Follow-up of Cases treated Surgically.--After operation all cases have been seen regularly in the department for two years. After this many have been

Transcription

1 THE SURGICAL TREATMENT OF BASAL-CELLED CARCINOMA By R. J. V. BATTLE, M.Chir., F.R.C.S., and T. J. S. PATTERSON, F.R.C.S. St Thomas's Hospital, London [RODENT ulcers appear in many forms, but from the surgeon's point of view there are only two types. One remains superficial and localised; the other not only invades deeply, destroying the deeper tissues down to and including bone, but also spreads widely in the skin. The first group carries a good prognosis. These turnouts are by far the more common and provide material for large series of cases treated by radiotherapy with a very low recurrence rate (Churchill-Davidson and Johnson, 1954). The less common invasive group, either because of incomplete eradication or by expansion of the field of origin, is responsible for most of the recurrences after treatment, whether by radiotherapy or by surgery. Surgery has an important part to play in the treatment of rodent ulcers. The purposes of this paper are to define the indications for surgical treatment and to study the small group of invasive turnouts with a view to improving the results of treatment. It is based on the experience of the management of 242 patients with 286 rodent ulcers in the comparatively small Department of Plastic Surgery at St Thomas's Hospital in the ten years from 1947 to 1956 (Table I). TABLE I Total number of patients. Male. Female Number of ulcers Age distribution-- under to to to 50 5 to to 7 7 and over (youngest patient I5) Distribution of Rodent Ulcers (Fig. I).--This follows the usual pattern. In ten patients there were multiple ulcers. Biopsy.--Two patients refused surgical treatment and were referred to the Radiotherapy Department. One patient presented with recurrent ulceration after irradiation of a rodent ulcer. While awaiting surgical treatment the area healed and has remained healed to the present time. With the exception of these the diagnosis in all cases has been confirmed histologically. Follow-up of Cases treated Surgically.--After operation all cases have been seen regularly in the department for two years. After this many have been 118

2 THE SURGICAL TREATMENT OF BASAL-CELLED CARCINOMA 119 discharged to the care of their own doctors with instructions to report if there is any further ulceration. For the purpose of this paper about half the cases have been recently examined personally ; the remainder have been followed up by letter either to the patient or to his doctor. The very great length of time which elapses in some cases after primary treatment, before a recurrence or the incidence of a second primary, makes us wonder whether even ten years is a long enough period for adequate follow-up. In a condition where multiple tumours are so common, it may be that a different standard of cure-rate is required. Surgical Results. -- One hundred and ninety-seven patients have been followed up for three years, and within that number there have been ten recurrences. Only lo2 patients have been followed up over five years, and in this series there were two recurrences. The discrepancy between these two results may be explained by the increased severity of the types of growth with which we have been faced within recent years. ~ V. OPHTHALMIC LIMBS 5. We have had three " recur- TRUNK 22. rences" in patients who had D V. MAXILLARY been operated on ten years r.ec 4 previously. ~.< BACK 12 V. MANDIBULAR I LOIN Two patients died within a ~zzgz4 I. CHE$T 3 few weeks of operation, both F~G. from cerebral catastrophes (one of hemiplegia and one of cerebral hmmorrhage). Three patients died of other conditions and forty patients have not been traced. In a number of patients persistence of ulceration in spite of every attempt at eradication of the condition has led either to demise or to such crippling effects that the patients could no longer lead a normal existence. Two are alive but blind after forty and thirty years respectively. Another died after enduring many operations and irradiations over twenty-four years and one patient committed suicide at the age of 75 after a period of only five years, during which time it had been necessary to inflict upon him a facial palsy. PATHOLOGY Rodent ulcers are tumours of specialised cells of the basal layer--cells which would normally be responsible for the formation of epidermal appendages. The

3 I20 BRITISH JOURNAL OF PLASTIC SURGERY expanding or invading edge of these tumours is composed of compact masses or columns of such small, immature epithelial cells, easily recognisable under the microscope. Maturation which leads to keratinisation and to the production of " cell nests " may be observed at the centre of established epithelial masses but not at the growing edge. Although metastasis of rodent ulcers has been reported (De Navasquez, I94I ; Eckhoff, I951 ; Hunt, I952) there is characteristically no free dissemination via lymphatic or blood streams. Either tumour cells do not become detached from the main masses or else if they do so they are unable to survive in remote sites. This is in marked distinction to squamous carcinomas, which are tumours of surface epithelium which is less specialised and which has an invading edge of more mature squamous cells. These cells grow after the manner of regenerating surface epidermis, are able to disseminate, and survive as free metastases. It used to be taught that a rodent ulcer could change its character and become a squamous carcinoma, with an intermediate basi-squamous stage. It seems very doubtful if this ever happens (Whimster, I959). Most rodent ulcers grow slowly and are not painful. In time, however, they can penetrate all tissues including cartilage, bone, and dura. Early diagnosis is therefore essential and a brief account will be given of the different clinical types. Types of Rodent Uleer.--(i) The small ulcer with a rolled and translucent margin--the classical rodent ulcer. This is often seen round the eyes and on the nose, commonly near the inner canthus overlying the lachrymal apparatus or angular vein. (2) Cystic turnouts (Fig. 2, A). These are commonly found round the mouth, on the lips, or chin. Ulceration occurs late, and it is often difficult to differentiate them from other skin lesions, such as epidermoid cysts and moles. The diagnosis is sometimes made only after histological examination. We would stress here the importance of examining all recurrent lesions under the microscope. We have seen several rodent ulcers excised without microscopy under the impression that they were cysts and excised a second time after a recurrence without the surgeon being aware of his error. Among these cystic lesions are two well-defined groups :-- (a) Pigmented rodent ulcers. Histologically many rodent ulcers can be seen to contain small quantities of pigment and sometimes the pigmentation is visible to the naked eye. Such lesions can be distinguished from melanomata by the distribution of the pigment which is present in little aggregates scattered diffusely through the lesion producing a fine speckled appearance ; in a melanoma the pigmentation is either homogenous or fades gradually from darker to lighter across the lesion. (b) Hamartomata (Fig. 2, B). These appear usually as multiple lumps in the skin. Sometimes one or two of the lesions change character and become proliferative and ulcerated, but penetration is rare. Histologically they are still basal-celled, but it is clear that the cells are trying to reproduce the adnexa of the skin and hair follicles or sweat glands. These hamartomata are usually sensitive to irradiation (Fig. 2, B). (3) The third group, usually found on the forehead or nose, are shallow ulcers with irregular and ill-defined margins. On one side the lesion appears to be healing but elsewhere it slowly extends. It is probable that this group

4 THE SURGICAL TREATMENT OF BASAL-CELLED CARCINOMA 12I is the result of too much sun on white skin. In Australia and Africa one sees these ulcers which are often multiple. They are rarely seen in pigmented FIG. 2 Some of the many different clinical types of basal-celled lesions. A, Cystic type of ulcer occurring on the chin. B, Hamartoma. C, Extensive superficial lesion demonstrating areas of breakdown and other adjacent areas of healing. D, Cutaneous plaque resembling chronic eczema. skins which appear to have a natural resistance but which instead are more susceptible to a squamous-celled change. (4) In the fourth group are lesions that are rarely found on the face (Fig. 2, n). These are the cutaneous plaques resembling chronic eczema, Bowen's disease, or psoriasis. They are important only for their nuisance value and are not

5 122 BRITISH JOURNAL OF PLASTIC SURGERY dangerous. They form scaly patches on the trunk and limbs and are often multiple. Definite ulceration is less common than in eczema. They rarely recur following excision. All these preceding groups can be thought of as simple rodent ulcers. They constitute at least 9o per cent. (if not more) of all the lesions that we treat and it is their relatively benign aspect and progress which must have led Wakeley and Childs (1949) to comment on the easy surgical problem involved (Rank and Wakefield, 1958). There is a separate fifth group of rodent ulcers that has highly dangerous properties and which, though constituting less than IO per cent. of the total, is more difficult to cure than all the remaining ulcers put together (Fig. 3). The term " terebrant " was used by Sequeira (1911) to describe a highly invasive type of rodent ulcer. " The new formation and ulceration progress very rapidly in depth rather than on the surface and produce huge excavations... " Microscopically these lesions in their early stages are indistinguishable from the simple group, but there is some evidence that they can be differentiated histologically (Whim- Fro. 3 ster, 1959). In practice it is usually Penetrating lesion affecting the maxilla and nasal the clinical behaviour of these floor in a patient with old healing lupus, tumours that suggests the diagnosis ; it is not until there have been several recurrences after treatment that the surgeon realises he is dealing with an unusual type of tumour. On going through these case histories it is apparent that there may be some truth in the saying : " Once a rodent ulcer recurs after treatment it will always win in the end" (Bodenham and FitzGibbon, 1949 ; Bodenham, 1951). In some cases a large area of the skin of the face appears to be potentially turnout-bearing, and the results of radical surgery in this group may be disappointing. The primary growth appears to act as a trigger which sets off malignant change in surrounding unstable skin. After wide excision growth may still recur at the edge of the treated area. The problem is to know how wide to make this primary excision. It is difficult to be certain whether growth at the edge of a treated area is a true recurrence due to incomplete eradication or a fresh primary. Rodent ulcers are not uncommonly multiple, particularly on the face, and Willis (1953) states that there may be "microscopic loci in skin not visibly affected" and "the extent of the potentially neoplastic field is much greater than the small

6 THE SURGICAL TREATMENT OF BASAL-CELLED CARCINOMA I23 size of the initially appearing tumour would suggest--a point of great surgical importance." In this group one also sees rodent ulcers on the face of a victim of long-standing lupus or of treatment by X-rays (see Fig. 3). It has already been stated that actinic irradiation can be held responsible for some rodent ulcers, and in the case of lupus the carcinogenic agent may be the same because there are very few victims of lupus who have not had many sessions of ultra-violet rays. There are also women who have had treatment for hirsuties by X-rays twenty-five to thirty years before. The degeneration of the skin which follows slowly over the next decades may end with one or more rodent ulcers of the penetrating type. TREATMENT Radiotherapy.--In I954 two of our colleagues in the Radiotherapy Department at St Thomas's Hospital analysed the results of their treatment of 7ii rodent ulcers by X-rays (Churchill-Davidson and Johnson, I954)- They have treated only the smallest ulcers which penetrated neither cartilage nor bone. In 711 cases they have seen only twenty-six recurrences. (Followed up for three years without recurrences, 95"7 per cent ; for five years without recurrences, 92.6 per cent.) At the same time it must be noted that they did biopsies in only 32 per cent. of all the cases and that among the recurrences the writers did not count the lesions that had not disappeared in the course of treatment--fourteen in all (i "9 per cent.). It is clear that for the small ulcers, not yet penetrating underlying structures, the results of X-rays are excellent. Unfortunately we get many patients to treat who have large ulcers which penetrate bone and cartilage, and which have also been treated without success by radiotherapy (Table II). TABLE II Number of patients 22i Number of ulcers Ulcers already treated by radium or by X-rays.. I22 Without any treatment IO8 Already operated on.. 6 Already operated on and treated by radiotherapy 7 We have made an analysis of those ulcers sent to us for treatment, which had appeared following treatment by irradiation. Fifty per cent. of these lesions had persisted or had recurred less than a year after treatment. Thirty (plus one died) of the ulcers were not " rodents " but necrosis accompanied by radiodermatitis ; these lesions, after excision, have been cured. One of our patients died after a surgical intervention for necrosis of the mandible. This underlined for us the importance and the special danger that there is in treating the penetrating ulcers by radiotherapy. From the experience that we have drawn from our own series, X-rays are indicated for the treatment of rodent ulcers in the following cases :-- I. Small and superficial lesions. 2. Certain big and advanced lesions; where the irradiation will make the eventual surgery easier (Fig. 4).

7 I24 BRITISH JOURNAL OF PLASTIC SURGERY 3. Patients too old for surgical intervention, or who refuse surgery. 4. W h e n surgery and X-rays have not reached a cure, this does not mean A, B, C, D, FIG. 4 Basal-celled lesion of the orbit. When first seen before treatment with X-rays. After treatment with X-rays--recurring. The forehead has been employed to blank out the orbit after exenteration. The pedicle of this flap was later returned. Wearing a prosthesis. No recurrence after five years. that X-rays are useless for the entire course of the illness. In certain cases we have obtained some success by employing X-rays when all hope had been lost.

8 THE SURGICAL TREATMENT OF BASAL-CELLED CARCINOMA 12 5 Radiotherapy after Surgery.--If surgical treatment of large rodent ulcers is carried out on the lines described below, radiotherapy will not be required after surgery. In exceptional cases, terebrant growths which have initially recurred after several courses of radiotherapy and become apparently completely zadio-resistant, may become once more radio-sensitive after wide surgical excision (Kinmonth, 1957). In these very difficult cases, most of which have become incurable by surgery, radiotherapy is worth a trial. The role of surgery in the treatment of basal-celled carcinoma must be,considered under two headings :-- I. Excision of the lesion. 2. Reconstruction. Under the second of these we must again consider immediate and delayed reconstruction. Excision gives us two things of great importance--an exact diagnosis and the assurance that everything is excised. Small pieces of a tumour often provide ~mreliable evidence on section, and it is often no more difficult to remove the whole lesion than to take a piece for biopsy. Thus in any case where the clinical diagnosis is uncertain it is advisable to have the lesion completely excised for "the best biopsy is one in which the entire lesion is removed and examined-- diagnosis and possibly cure at one time" (Battle, 1955) (Fig. 5)- Surgical Treatment.--It is rare to find one of our patients with a small lesion which can be removed without leaving a defect. A free graft is sufficient for the small defect, and it is the grafts taken from behind the ear which give the best results. Very often a flap is necessary, especially (I) when the eyelid is missing, (2) when bone is exposed, (3) when the dura, lateral sinus, or temporomandibular joint are exposed. It is necessary to find a neighbouring flap which is not always easy or, if this is not possible, a flap of the skin of the forehead. Growths round the Eye.--Growths round the eye, particularly in older patients, are best treated by surgical excision. Radiotherapy may cause damage to the lachrymal apparatus and scarring in the lids, producing ectropion ; there may be actual damage to the globe and the hazard of a post-irradiation cataract is well understood. During surgical treatment damage to the lacrymal apparatus may be unavoidable if it is involved by growth. Even if the extent of surgical excision seems to make damage certain, the symptoms which result are very variable and may be minimal. This is in contrast to the post-irradiation case where symptoms may be distressing and prolonged. Ectropion may be avoided by careful attention to the direction of scar lines during excision of the tumour. Except in small lesions, removal of skin in the horizontal plane parallel to the lid margin will produce ectropion. If this type of incision is essential, then immediate skin replacement must be carried out. It is better if the scar can be placed obliquely, the nearer to the vertical plane the better. Small growths of the free border can be excised as a "V" in full thickness of the lid and sutured without distortion.

9 126 BRITISH JOURNAL OF PLASTIC SURGERY Destruction of part of one or both eyelids must at once be followed by reconstruction, or else (and this is true of the upper eyelid) the eye may be lost. If there is invasion of the orbit, this has to be exenterated, leaving a large raw A B FIG. 5 Two basal-celled lesions in the right cheek treated by excision and repair with a large rotation flap. A, Shows the presence of (I) a large penetrating ulcer over the infraorbital margin, and (2) a small superficial lesion in front of the right ear. B, Excision of both lesions and the immediate repair with a rotation flap. C, The result nine months later. There has been no recurrence but six years after this repair another lesion appeared in the left cheek which was promptly removed under local anmsthesia. C surface of bone to be covered. It used to be our practice to employ the forehead for this cover--a somewhat extravagant procedure that has two advantages. Firstly, it is an insurance of quick healing with a durable skin cover that will bear

10 THE SURGICAL TREATMENT OF BASAL-CELLED CARCINOMA 12 7 the weight of a prosthesis, and secondly it will also stand up if necessary to irradiation of any subsequent recurrences. Against the immediate use of the forehead, the orbital bone readily accepts a Thiersch graft, and the forehead can be spared for use later, should recurrences lead to the necessity for exposure of the cribriform plate or the dura or the t~nderlying brain itself. On the whole, FIG. 6 Rodent ulcer penetrating cartilage of right ala. Treatment--excision of entire area in full thickness and immediate reconstruction with a composite Wolfe graft from lobule of right ear. therefore, we have come to employ a free graft for the orbit and to keep the forehead in reserve. Furthermore, no reconstruction can produce anything similar to the normal eye with its movements and eyelids with their closure, and there is therefore only one ultimate fate for these patients who have had an exenteration--a prosthesis to conceal their deformity from the prying eyes of their fellows. A ground glass in their spectacle frame is not enough. The prosthesis can be a simple eye-shade that conveys the Nelson touch, or else it can be more complicated and can carry an eye and an eyebrow. Rodent Ulcers of the Ear.--There is little subcutaneous tissue between the skin and the cartilage of the pinna. If cartilage becomes exposed and infected, as is common in burns of the ear, it becomes progressively necrotic and extremely painful and is gradually absorbed. In cases treated by radiotherapy the risk of necrosis is considerable, even if the growth was not previously adherent to the cartilage. Once necrosis of the cartilage is established it may prove intractable

11 I28 BRITISH JOURNAL OF PLASTIC SURGERY and pain is severe. Radiotherapists would agree that rodent ulcers which have already invaded bone or cartilage should be referred for surgical treatment, but, in fact, the risk of cartilage necrosis makes it advisable that all rodent ulcers of A B FIG. 7 Basal-celled lesion of the ear. (Examination of the specimen suggested multicentric origin). A, When first seen. B, Complete excision and repair with a large scalp flap. A small free graft completed the cover in front of the external auditory meatus. G, Wearing his prosthesis. C the pinna should be treated by surgery. If adherent to cartilage, surgical treatment is essential. Adherence to cartilage of ear or nose can be demonstrated at operation by the injection of saline or local anaesthetic under the ulcer in an attempt to raise it off the cartilage. If the ulcer is adherent, the cartilage should be removed; probably in this case a full-thickness defect should be created by sewing skin to skin round the margins and further cartilage may have to be removed to allow easy skin closure. If the deeper layer of skin is left, a Thiersch graft will take readily. Full-thickness defects of the rim of the ear can be repaired simply by

12 THE SURGICAL TREATMENT OF BASAL-CELLED CARCINOMA I2 9 converting the defect into a series of triangles. Defects of the concha can be obliterated by the use of a flap of post-auricular skin. Removal of the ear in an adult can always be followed by the wearing of a prosthesis. The only indication for total reconstruction of the ear in an adult must be an inability on the part of the patient to tolerate the gadget. If he demands a reconstruction then it must be pointed out that many stages will be necessary and that the final object will in no way resemble an ear (Fig. 7). In the severe cases in which the lateral sinus and dura become exposed, and certainly in those where,:the temporo-mandibular joint remains open to the four winds, a scalp flap is always available to produce the protection necessary. In all severe lesions involving the eye and the ear our only problem is to obtain early healing with sound skin cover and then to organise a camouflage by artificial means. Rodent Ulcers of the Trunk.--Large, superficial rodent ulcers of the trunk, particularly in areas where the blood supply is poor, such as the midline of the back, are liable to radionecrosis if treated by radiotherapy. In view of their size and site, surgery is preferable. The area may be small enough to be closed by direct approximation but, if not, then a free skin graft is required. Repair of Defects of Scalp and SkulL--When the bone of the skull is denuded of pericranium, a free graft willnot survive unless the outer table is removed and the graft bedded on the vascular diplce. Bare bone should be covered by a flap of adjacent scalp. In the pre-operative preparation of these cases a wide area of scalp should be shaved, leaving always the actual hairy margin as a landmark, to avoid, if possible, transferring hairy skin unnecessarily on to the face. In irradiated cases a free graft on the pericranium may fail to take, and bone becomes exposed and sequestrates very slowly as with exposed skull in other conditions. Cure of this defect then requires full-thickness excision of bone (unless bleeding bone is reached) and repair by a local flap from the scalp. A free graft will grow on exposed dura and suffices as a temporary measure, but provides insufficient cover to protect the brain from injury in daily life. To complete the repair, a bone graft may be needed and this will require cover by a flap. Normally we postpone this procedure to the time of delayed repair. If brain is exposed a flap will satisfactorily cover the defect (Fig. 8). This can be transferred from adjacent scalp. There is no need to line such a flap with fascia or any other material. Endothelium grows very rapidly over the under surface and adhesion to underlying tissue does not occur (Fig. 9). CONCLUSION To summarise the points made so far in the treatment of simple rodent ulcers we believe that surgical treatment should be advised in the following cases :-- I. Small lesions where the diagnosis is uncertain. 2. Rodent ulcers of the pinna. 2C

13 130 BRITISH JOURNAL OF PLASTIC SURGERY Fit. 8 A, B, Extensive penetrating lesion of left frontal bone. Dura involved over a wide area. C, D, Entire lesion excised. Scalp flap brought forward from the back of the head. Immediate cover of the donor area obtained with a Thiersch graft. The pedicle of the flap was replaced at a later stage. Recurrence took place within a year along the supraorbital margin and the left eye was eventually exenterated. (Collaboration with M r Harvey Jackson.)

14 THE SURGICAL TREATMENT OF BASAL-CELLED CARCINOMA I3r 3. Rodent ulcers of the eyelids and inner canthus. 4- Rodent ulcers over the cartilaginous skeleton of the nose. 5. Large rodent ulcers of the trunk. 6. All recurrences after radiotherapy and failures to respond to radiotherapy. A B FIG. 9 A, Severe lesion penetrating the left frontal bone and involving the posterior wall of the orbit. Dura was involved over a wide area. B, Entire area excised and orbit exenterated ; scalp flap employed to cover the brain and orbital floor. The donor area of this flap was covered with a Thiersch graft. (Collaboration with Mr Harvey Jackson). Radiotherapy is advised for the following cases :-- I. Sites other than those enumerated above. 2. The patient refuses operation. 3. Rarely, the patient is considered to be unfit for operation. On going through the records of large rodent ulcers treated in this department, a higher recurrence rate was noted in those which involved the orbit. Ten of these patients have had the orbit exenterated. The clinical course of these tumours had been typical of the terebrant type and we have made a special study of the records of these patients. It would be fair to say that association with one or even with both eyes is a characteristic of the terebrant lesion, and it is perhaps this association that makes it so difficult to produce a radical cure. The neighbourhood of the eye, particularly the lower lid and inner canthus, is a common site of origin. The orbit may, however, be involved by a rodent ulcer which in the first place originated at a distance. The spread of such tumours seems to follow a course which is to some extent predictable (Whimster, I959). From a point of origin near the centre of the face, the growth spreads,.centrifugally, but more rapidly to one side in an upward and outward direction

15 IB2 BRITISH JOURNAL OF PLASTIC SURGERY until one orbit is reached. Involvement of the other orbit then takes place by spread upwards and inwards over the glabella. The turnout takes many years to run this course, which is illustrated by the record of G. S., now aged 70, who first received treatment at this hospital in 1917 for a small rodent ulcer.on the left side of the nose (see below, Fig. IO). Two patients in this series have been under observation at this hospital for more than twenty-five years. In these it is interesting to note how often a suspicious area of recurrence with a small crust or scab has been seen to be healed at the next attendance, only to present as a frank recurrence some months later. These tumours appear to send up off-shoots which break through the superficial layers of the skin and then fail to survive, so that the epithelium heals over for a time. In such cases any small raw area or scab is most probably a recurrence and should be treated by excision biopsy. Once the diagnosis of this type of tumour has been made, treatment should be by surgical excision. This may be carried out with diathermy, although the skin incision is made with a knife to prevent any possibility of necrosis of the skin.edge. The rapidity of spread of growth along the medial wall of the orbit and frequent involvement of the ethmoid cells make it essential that clearance should be particularly radical in this area, and the ethmoid cells should always be removed when under suspicion. To ensure adequate excision in depth, close co-operation with the pathologist is essential. He may be able to distinguish the type of growth likely to recur in its early stages. He will decide whether excision has been adequate or whether further areas should be removed, and this is where frozen sections can be so valuable. If the line of excision is histologically clear of the growth, recurrence in depth is rare and the frequent disappointments are caused by further growth.on the surface at the edge of the treated area. Fig. 7 shows a rodent ulcer which had been present on the side of the head without treatment for six years. There is a separate growth in front of the car 2 cm. away from the main growth with no neoplastic cells connecting them. In this case, if, before the smaller lesion had developed, a 2 cm. clear margin had been excised, it would still not have been enough to prevent recurrence. It would be impossible to arrange a comparable trial of various margins for excision, as.conditions vary so much from tumour to tumour. Most surgeons understand what is meant by the term " wide excision." At this moment perhaps it is not possible to state exactly how wide this should be. Radiotherapy.--Of the ten cases described, six recurred after full doses of irradiation. The remaining four were regarded as unsuitable for radiotherapy owing to the danger of damage to the eye, and involvement of bone by the growth. Radiotherapy may play a part in the primary treatment of these large rodent ulcers, if only to reduce the size of massive growths before operation. Should it prove impossible to excise a tumour completely radiotherapy may safely be given to the tumour area through a skin flap. Such cases are really inoperable, but palliative treatment may be required to remove a fungating growth or a useless and painful eye. Here radiotherapy post-operatively may prevent or delay recurrence. It may be argued that the cosmetic results of surgical treatment are bad and produce a severe mutilation in addition, but morbidity after operation is slight

16 THE SURGICAL TREATMENT OF BASAL-CELLED CARCINOMA I33 and the skill of the prosthetic appliance maker does much to disguise the deformity. General Comment.--The clinical course and response to treatment of these tumours differentiate them from the majority of rodent ulcers, and it is clear that different principles of treatment are required as well as different standards in assessing results. Where a wide area of skin is liable to undergo malignant change FIG. IO This patient first came to the hospital in I917 (see text for case history). The lesion for which he reported at this time was eventually removed and the orbital and cheek defects repaired with forehead flaps. Recurrence at the right inner canthus took place thirty years after the original lesion and is shown in 1954 to be still not under control. Penetration has continued slowly to the present time--surgery has been abandoned. it is never possible to speak of a " cure" of the disease. The aim of treatment will be to eradicate the primary focus with no damage to surrounding tissues and to ensure that if recurrences occur they will be accessible. The majority of recurrences in this group have been at the edge of the treated area. It may be that in the present state of our knowledge the best that can be done is to ensure that the primary focus has been adequately removed in depth and to accept the fact that further growth in the peripheral skin may occur. Palliative Operations.mSurgical treatment which has no hope of curing the disease may be required for :m I. Removal of a fungating growth and relief of pain, discomfort, and smell. 2. Reducing the chances of hremorrhage. 3. As an aid to radiotherapy, either to provide exposure or to re-surface a deep area of tumour with fresh skin which can withstand a further turnout dose.

17 I34 BRITISH JOURNAL OF PLASTIC SURGERY CASE REPORT G. S., male, aged 70 (Fig. lo). 19i 7. Rodent ulcer left side of nose. Treated with radium on several occasions Ulcer 2 in. diameter below left eye involving the side of the nose and the inner canthus. Then had repeated recurrences treated by diathermy excisions. April I938. Destruction of left nostril. Invasion of maxilla. Recurrence in left lower eyelid. September Recurrence at the inner end of the left eyebrow followed by :further recurrences treated by local excisions. September Eye involved. Operation : evisceration left eye. September No further recurrence. Repair of the defect carried out in stages by Mr H. Elliott Blake, F.R.C.S. February Recurrence at the root of the nose and in the right inner canthus. It has taken thirty years from the first appearance of this ulcer in the left side of the nose for growth to reach the orbit on the opposite side. February Fig. IO shows the grafted areas of the recurrences in 1947 and further growth on the edge of the graft at the right inner canthus Pain in the lower jaw due to several simple dental cysts which were removed. September Recurrence of growth at the right inner canthus. Operation showed ethmoid cells and medial wall of orbit extensively involved. Partial removal of tumour only, as it was not considered justifiable to remove the remaining eye in a man of his age until the onset of pain made it essential. SUMMARY I. The various clinical manifestations of the basal-celled carcinomas have been described and discussed. Special emphasis has been laid on the dangers of the "terebrant" variety. 2. An attempt has been made to evaluate the role of surgery in their treatment. We consider it most significant that approximately one half of the lesions which we have had to treat had previously failed to react favourably to radiotherapy. 3. Recurrences after our surgery have been more common in the first two years after treatment, but have been seen up to ten years or longer. The ulcers most likely to recur have been those of the terebrant variety, and many of these have been close to the eye. These recurrences are partly explained by inadequate excision--a temporisation forced on us by an understandable relu&ance to sacrifice the eye--but also by the characteristic of terebrant lesions, which is to spread by expansion of the field of origin. Recurrences are thus seen close to, but outside, the actual area of excision. These terebrant lesions are usually radio-resistant and form the hard core of :failures of both surgery and radiotherapy. 4. In our view there is no single approach to the problem of basal-celled carcinomas. Close co-operation between the surgeon and the radiotherapist will continue to be the basis on which treatment can be planned for any one case. This work has been carried out in St Thomas's Hospital. We are greatly indebted to Dr Fleming and Dr Ian Churchill-Davidson of the Department of Radiotherapy, to Mr G. G. Penman and Mr H. Ridley of the Ophthalmic Department, to Mr Harvey Jackson of the Department of Neuro-surgery, for close co-operation and advice; to Dr I. IV. IVhimster of the Medical School Pathology Department, who taught us anything we have learnt about the pathology of these lesions ; and to Mr Brandon of the Photographic Department for all.the photographic records.

18 THE SURGICAL TREATMENT OF BASAL-CELLED CARCINOMA 135 REFERENCES BATTLE, R. J. V. (r955). Trans. Stffohn's Hosp. Derm. Soc., p. 25. BODENHAM, D. C. (I95I). Brit. ft. plast. Surg., 4, I73. BODENHAM, D. C. and FITZGIBBON, G. M. (I949). Brit. ft. plast. Surg., 2, 13. CHURCmLL-DAVlDSON, I, and JOHNSON, E. (1954). Brit. reed. ft., r, I465. DE NAVASQUEZ, S. (I94I). ft. Path. Bact., 53, 437. ECKHOFF, N. (r95i). Brit. J. plast. Surg., 3, 264. HUNT, A. H. (I952). Brit. ft. Surg., 40, I51. KINMONTH, M. H. (I957). Personal communication. RANK, B. K. and WAKEFIELD, A. R. (I958). Brit. ft. Surg. 45, 53I. SEQUEIRA, J. H. (I91I). "Diseases of the Skin," p London : J. & A. Churchill. WAKELEY, C. and CHILDS, P. (I949). Brit. reed. ft., x, 737. WHIMSTER, I. (I959). Personal communication. WILLIS, R. A. (x953). " Pathology of Turnouts," 2nd edn. London: Butterworth & Co.