How Much Excision is Enough for BCC Clearance?
How much margin is enough to achieve complete excision for a BCC?
If you look at the above left picture, this is a case study where I performed an excision on an ulcerated, nodular BCC.
Due to size (>2cm) and ulceration, I would have preferred Mohs for this patient based on standard guidelines. However, despite my recommendation, the patient insisted he was not able to wait a full day if Mohs was performed due to his lifestyle and current challenges he was facing.
He had to tend to his frail elderly wife, tend to his 20 acre farm, and did not have the social support for him to be absent for that long. We discussed the possibility of positive margins if an excision was performed, and he was willing to take that risk.
With that, I performed an excision for the patient.
The margins I used for this case was 5mm, wider than the standard 4mm excisional margins I typically use for a "low risk" BCC (site marked with gentian pen in above right picture prior to excision. Note: Other biopsies were taken as you see excision marked as "C" and another biopsy site to posterior shoulder marked as "D").
Results?!...Positive Margins 😩!
So, the takeaway point for this case study is...
There will be times in clinic when you will have to go against standard of care due to who the patient is, his/her circumstance, medical conditions, social factors, lifestyle, etc.
As a dermatology provider, it is up to us to balance our best clinical judgement to whatever is going on in our patients' lives.
In retrospect, should I have deferred the excision and pushed harder for Mohs?
Should I have taken wider margins to guarantee a higher clearance rate?
The answer to both of these questions are most likely...YES!
...But, what gives me peace of mind, as a provider, is knowing that I thoroughly discussed all the treatment options and risks to the patient. I listened to him understanding his request...and we both came up with a collaborative decision together.
That discussion, prior to the final decision, made that follow-up phone call much easier when I had to inform him about the bad news...that he had positive margins needing to return back for care utilizing Mohs.
He was understanding. There was no resentment. He, from the very beginning, understood the risk.
Cases like these are our best teaching moments, and I hope you will remember what the takeaway point is in this case study...
Listen to your patient and use your best clinical judgement based on who...your...patient...is. Sometimes we may have to go against the typical standard of care, but that is ok...as long as both parties, the provider and the patient, both are understanding of the risk.
For best margin control for low risk and high risk BCCs, here is a great resource to use!
ALL my best,
Theresa Talens, DNP, FNPC (#TheresaSurgDermNP) ❤️
Check out more great FREE resources here! ➡ P.U.L.S.E. Dermatology & Procedures
