Basal cell carcinomas (BCCs) are the most common malignancy, with an increasing global incidence in recent decades. However, even though the mortality rate due to BCCs is very low, treatment-related costs impose an important burden on the health care system.1,2

Although the majority of BCCs are easily cured, high-risk basal cell carcinomas (HRBCCs), which represent a significant proportion of BCCs, require special attention to be eradicated.2,3

Mohs micrographic surgery (MMS) is the treatment of choice for HRBCCs, but this method requires special instruments and both surgical and pathologic experts; it is also expensive.4–6

Staged excision with pathologic margin control (SEPMC) is a simple and accessible procedure with a high cure rate that is suggested for the treatment of special types of BCC or for special sites such as periorbital or nasal areas.6–10

Considering the very high prevalence of BCCs, the relatively high number of HRBCCs, and the lack of access to MMS at most dermatosurgery centers worldwide, the present study evaluated the results of SEPMC in HRBCCs in the head region over seven years.

A total of 122 patients, 47 (38.5%) females and 75 (61.5%) males, were recruited in this study. The age range of the participants was 38‒81 years, with a mean age of 57.66 ± 9.13 years (Table 1).

The nasal area was the most common site of treatment 49 (40.2%), and the periorbital area 19 (15.6%) and forehead 10 (8.4%) were other commonly treated areas (Table 1).

Clinically, 100 (82.0%), 12 (9.8%), and 10 (8.2%) BCCs manifested as nodular, superficial, and morphoeic types, respectively (Table 1).

Pathologic assessment of lesions revealed 44 (36.1%) high-risk and 78 (73.9%) low-risk pathologic types (Table 1).

Seventy-seven (63.1%) patients presented with primary BBCs and 45 (36.9%) patients had recurrent BCCs as a risk factor, who had been previously subjected to inappropriate procedures (Table 1).

Moreover, one-, two-, three-, and four-stage surgical excisions were done in nine (7.4%), 56 (45.9%), 37 (30.3%), and 20 (16.4%) lesions, respectively (Table 1).

Out of 122 lesions, 109 lesions (89.3%) were cured and only 13 lesions (10.7%) showed recurrence during the follow-up period (Table 1).

Other demographic and clinical characteristics of the patients are presented in Table 1.

No complications, including infection in the surgical or para-surgical sites and bleeding, were seen during the surgical and follow-up periods.

To better quantify the relationship between the study variables and the number of surgical excisions and treatment outcomes, a more concise classification of some of the variables was performed (Table 2).

The results of logistic regression analysis showed a significant relationship between the number of surgical excisions and tumor location, multiplicity of risk factors, tumor size, and recurrent lesions (p < 0.05; Table 2).

The results of logistic regression also showed a significant relationship between treatment outcome and pathologic type, recurrent cases of BCCs, multiplicity of risk factors, and disease duration (p < 0.05; Table 2).

This study showed a 89.3% cure rate for HRBCCs through SEPMC, with a mean of 2.63 stages of excision over 48 months of follow-up.

Patients with a tumor size more than 20 mm, nasal BCCs, recurrent BCCs, and those with more than two risk factors required more surgical excisions.

The results of this study showed that failure of SEPMC was more possible in the high-risk pathologic types, recurrent BCCs, multiple risk factors, and long-standing diseases.

In the present study, patients with recurrent BCCs and more risk factors required more surgical excision and had more possibility of treatment failure. Therefore, patients with the mentioned variables require more attention for a complete cure.

Several studies have indicated 95% cure rate for BCCs through SEPMC.6–9

The present study also showed a nearly 90% successful treatment rate for HRBCCs by SEPMC.

It is believed that this discrepancy is due to the presence and multiplicity of the risk factors, particularly recurrent BCCs. In addition, in some previous studies, SEPMC has been performed in either low- and high-risk BCCs or specific areas such as the nose or periorbital area.7–9

The factors that cause treatment failure through SEPMC include main tumors with skip areas, perineural invasion of some high-risk BCCs, and inconsistency between the surgeon and the pathologist in marking the tissue samples for pathologic assessment.11,12

It appears that recurrent BCCs lead to irregular growth and expansion of tumor islands from the primary tumor location, making them difficult to cure by SEPMC and even by MMS.10 Many studies have reported the successful treatment of recurrent BCCs is less probable than that of the primary BCCs, even through MMS, and requires more surgical excisions, which is consistent with the current findings.13–15

Obviously, in cases of the disease with delayed treatment, the lesion is associated with an increased size, deeper penetration, and more possibility of skip areas and metastasis.1,16,17 Therefore, treatment failure is more likely in cases with a long evolution, and especially after ordinary surgical excisions.

In the present study, nasal lesions had a higher number of surgical excisions, which is consistent with the results of many previous studies. Nasal BCCs are more likely to develop fan-like dissemination and perineural invasion. There are also more pathologic and clinically high-risk cases that increase the number of surgical procedures.5,18,19

BCCs with high-risk pathologic features – including morphoeic, infiltrative, and micronodular types – are more likely to develop skip area dissemination and perineural invasion; therefore, recurrence is possible even with MMS.2,11–13,16,17

In the current study, patients with high-risk pathologic lesions showed a significantly higher recurrence rate than those with low-risk pathologic lesions despite staged surgical excisions.

Treatment of HRBCCs through SEPMC resulted in a high cure rate. Patients with more than two risk factors and recurrent lesions required a higher number of surgical excisions and had a higher possibility of treatment failure.

Patients with BCCs larger than 20 mm and nasal lesions required a greater number of surgical excisions. BCCs with high-risk pathologic type and duration of more than 48 months were associated with more possibility of treatment failure. The authors suggest new studies for better assessment of the findings of the present study.

None declared.

Reza Kavoussi: Drafting and editing of the manuscript; collection, analysis, and interpretation of data.

Hossein Kavoussi: Approval of final version of the manuscript; conception and planning of the study; participation in the study design.

Ali Ebrahimi: Participation in the study design; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.

Nader Salari: Statistical analysis; critical review of the manuscript.

Seyed Hamid Madani: Conception and planning of the study; collection, analysis, and interpretation of data.

None declared.