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Basal cell carcinoma of the head and neck: Identification of predictors of recurrence.


The goal of this retrospective study was to identify factors that predict the recurrence of basal cell carcinoma of the head and neck. We reviewed the medical records of 165 patients who had undergone a wide surgical excision (negative margins) of one or more basal cell carcinomas of the head and neck. Univariate analysis revealed that recurrence was significantly influenced by the patient's gender (p[less than]0.0l), the presence of preoperative risk factors (p[less than]0.05), the presence of multiple lesions (p[less than]0.01), and their histopathologic subtype (p[less than]0.05). Multivariate analysis revealed that the best predictors of recurrence were the presence of preoperative risk factors and the presence of multiple lesions (p[less than]0.01); the lesion's histologic subtype approached but did not reach statistical significance in predicting recurrence (p=0.06).


Basal cell carcinoma accounts for 65% of all epithelioid tumors in humans. Approximately 85 to 90% of all basal cell lesions occur on the head and neck. These malignancies, which have a slight predilection toward males, occur most often on the nose, in the malar region, and on the forehead. The major causes of basal cell carcinoma are sun exposure, genetic factors, immunosuppression, and previous injury. Transplant patients and patients with lymphoma or leukemia also have a greater propensity for basal cell lesions, presumably secondary to immunosuppression. [1] Additionally, the pathologic subtypes of tumors--which include nodular (the most common), sclerosing, and basosquamous lesions--might indicate their potential aggressiveness. [2-4]

Materials and methods

We reviewed data entered into the tumor registries of two major teaching hospitals (Norton Hospital and Jewish Hospital) affiliated with the University of Louisville. These data were entered from 1989 to 1994. Our aim was to identify all cases of basal cell carcinoma that were surgically removed with negative margins. The study population was confined to patients who had previously untreated basal cell lesions in the head and neck region. These patients had been treated by otolaryngologists, plastic surgeons, and dermatologists.

A total of 165 patients (88 men and 77 women) met the criteria for this retrospective analysis. In each case, we recorded the patient's age, gender, and preoperative risk factors, as well as the number of lesions, the site of each lesion, the histopathologic subtype of the lesion, the type of excision, and the type of reconstruction. Based on 18 months of followup, both univariate and multivariate analyses were performed to identify any relationships between these factors and the rate of recurrence.


Overall results. Twenty-three of the 165 patients in this study experienced a recurrence of basal cell carcinoma, for an overall recurrence rate of 14%.

Age. Patients ranged in age from 29 to 81 years (mean: 65). The mean ages of patients who did and did not experience a recurrence were 67 and 64 years, respectively. The difference did not reach statistical significance.

Gender. Recurrence rates were 18% among the men and 9% in the women. This difference did reach statistical significance (p[less than]0.01), and confirms the findings of other studies. [5]

Risk factors. Preoperative risk factors included a history of malignancy (e.g., lymphoma), radiotherapy, scarring, xeroderma pigmentosum, or basal cell nevus syndrome. Patients who had at least one risk factor had a significantly higher risk of recurrence than did those who had no risk factors (p[less than]O.O5).

Number of lesions. Patients who had multiple lesions had a markedly higher recurrence rate (43%) than did those who had only a single lesion (9%). The difference was statistically significant (p[less than]0.Ol).

Site. As has been seen in other studies, lesions often arose in those areas of the head and neck that are exposed to the sun, particularly the midface (figure). Although there was a higher rate of recurrence of lesions in the areas of the nose, medial canthus, and lips than elsewhere, the differences were not statistically significant. Additionally, there were more sclerosing subtypes of basal cell carcinoma found on the midface than at other sites.

Histopathologic subtype. All pathology reports were reviewed, and all lesions were confirmed to be basal cell carcinomas. Patients with aggressive subtypes (sclerosing and basosquamous lesions) had a significantly higher recurrence rate than did those with nonaggressive subtypes (p[less than]0.05).

Type of excision. Almost all lesions were surgically excised by an otolaryngologist or a plastic surgeon. Only eight patients underwent Mohs' chemosurgery, so it was difficult to compare this procedure with conventional techniques in this cohort of patients. In view of the fact that these eight patients underwent excision as inpatients, their lesions might have been generally larger.

Type of reconstruction. Patients whose postsurgical wounds were amenable to primary closure had a recurrence rate of 12%, compared with a 17% rate among those who required more complex closures or grafts. The difference was not statistically significant.

Multivariate analysis. When all these variables were evaluated by log rank analysis, the best predictors of recurrence were the presence of preoperative risk factors and the presence of multiple lesions (p.[less than]O.O1). The difference in recurrence rates according to histologic subtype approached but did not reach statistical significance (p=O.O6).


Between 1989 and 1994, 165 patients were treated at the University of Louisville for basal cell carcinoma. The size and depth of their lesions ranged from 5 mm and superficial to 15cm with invasion of the skull base. Prompted by our need to understand outcomes in patients with negative surgical margins, we were able to perform an outcome analysis that can help guide therapy in high-risk patients with basal cell carcinoma. Our retrospective study collected data from two hospitals and involved several surgeons in different specialties.

Many researchers who have compared multiple modalities (i.e., radiotherapy, electrodesiccation and curettage, Mohs' surgery, and surgical excision) have found that surgical excision and Mohs' chemosurgery offer the best cure rates. [5-11] Recurrence rates of 5 to 19% have been reported for initially untreated basal cell lesions that were surgically excised. [12-7] The 14% recurrence rate in our series is comparable to those previously reported.

Four variables were found to have a statistically significant influence on the recurrence of basal cell carcinoma: gender (p[less than]0.Ol), the presence of preoperative risk factors (p[less than]O.O5), the presence of multiple lesions (p[less than]O.0l), and the histopathologic subtype of the lesion (p[less than]O.O5). Age and the lesion's specific site on the head and neck were not statistically significant predictors of recurrence. Applying a multivariate analysis to these same variables, the best predictors were found to be the presence of preoperative risk factors and the presence of multiple lesions (p[less than]O.0l).

A high proportion of primary lesions were located in the midface, as were a correspondingly high number of recurrences (figure). Other researchers who have examined specific sites on the face found significantly higher recurrence rates for lesions located in the periorbital and nasal areas. Lesions in these areas have long been difficult to remove by surgical excision and Mohs' chemosurgery because of the potential for causing cosmetic deformity or functional disability. [12,18]

The histologic makeup of lesions has long been the focus of dermatopathologic and pathologic investigation. In our study, histologic subtypes were found to be a significant independent predictor of basal cell recurrence. We found that a higher percentage of the sclerosing subtypes recurred in the midface, which might be explained by the virulence of the lesions at this location rather than by the location itself.

The virulence of disease in patients who have multiple lesions at their initial presentation might mean that these lesions have a different biologic potential than do solitary lesions. In our analysis, this variable was a significant independent predictor of recurrence. Most studies have focused on the recurrence of lesions after the first lesion is treated and not on the synchronous lesions as we did. [19-21]

In conclusion, we would like to emphasize two points: 1) identifying risk factors for recurrence provides us with an opportunity for better surveillance of at-risk patients, and 2) the findings of this study imply that there is a continuum of biologic behavior in a basal cell carcinoma.

From the Department of Surgery, Division of Otolaryngology, University of Louisville (Ky.) School of Medicine.


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Author:Barnett, Susan N.
Publication:Ear, Nose and Throat Journal
Article Type:Brief Article
Date:Mar 1, 2000
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