Afdeling Plastische Chirurgie, Dienst Heelkunde, Kliniek Minnewater, St Janshospitaal, Bruges, Belgium

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1 BASAL CELL CARCNOMATA OF THE HEAD AND NECK By GuY MONBALLU, M.D. Afdeling Plastische Chirurgie, Dienst Heelkunde, Kliniek Minnewater, St Janshospitaal, Bruges, Belgium THS survey is based on information collected from the records of the Combined Clinic at Nottingham over the period 199 to r964 and chosen by the departments dealing with malignant diseases of the skin (radiotherapy, dermatology and plastic surgery). From 96 all malignant skin lesions were referred to the Combined Clinic to be diagnosed and codified and for planning of treatment. One hopes that in years to come the figures obtained will provide a more accurate image of the distribution of skin malignancies in the overall population. This paper wilplimit itself to basal cell carcinomata of the head and neck and in particular will present the results of treatment. MATERAL A total number of 6 basal cell carcinomata were studied from 478 patients. The sex ratio was 66 males ( per cent.) and 1 females (4 per cent.). Previous reports corroborate the greater frequer/cy in men (Churchill-Davidson and Johnson, 194 ; Ferrara, 196o ; Tanner, 96O ; Hayes, 196). There were no coloured patients with basal cell carcinomata in this series, though immigrants are common in the area. Histopathological section of the lesions was carried out in all cases. This is considered to be of fundamental importance because the clinical diagnosis is not always certain and Schrire (196o) reported a o per cent. error rate even in the most experienced hands. Main (96) analysing our first oo cases at the Combined Clinic gives ~/misdiagnosis of 7" per cent. Age Group.--The patient's ages ranged from 7 to 91 years. Their age at the time of attending the clinic is shown in the following figure. The peak incidence was in the sixth decade. The age difference between the sexes was not markedly significant, but there was a slight tendency for men to develop the condition earlier (average age of 9"7 against 6o'89 in females). Number of Sites.--Most patients developed a solitary tumour in the head and neck area but 78 patients (16-1 per cent.) had a multilocal distribution. This is rather a high figure compared with the results of other authors (O' per cent., Churchill-Davidson and Johnson, 94 ; " per cent., Philip, 949 ; 7"4 per cent., Thomas, 9 ; 1"9 per cent., Belisario, 99 ; ' per cent., Hayes, 196). n Table is given a survey of the number of sites in both sexes. Twenty patients showed multiple tumours of varying type. The basal cell carcinomata were mostly associated with squamous cell carcinoma (4) and intra-epidermal carcinoma (). The remaining ones were found associated with malignant melanoma, mixed parotid tumour and multiple intra-epidermal carcinomata and squamous cell carcinomata. Size of Basal Cell Carcinoma.--The size of the lesions is reviewed in Table. Only those lesions actually measured were taken into account. Most lesions not measured were recurrences. The majority (7 per cent.) were of a small size and their diameter ranged from mm. to 9 mm. 00

2 BASAL CELL CARCNOMATA OF THE HEAD AND NECK t- ~8o "6 L 60 $ E ~ ,H H - - r'i 1 F-' g g 0-g go-gg unknown AGE Delay between Onset and Treatment.--The delay between onset and treatment of all cases is shown in Table. The maximum delay was 4 years and the shortest interval was two months. Two hundred and twenty-four patients were unable to recall the time of onset accurately. No relationship could be found between the extent of the lesions and their duration. On the other hand 66 per cent. of the patients aware of the first appearance of the lesion sought treatment within two years of the onset of the growth. Nevertheless 1 per cent. of the reviewed patients did not seek treatment for five years. This percentage does not differ much from that given by other investigators (Hayes, 196). Type of Basal Cell Carcinoma.--The clinical appearance of the basal cell carcinomata has led to the classification of typical and atypical basal cell carcinoma. The typical basal cell carcinoma features the appearance of a nodule (or of an ulcer) in the early stage. The atypical covers a few characteristic varieties, which are given in Table V, together with their frequency. The clinical diagnosis could not be determined in lesions. The majority of these were recurrences having had previous treatment. Primary versus Secondary Cases.--A fundamental difference in this analysis is a subdivision of the basal cell carcinomata into primary tumours, which have not had prior treatment, and secondary lesions, which have had. Of the reviewed patients the primary lesions amounted to 46 and the secondary to O4. Of this number patients with 7 tumours showing multiple basal cell carcinomata are excluded. Of these 8 were secondary and 9 out of the i showed multiple recurrences. t was not always possible in these cases to differentiate the recurrences from fresh lesions of multicentric origin. These patients were followed up closely. Their different behaviour favours classification as a separate group, which cannot be included in the overall picture without interfering with the final conclusions. Distribution of Basal Cell Carcinomata.--The distribution of the lesions is given in Table V. The location of the basal cell carcinomata was based on pre-operative photographs. Forehead, nose, cheek, temple, lower lid and inner canthus are most commonly involved in agreement with other reports (Belisario, 99).

3 0 BRTSH JOURNAL OF PLASTC SURGERY TABLE Number of Basal Cell Carcinomata Male Number of Patients Female Total 0 18o TABLE Diameter in cm o --0 Undetermined Total Male 8 8 Female 6 ~ s~j L4F Total O TABLE Delay in Years Male m io 4 1 O +,j Undetermined Total,4-~ --%,,-T Female o " r TABLE V Type of Basal Cell Carcinoma Typ ical Atypical Multiple ~--7 Cystic - Cicatricial _. Pigmented Terebrant Cylindrical Male Fer0ale r 4

4 BASAL CELL CARCNOMATA OF THE HEAD AND NECK 0 TABLE V--Distribution of Basal Cell Carcinomata in the Head and Neck Area Site Right Left Total Forehead Nose Cheek Temple. Scalp Upper eyelid Lower eyelid nner canthus Outer canthus Ear Vreauricuiar region Postauricular region Nasolabial fold Upper lip Lower lip Chin Neck O O Pre-existing Lesions.raThe significance of pre-existing skin conditions and the influence of certain contributory factors is difficult to estimate. A history of trauma was frequently associated with new growth or ulceration, but it was impossible to determine the exact relationship A hypothesis of cancer resulting from a superficial single trauma has recently been put forward by Neuman et al. (196). n Table V are given the skin conditions found connected with new growth. TABLE V--Pre-existing Lesions Mole Seborrho~ic wart Cyst Trauma Burns scar Lupus vulgaris " Trichoepithetioma 9 Lupus + radiotherapy Ringworm + radiotherapy Senile keratosis 1 Herpes zoster scar 7 Calcinosis cutis Syringocystadenoma " TREATMENT The choice of treatment in most cases was made at the Combined Clinic. The follow-up was carried out in the department in charge of treatment. Final assessment as to the result of treatment was made at the Clinic. Two hundred and ninety basal cell carcinomata were treated by surgery, 14 by radiotherapy, io by curettage, 1 by physical means (Colcemid and trichloracetic acid) while 7 old people refused obstinately to be treated by any means. Surgery.--The main form of surgical repair in each case is summarised in Table V. With regard to the actual operations carried out, the following figures can be pointed out : per cent. of the tumours were treated by biopsy-excision, 1 per cent. by excision and skin grafting and 1 per cent. by excision and some form of flap repair. The surgical problems encountered in dealing with malignancies in the perioorbital areas (including eyelids, canthi and bridge of nose) were investigated in detail elsewhere (Wynn-Williams, 1967).

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6 BASAL CELL CARCNOMATA OF THE HEAD AND NECK 0 A word of explanation is required for the cases tabulated under miscellaneous. These patients were subjected to initial extensive surgery because of the size or the penetrating action of the basal cell carcinomata. One patient had a mandibulectomy with resection of part of the lower lip, followed by immediate reconstruction by means of rotation flaps. One patient had a fenestration and skin graft to the dura. Another patient required a composite graft to the nose. One patient was treated by excision of the outer plate of the frontal skull bones and cover by a rotation flap of the scalp and another one by an exenteration of the eye and an inlay graft in addition. Radiotherapy.nThe dosage, duration of treatment and details of technique were recorded but the details are beyond the scope of this review. However the number of patients and different techniques used are given in Table V. TABLE V Number of Patients treated by Radiotherapy Superficial X-rays 9 Radon Elastoplast moul~l Radon seed implants x6 Gold seed implants Cobalt 60 megavoltage unit r Curettage and Diathermy.--This method of treatment was used by the dermatologist. One hundred and ten lesions were reviewed of which 8 belong to primary and secondary types with exclusion of multiple lesions. The recurrence rate was particularly high in primary lesions, amounting to per cent. Physical Means.--Colcemid, an antimitotic paste, was used in the dermatology department on O lesions on a trial basis. The reason for this was age, general health, site and rated growth. Biopsy-excision was carried out when possible following a course of treatment but the results were unreliable and unconvincing and treatment was abandoned. Trichloracetic acid was used in two patients ; one a secondary case, the other refused every other kind of treatment. Both had a satisfactory result and remained healed. Recurrence.--The recurrence rate was investigated separately in primary and secondary cases. Secondary Cases.--Secondary cases are analysed as a highly selective group. Only those patients were reviewed whose lesions were of such a nature that the joint Clinic was urged to give advice. The problems involved in secondary cases are indeed quite different when the recurrence rate, incidence of radionecrosis and nature and timing of initial treatment are to be considered. The secondary cases were studied as to their prior treatment: of O 4 patients reviewed, 6 showed a recurrence, radionecrosis, one a change to intra-epidermal carcinoma while 8 were seen with an entirely new lesion, the original one being healed. The recurrent lesions in this group were originally treated as follows : Radiotherapy = 44 Curettage = Surgery -- io Physical means = The secondary cases showed a much higher incidence of recurrence (9 per cent.). Treatment of these recurrences gave results which are in no way satisfactory. A similar view was reached by other authors (Cobbett, 96 ; Glas et al., 966). Of a total number of 6 recurrent lesions 4 were definitely healed, 1 (4 per cent.) tumours recurred and two patients refused to have further treatment after recurrence. The treatment carried out and the results are given in Table X.

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8 BASAL CELL CARCNOMATA OF THE HEAD AND NECK 07 The time between treatment and recurrence is given in Table X. t shows that even with a five-year follow-up the time of first evidence in o ( per cent.) of these would have been missed. n the main group, those treated by radiotherapy, it is interesting to note that 6 recurrences took place within the five-year follow-up period. The remaining 18 cases (4o per cent. of all tumours treated by radiotherapy) had a follow-up of more than five years before appearance of a recurrence. This seems to suggest the need to extend the follow-up period beyond the five-year limit. The basal cell carcinomata treated by radiotherapy showed the highest recurrence rate, but no conclusion can be drawn from these figures because the total number of basal cell carcinomata treated by that method in previous years cannot be estirnatcd. No definite relationship could be found between the physical effects of radiation therapy and the subsequent appearance of malignancies. TABLE X Recurrence of Primary Cases Recurrence after Lesions Radiotherapy Healed following Surgery ~ Curettage Radiotherapy Unhealed following i Curettage Physical means Radiotherapy 4.. Surgery.., Curettage 19 o,. Physical Means lr....o.,. Diathermy Primary Cases.--Primary cases are analysed in relation to recurrence rate in Table X. Thirty-seven (8" per cent.) lesions recurred, of which healed after a second treatment. Five tumours ( per cent.) recurred for a second time, one of which was treated by Colcemid. Most recurrences took place after treatment by diathermy and curettage (6 per cent. of all recurrences in primary cases). n the cases treated by curettage and diathermy as an initial procedure the high recurrence rate of 4 per cent. was found. The site of the recurrences is given in Table X. The nose and adjoining regions (nasolabial fold and inner canthus), temple and cheek account for 6" per cent. This is probably due to a rather too conservative approach in carrying out treatment in an area where the proximity of important structures and the cosmetic result are major considerations. However, considering these influences, only 8 basal cell recurrences followed surgery in the above mentioned areas. The majority of recurrences followed curettage ( tumours) and radiotherapy (4)- Radiotherapy and curettage seem thus less satisfactory in dealing with basal cell carcinomata in these particular areas. Confronted with these unfavourable results one should be cautious in proposing one form of treatment or another until after careful examination. Treatment Failures.--There were basal cell carcinomata resistant to radiotherapy which required surgical removal. Three superficial basal cell carcinomata which had a trial dermabrasion showed persistence of malignant cells in a biopsy section.

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10 BASAL CELL CARCNOMATA OF THE HEAD AND NECK 09 These cases were treated by excision. One patient had a recurrence within a few weeks after curettage and required further treatment, These cases were not included in the total recurrences. Radionecrosis.--The average period from treatment until evidence of radionecrosis in secondary cases was 7 years, ranging from 1 months to 6 years, which is a much longer time interval than the 4½ years reported by Traenkle (9, 96O) and the ½ years reported by Churchill-Davidson et al (94), but similar to the period reported by Bennett and Carter (96). Histopathological sections were carried out in all patients to exclude the possibility of a recurrence. Only primary cases developed radionecrosis : after a period of years in 4 patients and after one year in the remaining patient. Follow-up Period.--The follow-up of all cases is shown in Table Xl. Although the follow-up period for primary cases has not been long enough for definite conclusions to be reached, an analysis of the results indicates the methods of treatment with their advantages and disadvantages. t also gives an indication of the best form of treatment for a patient according to age and location of the tumour. TABLE XmFollow-up Period Secondary Cases Radiotherapy Surgery and curettage Primary Cases No Follow-up Deceased Duration years.oo ii 7 6., o...., o O+ Cause of Death.raThe total number of deaths amounted to 4. Only one patient died from carcinomatosis of the face due to progressive invasion of the brain. The remaining patients died from varied causes, most as a result of a cardiovascular accident. One patient died of cardiac failure within 4 hours after operation. Fifty per cent. of the deaths occurred after less than two years of follow-up. MULTPLE BASAL CELL CARCNOMATA Under this group are cases with a history of multiple basal cell carcinomata appearing repeatedly or simultaneously at intervals in different parts of the head and neck. Many of these new growths have a multicentric origin and differentiation between a recurrence and a new lesion is difficult. The lesions do not follow a regular pattern in contrast to the single basal cell carcinoma with local destructive and progressive activity. As already mentioned, x patients (" per cent.) with 7 basal cell carcinomata were found to have multiple lesions at the same time or at different time intervals. A few patients showed also a variety of other tumours, mainly squamous cell carcinoma and intra-epidermal carcinoma. The best form of treatment was not always easy to decide and sometimes we were confronted with a situation of multiple new lesions at each follow-up which can lead

11 10 BRTSH JOURNAL OF PLASTC SURGERY to an uncontrollable state. Consequently different methods of treatment were employed according to site, age, size and multiplicity of the lesions. Radiotherapy was frequently considered in the older group of patients to start with while surgery was carried out as a secondary procedure, and for smaller lesions curettage and diathermy. However, no method of treatment can ensure definite control and close follow-up was necessary. The follow-up period extended from 1 year to years and the average follow-up period was found to be 8 years. Multiple Recurrences.--Although the basal cell carcinoma is considered the most" benign" of the malignant skin tumours, one is still unable to foresee the potential activity of the malignant cells. Analysis of secondary tumours which were unsuccessfully treated after a first recurrence throws indeed a disturbing light on the fate of previously treated basal cell carcinomata and rcvcals the inability to outline the extension of tumour invasion and the difficulty of eliminating malignant cells. This is surprising in view of the response in dealing with the original lesion. This unusual behaviour has been pointed out by other authors (Cramcr, 196 ; Lewin, 196 ; Gibson, 1964 ; Glas, 1966). The penetrating action of this particular basal cell carcinoma which sometimes results in devastating effects has been emphasised and the clinical entity has been designated ulcus terebrans (ngram and Brain, 197). Treatment of a recurrence should therefore be a more extensive procedure well beyond the doubtful margins of the involved area. Nine tumours recurred after surgical treatment of the first recurrence where the original lesion had been treated by radiotherapy. One patient died of carcinomatosis of the face ; the remaining eight cases were controlled with a follow-up period ranging from to 14 years from onset of the lesion. The recurrences in three cases which developed after radiotherapy were finally controlled by surgery. Their follow-up ranges from O to o years. One patient died from arteriosclerosis after a ten-year follow-up. The remaining cases were controlled after surgery except for one who had curettage and another one who died of arteriosclerosis. All these lesions had at least three recurrences : one patient suffered six recurrences and the lesion now seems under control after a large hemimaxiuectomy and deep X-ray therapy. Of the primary lesions only five cases had a history of multiple recurrences. One patient could not be controlled after extensive surgery and deep X-rays and the condition is still progressing. This woman of 71 years of age had a history of basal cell carcinoma of the frontal region of O years' duration. The lesion was fixed to the frontal bones over a surface area O by O cm. and a radiograph showed invasion of the skull bones. The affected area was excised with the involved bone and the defect covered by split thickness skin grafts applied direct on the dura. Recurrence took place after six months and deep X-rays were able only temporarily to stop further progression. Radiographs showed complete invasion of the cranial bones. She developed subcutaneous extensions of her basal cell carcinoma in the temporal and preauricular area. CONCLUSONS The results of treatment of primary lesions give a total cure rate of 91"9 per cent. Limited to the cases treated by radiotherapy and surgery alone the ratc of cure rises to 97" per cent., which can be compared with other series. The results of treatment by curettage which give a recurrence rate of 4 per cent. in this series arc definitely unsatisfactory.

12 BASAL CELL CARCNOMATA OF THE HEAD AND NECK 11 The interest of the investigation of secondary cases is of another nature. The follow-up period is here well beyond the five-year limit (77 per cent. of the lesions) with an extreme limit of 1 years. The main group of recurrences is seen after radiotherapy treatment and the average latent period between treatment and new growth is 9 years and O months. t should therefore be reasonable to extend the follow-up period beyond the usual five-year limit. t also suggests a more careful approach when radiotherapy is used in treating basal cell carcinomata as the influence of X-rays in the long run is not without harm. One would like radiotherapy to be the elected form of treatment in the older group of patients where the expectancy of life is much shorter and the danger of having to deal at a later date with complications such as radiodermatitis and radiation cancer is more remote. Confronted with the overall results obtained in this series surgery seems to be the treatment of choice in the younger group of patients. However the surgical approach should be a radical one, well beyond the doubtful margins of the lesions. An acceptable cosmetic result, although a legitimate desire of the plastic surgeon, should not interfere with the primary aim of surgery to eradicate the malignancy and cure the patient. Any second attempt is indeed less likely to succeed. SUMMARY An analysis of the basal cell carcinomata seen at the Combined Clinic in Nottingham during the period is given, dealing mainly with the results of different forms of treatment. Six hundred and thirty-three basal cell carcinomata in 478 patients were studied in relation to size, type, site, delay between onset and treatment, prior treatment and distribution. The recurrence rate in primary and secondary cases was investigated as well as the treatment failures and complications. Multiple basal cell carcinomata are reviewed separately. The conclusions show that radiotherapy as well as surgery can achieve a high rate of cure, preference being given to surgery in young patients while radiotherapy is favoured for the older group. Treatment by curettage and diathermy is definitely unsatisfactory. REFERENCES BELSARO, J. C. (99). " Cancer of the Skin." London : Butterworth. BENNETT, J. E., and CARTER, D. (96). Archs Surg., Chicago, 86, O6. CHURCHLL-DAvDSON,., and JOHNSON, E. (194). Br. rned. jr., x, 146. COBBETT, J. R. (196). Br. jr. Surg.,, 47- CRAMER, L. M. (196). Plastic reconstr. Surg., 9, 14. FERRARA, R. J. (96O). Archs Derm. Syph., 81, O. GBSON, T. (1964). Plastic reconstr. Surg., 4, 49. GLAS, R. L., SPRATT, J. S., and PEREZ-MEsA, C. (1966). Surgery Gynec. Obstet.,, 4. GRFFTH, B. H. (196). Plastic reconstr. Surg., 6, o7. HAYES, H. (196). Plastic reconstr. Surg., o, 7. ~GRAM, J. T., and BRAN, R. T. (97). " Diseases of the Skin," 6th ed. London: Churchill. LEWl% M. L. (i96). Plastic reconstr. Surg.,, 4- MAN, P. T. (196). M.D. Thesis, University of Aberdeen. NEUMAN, L., BEN-Hm, N., and SHULMAN, J. (196). Plastic reconstr. Surg.,, 649. PHLP, J. F. (1949)- Malignant Disease : A Report of Results of Treatment in the Royal nfirmary, Aberdeen, 19o-194. SCltRRE, T. (196o). Triangle, 4, 88. TANHER, L. (960). Archs belg. Derm. Syph., 6, 79- (Cited by Main, P.T., 196.) THOMAS, G. M. (19). A report on cancer of the skin. Public Health and Medical Subjects. (Cited by Main, P.T., 196.) TRAENKLE, H. L. (19). Archs Derm. Syph., 7, (196o). Archs Derm. Syph., 81, 9o8. WYNN-WLLAMS, D. (1967). Br. J. plast. Surg., 0, 1.