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1800 867 1390Case discussion: How would you treat this patient? [10 October]
In this week’s case discussion, we are asking about treatment options rather than diagnosis. This man presented to Dr Terry Harvey following a biopsy elsewhere. This lesion on the helical rim of the left ear was confirmed by a biopsy to be an infiltrative subtype basal cell carcinoma that measured 8x8mm. How would you treat this skin cancer?
Update:
The lesion was removed and repaired with a full-thickness wedge excision. Here are the photos:
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Actually I would refer these days but consider it requires at least a full wedge resection with good 5mm margins.
As is infiltrative I do not consider is suitable for topical treatment.
Refer, as infiltrative bcc are aggressive and the site is known for recurrence and need 5 mm margin or more, this site may need a graft or flap
Mohs surgery and radiotherapy after.
Clinically 2 high-risk factors: 1 Area H (the ear) and 2 An Infiltrative BCC. This case would be a good candidate for Mohs surgery, otherwise the excision has to have a 5mm margin clearance in all planes.
Wedge resection with wider margin at least 5mm
Wedge resection 5mm clearance ,quite easily performed and good cosmetic result usually
Infiltrative BCC is a tricky skin cancer needs excision with enough margin . Incomplete excision is not uncommon .
Double advancement flap or wedge excision are possible management options , however Radiotherapy is an option as a primary treatment or 2ry treatment if incompletely excised .
Needs Moh’s surgery to ensure clearance.
Wedge resection with 5 mm. Mohs surgery. Refer as well.
I would excise this with 5 mm margin to be sure of curing the patient; in my experience a FT graft heals really well on the ear and is far easier to do than an extensive flap . It is also good cosmetically on the ear and doesn’t cause any deformity. If a margin is involved it is easy to take a little more and sometimes close that wound primarily or at worst another graft . I usually take the donor skin from the preauricular area on the same side which means one drape and using the hair free zone in men . The sticky drapes are great to keep the area sterile and my assistant ie nurse or med student is invaluable in holding the ear . I find it only takes 30 to 40 minutes depending on the size of the lesion . I don’t use prophylactic antibiotics when operating on the ear but often do on the nose around the nasal orifice seeing as 50 % of people have staph aureus colonising the nose .
I would an excision to cartiledge then do an h advancement flap of the helical rim. I have done a
few of these and work very well.The idea is to ensure that good margins are selected. I would hurt to do a wedge excision for such a small tumour
Refer patient for radiation therapy
Delayed closure after 5mm margins -> if cleared
followed by advancement flap.
Delayed closure if cleared after wedge resection 5mm margins.
Mohs margin control surgery expensive (typically) via referral to Dermatologist.
Wedge excision
Mohs surgery as that is available in my area .
I would remove the tumour by removing a helical segment with a 4mm lateral margin either way.
I would then repair with a helical rim advancement flap. utilising redundant skin in the lobe the post auricular skin is dissected off the perichondrium down to the post auricular fold and the distal helix separated from the along the rim.The helix is then advanced into the defect with a Burrows triangle excised from the lobe. the helix is cosed with mattress sutures.
V resection with 5mm margin and Mohs surgery .
Infiltrative BCC 8×8 mm in a high risk area would require a Moh’s Micrographic surgery with graft.
Great photos and very neat job.
Question.
Do your sutures involve the cartilage, or just the overlying perichondrium and skin?
Thanks.
5/0 Monosyn absorbable to approximate the cartilage, then the external 5/0 nylon only involve the overlying skin and are placed both anteriorly and posteriorly on the ear surface.
The question of interest for me as a surgeon, despite performing this surgery—does it require full thickness excision in terms of including cartilage, when the lesion originates in the epidermis .Wide excision of epidermis and dermis insufficient ? –any literature which supports or discusses??
Re: the wedge of cartilage being needed or not
For clearance of the tumour – no.
For repairing the defect – yes.
In an ellipse – the Burrow’s triangles don’t need to be removed to clear the tumour.
In a flap – the flap doesn’t need to be fashioned to clear the tumour
In a graft – the graft doesn’t need to be harvested to clear the tumour.
However – in all of these cases these things are done in order to repair the defect.
In this case – doing a wedge in 30 minutes was a faster, effective and cheaper option for the patient with a great cosmetic outcome. A removal of skin/dermis only and helical advancement flap or graft would be slower, more expensive, and at best a comparable cosmetic outcome.