 13 Neck 9 14 Upper lip 15 Lower lip 16 Scalp Ear Nasolabial fold 19 Chin 0 5 10 15 20 (%) Figure 2: HNBCC presentation—anatomical sites. The commonest site was on the nose. Free flap 1.1% Primary Local flap closure 51.8% 35.3% Skin graft 11.8% Figure 3: Methods of wound closure. From right to left in a clockwise direction: an 80-year-old lady with a pigmented ulcerative BCC over her left cheek, pathology excised with a 2 mm margins, wound closed primarily; a 60-year-old lady with a pigmented ulcerative BCC over her right preauricular region, the wound was too extensive for primary closure after tumour resection, and yet there was insufficient tissue for local flap reconstruction, hence a full thickness skin graft was harvested from the postauricular region for wound coverage; a 70-year-old lady with a nonpigmented nodular BCC over her nose tip. Excision was performed with a 2 mm margin followed by reconstruction with a bilobed flap; a 50-year-old lady who presented with a pigmented ulcerative BCC over her right auricle which invaded into the superficial and deep lobes of the parotid gland; facial nerve was intact. Wide local excision of tumour with total conservative parotidectomy was performed. The defect was reconstructed with a free anterolateral thigh myocutaneous flap. Site 4 International Journal of Surgical Oncology 2 mm margin 3 mm margin N = 158 N = 77 Involved margins Close margins Involved margin Close margin N = 22 N = 18 N = 7 N = 6 (13.9%) (11.4%) (9.1%) (7.8%) Inadequate margin Inadequate margin N = 40 N = 13 25.3% 16.9% Figure 4: Treatment outcome—the greater the skin margin taken on tumour excision, the better the tumour clearance rate. Involved margin Close margin N = 42 N = 25 Re-excision Radiotherapy Observe Re-excision Observe N = 32 N = 4 N = 6 N = 2 N = 23 (76.2%) (9.5%) (14.3%) (8%) (92%) Recurrence Recurrence No recurrence No recurrence No recurrence N = 1 N = 4 Figure 5: Management of patients with involved and close margins and associated recurrence rates. presented differently compared to the Caucasian population, adequate tumour control and conservation of normal tissue whereby HNBCC commonly presented as nonpigmented in an attempt to achieve acceptable functional and cosmetic nodules in male patients (Table 1)[6, 11, 17–19]. outcome. Excision of HNBCC with a 2 mm skin margin for The difference in trends, rates, and presentation in the well-defined lesions was adequate in most cases, with an two ethnic groups could be accounted for the difference in overall recurrence rate of 5.5%, which was comparable to skin types (Fitzpatrick types III and IV in Chinese versus that of large-scale studies conducted worldwide [20–23]. I and II in Caucasians), geographical latitude, sociocultural As cited in other reviews, our data also showed that the differences, varying occupational and sun exposure, skin nose was the site with the highest incidence of recurrence and protection, and differences in disease awareness and surveil- inadequate margins. This could represent embryonic fusion lance. planes where tumour can spread aggressively or because of There is no consensus as to the amount of skin margin a scarcity of surplus skin tissue which may present technical taken on tumour excision. However, as one would expect, difficulty on skin closure, resulting in a more conservative the greater the skin margin taken on tumour excision, the excision margin [24–27]. better the tumour control. In excising tumour over the For such difficult mid-face lesions, excision under frozen head and neck region, there is always a balance between section guidance or even Mohs micrographic surgery could International Journal of Surgical Oncology 5 Inadequate margin N = 67 Further treatment Observe N = 38 N = 29 Recurrence Recurrence N = 1 N = 4 2.6% 13.8% (P value = 0.106) Figure 6: Treatment outcomes of patients who chose to undergo further treatment versus observation in those with inadequate margins. Table 1: A table comparing our results with other Asian and Caucasian populations. Hong Kong (QMH) Singapore Japan Korea Australia N = 273 N = 292 N = 243 N = 78 N = 6252 Mean age (yrs) 73.1 70.9 59.0 58.2 62.0 M:F 0.70 0.95 0.97 0.90 1.13 Pigmented (76.2%) Pigmented (63%) Pigmented (75%) Pigmented (55%) Nonpigmented (93%) Clinical features Ulcer (64.8%) Ulcer (NA) Nodule (NA) Ulcer (NA) Nodule (50%) Site Nose (32.3%) Nose (37.0%) Nose (NA) Nose (26.9%) Nose (40.6%) In cases of inadequate skin margins, reexcision should be advocated to prevent recurrence and to decrease the chance of more radical surgery in the future; incompletely excised tumour and recurrent tumours are contributing factors to more aggressive tumour behaviour. The presence of scar tissue obscures monitoring and delays clinical detection. Fibrotic scar tissue entraps malignant cells and favours deep extension by preventing upward migration [27, 31, 32]. 5. Conclusions HNBCC commonly presented as pigmented ulcers over the cheek and nose of elderly female patients of Chinese ethnicity in our locality. This corroborated with studies conducted in 0 20406080 100 other Asian countries but contrasted with those of Caucasian Time(months) populations in that HNBCC commonly presented as non- pigmented nodules in the male population. Tumour excision Figure 7: A graph depicting tumour recurrence over time. with a 2 mm skin margin for HNBCC with well-defined margins yielded a tumour control rate comparable with other large-scale studies. Various reconstructive techniques be advocated to enhance complete tumour removal whilst could be adapted in cases where primary skin closure could preserving the maximal amount of normal tissue [11, 19, 23, not be achieved after adequate tumour resection. Reexcision 28–30]. 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