Saturday, March 24, 2012

Recurrent BCC with Perineural Invasion

The patient is a 56 yo woman who had micrographic surgery for a BCC on the tip of the nose in August of 2008. The initial typing could not be done b/c the specimen was a superficial shave and deeper component could not be appreciated.

She presented in March 2012 with a subtle area of hypopigmentation at the site of the tumor. Because of the firmness of the nasal tip, induration could not be appreciated. The patient was worried that this might be a recurrence.

Clinical Photo:

A 3 mm punch biopsy showed "infiltrating BCC with perineural invasion (PNI)."

Photomicrographs courtesy of Dr. Jag Bhawan. Please click on Picasa for more images.
Teaching point: The initial shave bx was not adequate to type the lesion and this was also not commented on by Mohs surgeon. Complex BCCs of the nasal tip pose special problems. Dr. highlight some of these.

Questions to Mohs surgeons: How would you approach this woman who is concerned about cosmetic appearance of nose after second Mohs procedure? Is it likely that after almost four years of insidious growth this tumor may pose special problems for closure and necessitate plastic surgical reconstruction?

View Dr. Michael Albom's Comments on this patient.

1. Leibovitch I, et. al,
Basal cell carcinoma treated with Mohs surgery in Australia III. Perineural invasion. J Am Acad Dermatol 2005 Sep;53(3):458-63.
Abstract Conclusion:
PNI is an uncommon feature of BCC. When present, PNI is associated with larger, more aggressive tumors, and the risk of 5-year recurrence is higher. This emphasizes the importance of tumor excision with margin control and long-term patient monitoring.

2. Geist DE et. al. Perineural invasion of cutaneous squamous cell carcinoma and basal cell carcinoma: raising awareness and optimizing management. Dermatol Surg: 2008 Dec;34(12):1642-51. Division of Dermatology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA.

ABSTRACT: BACKGROUND: Perineural invasion (PNI) by cutaneous squamous cell carcinoma (CSCC) and basal cell carcinoma (BCC) is an infrequent but not rare complication of traditionally low-morbidity skin cancers that can lead to catastrophic sequelae; 2.5% to 14% of CSCC and approximately 3% of BCC exhibit PNI. Tumors with PNI tend to be larger, have greater subclinical extension, have a higher rate of recurrence, and have a greater risk of metastases. Tumors with PNI may result in major neurologic deficits.

OBJECTIVE: To review current recommendations for the management of PNI and to evaluate a treatment strategy involving excision using Mohs micrographic surgery (MMS) followed by adjunctive radiotherapy.

MATERIALS AND METHODS:Cases of PNI treated with MMS and radiotherapy were reviewed for recurrence, disease-free follow-up, and adverse events.

RESULTS:Twelve patients with incidental PNI treated with MMS and adjunctive radiotherapy are presented. After 3 to 32 months of follow-up, there had been no recurrences. Adverse events from radiotherapy were minor and self-limited.

CONCLUSIONS: The use of adjunctive radiotherapy in these patients remains controversial. When managing superficial skin tumors with PNI, a multidisciplinary team including a cutaneous surgeon and a radiation oncologist familiar with PNI is recommended.


  1. from Dr. Jenny Stone, Mohs Surgeon: "This indeed may be a recurrence and I would warn the patient that the post-op defect may be much larger than what is visible clinically (which is not much at present). Therefore, it may be wise to set her up with plastics for repair. Tumors with perineural involvement may have skip areas and may be the reason for the recurrence - skip areas may be difficult to see on Mohs sections. It would probably give her an extra margin of safety to do adjunctive radiation to the area once everything is healed, esp. since Mohs was done before."

  2. Dr. Michael Albom has commented. Here is an extract (a pdf of his full comments is in the case report above): "This is a difficult case for several reasons. As you point out, the shave bx that was done in 2008 was inadequate. As such the Mohs surgeon made the assumption that this lesion was of minor consequence. He or she should have initially removed full thickness skin as part of the treatment in 2008.
    As of this time, there is no clinical way to determine the actual extent of this recurrence. An MRI might be helpful to discover if the lesion has tracked to the anterior medial septum. However, scans have limitations and may not give clear cut findings as to the spread of disease. Confocal microscopy is being used in a limited number of centers, but, with recurrent disease as this, I don’t know if a significant number of these types of difficult cases have been done with long term follow-up to corroborate successful outcomes. When I refer to long term follow-up, I mean a minimum of 5 years." see pdf for fullcomments

    1. As another Mohs surgeon, I agree with Dr. Stone that the defect may be quite large with significant subclinical extension. However, her best chance at completely and definitively removing her cancer is still with Mohs surgery. Post op radiation may not have additional benefit (the cited reference has no control arm, so the true incidence of recurrence in this group without radiation is unknown). However, radiation's effects on the skin have other deleterious effects (which are important to consider if aesthetics are an issue), the treatments are costly, and time-consuming. I would be hesitant to pursue this after nasal reconstruction if the Mohs sections were of good quality and clearly negative. Finally, regarding reconstruction, many Mohs surgeons are comfortable with large complex repairs for catastrophic nasal wounds. If her Mohs surgeon is in this bracket I would not expect any additional benefit in having plastics perform the repair (she should have a frank discussion with him or her prior to surgery obviously). We routinely do forehead flaps and other advanced techniques for nasal reconstruction the same day as Mohs surgery, under local (avoiding the need for general anesthesia & its complications) and without the additional cost to the patient or insurance company that seeing a separate surgeon necessitates. We do what is best for the patient regardless of the multiple surgery reduction rule.

  3. I have reviewed the comments by Dr. Stone and Dr. Albom and am in agreement for the most part. I do find less fault in the original biopsy performed in 2008 than the initial Mohs layer performed after the biopsy. A biopsy is a litmus test to diagnose whether of not cancer is present at a clinically suspicious lesion, not to stage a potentially aggressive skin cancer. Shave biopsies are frequently misleading. Scott Fosko once published a paper over 10 years ago I believe that demonstrated up to 40% of basal cell carcinomas read as superficial had infiltrative features when Mohs was performed. Therefore it behooves the Mohs surgeon to take an adequate first layer even in the spirit of tissue conservation.
    Otherwise, this is classic case for Mohs surgery, i.e. a recurrent aggressive BCC in a cosmetically sensitive area. Mohs is still the treatment of choice for highest cure rate and tissue conservation. I think her reconstuctive prognosis is still very good. Even as a worse case scenario if she requires a paramedian forehead flap and cartilage grafting, these are procedures that can be performed with reproduciably good results by a qualified reconstructive surgeon, whether they are plastic surgey or Mohs surgey trained.
    Kevin Mott, MD

  4. This is a great post. I really wanted to know something like this and you gave me what i was looking for.

    Skin Cancer Treatment


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