Dear Editor, We read the paper by Chadha and Wright on small margin excision of periocular basal cell carcinoma (BCC) with interest. (1)The authors justify the use of small margins, without margin control (excision and closure without confirmation of histologically clear margins) by their low recurrence rates over a follow up period ranging from 37-59 months.

There has been extensive debate on the ideal approach to the patient with a suspicious skin lesion. We consider the issues here to be two fold: complete tumour removal and reduced recurrence rate and these two have been linked in most studies.(2) The next dilemma for most of us is to determine factors affecting subclinical tumour extension to achieve a complete removal with minimum excision of healthy tissue. Mohs micrographic surgery is considered the gold standard as it is shown to achieve a 98% 5-year cure rate (1773 cases of BCC).(3) Modifications have been sought due to the stringent training and processing requirements of the original technique and acceptable results have been achieved with staged ‘Slow Mohs’ (4) and multi-stage fast paraffin sections; (5)with maybe a varying of the margins based on tumour morphology.(6)

Data from this study would suggest a tumour debulking (excision and closure without margin control) would be equally effective in terms of final outcomes of recurrence rates, as the authors make no attempt to ensure complete removal. Recurrence in patients reported to have complete excision (2.6%, 2/78) is the other argument for this being an acceptable approach. However, interestingly their data also shows an incomplete excision rate ranging from 11.9% (single stage) and 17.4% (two stage excision group presumed to be larger lesions) and a clinical recurrence rate of 2.6% for complete excision versus 14.3% in incomplete excision group (followed up only) and 0% having undergone further excision to ensure complete removal. Also, these recurrence rates stated are for less than 5 years and survival curves may help in estimating the true incidence.

There is good evidence to support a policy of retreatment of incompletely excised tumours especially when they present at critical sites, the deep surgical margins are involved, histology shows a more aggressive subtype and surgical defect is repaired using flaps and grafts.(7) We must not forget recurrences put the patient in a higher risk group being more difficult to evaluate, with more aggressive and larger invasive tumours needing more extensive excision second time round. Recurrence rates of 10% are not considered acceptable in routine primary eyelid tumours where the functional and cosmetic outcomes have much more significant implications than elsewhere in the body.(8)

We understand the service pressure in the National Health Service or elsewhere but quality of care to the patients should be our ultimate aim. A service adaptation to increase efficiency with more appropriate use of the minor outpatient theatres for small lesions not needing major reconstruction, discharge from eye clinics earlier than the mandatory 5 years with follow-up in primary care clinics/ even GP surgeries can ensure complete tumour removal without increasing the service load. The added advantage of reduced patient anxiety and surgeon confidence cannot be under-estimated as these may actually increase the follow up visits much more than the already higher number proposed by the authors in presence of an incomplete excision.

References: 1. Chadha V, Wright M. Small margin excision of periocular basal cell carcinomas. Br J Ophthalmol 2009; 93: 803-806. 2. Cook BE, Bartley GB. Treatment options and future prospects for the management of eyelid malignancies. An evidence-based update. Ophthalmology 2007; 108: 2088-2100. 3. Mohs FE. Micrographic surgery for the microscopically controlled excision of eyelid cancers. Arch Ophthalmol 1986; 104: 901-909. 4. Morris DS, Elzaridi E, Clarke L, Dickinson AJ, Lawrence CM. Periocular basal cell carcinoma: 5 year outcome following Slow Mohs surgery with formalin-fixed paraffin-embedded sections and delayed closure. Br J Ophthalmol 2009; 5. Khandwala MA, Lalchan SA, Chang BYP, Habib M, Chakrabarty A, Cassels Brown A. Outcome of periocular basal cell carcinoma managed by overnight paraffin section. Orbit 2005; 24: 243-247. 6. Hsuan JD, Harrad RA, Potts MJ, Collins C. Small margin excision of periocular basal cell carcinoma: 5 year results Br J Ophthalmol 2004; 88: 358-360. 7.Telfer NR, Colver GB, Morton CA. Guidelines for the management of basal cell carcinoma. Br J Dermat 2008; 159: 35-48. 8. Anderson RL. Micrographic technique Arch Ophthalmol 1986; 104: 818-819.