Primary Care Surgical Association

Non Melanoma Skin Cancer (NMSC) Guidelines.

Summary document
Most clinically obvious or suspicious small NMSCs in easily accessible sites are best
excised with elliptical excision and primary closure with at least 4mm margin to include a
generous cuff of subcutaneous fat. This should be followed by histological confirmation of
clear margins. Certain high risk NMSCs may require much larger clear margins.
The aim is to ensure curative treatment combined with a good cosmetic result and a low risk
of complications.
However, doctors with extra training, experience and the appropriate equipment may choose
to treat selected cases of NMSC with other modalities such as Cryosurgery, imiquimod 5%,
flaps, grafts, PDT or curettage and cautery.
Preliminary biopsy may be necessary when a firm clinical diagnosis cannot be made, where a
treatment other than surgical removal is chosen or prior to extensive surgery in cosmetically
sensitive regions.
It is imperative that GPs be aware of their limitations and refer where appropriate.
There are varying levels of lesion recognition knowledge and surgical skill level throughout
the membership. Therefore it is difficult to give a specific set of rules or guidelines but
doctors who have completed basic surgical training such as the ICGP minor surgery course
and who are competent in elliptical excision and layered closure (level 2 community surgery)
could consider removing small (<10mm) BCCs or SCCs on the body below the clavicles
but not on the face or lower leg. Doctors with more experience in skin cancer who have
undergone advanced training in surgical skills and lesion recognition (level 3 community
surgery) could consider treating selected facial lesions and lesion larger than 10mm on the
body. However high risk cases of NMSC should warrant consideration for referral, preferably
with clinical photos and histology if easily obtainable.
High risk cases would include:
Recurrent tumours despite treatment.
Anticipation of difficulty with technique, size of tumour or anatomy.
Such as
Cosmetic concerns such as NMSC on the face in young women
NMSC on the vertex of the scalp
Large tumours: BCC or SCC ( >10mm on the face and > 20mm on the body)
Large tumours on the lower leg
NMSC involving the naso labial fold , pre aricular fold or the post aricular folds
Poorly differentiated SCC or those with perineural, perivascular or lymphatic
involvement.

PCSA Non Melanoma Skin Cancer Guidelines

Acantholytic , spindle and desmoplastic SCCs.

Tumours >4mm in depth or extending into or beyond the subcutaneous tissue.
Deeply invasive NMSC on the lip, ears, nose or eyelids.
Tumours where palpable regional lymph nodes are suggestive of metastatic spread of
SCC.
Infiltrating or scar like morphoeic BCC
Tumours with indeterminate margins or tethered to underlying structures.
Organ transplant or other chronically immunosuppressed patients who are best
referred to organ transplant clinics.
Any doubt about appropriate treatment.
Recommended treatment is beyond the skills of the practitioner.
Rarer tumours, Eg: Merkle cell tumours ,Dermatofibrosarcoma protuberans.

Doctors who carry out elective skin cancer work should fulfil the following criteria:

The clinician must have a robust system in place for ensuring the biopsy sample is
transferred to the histology container, accurately labelled, packaged, transported to the
laboratory and all of this recorded.
All specimens should be sent to a dermato-histo-pathologist with an interest in skin
cancer and who is linked with a MDT.
A tracking system to monitor results as they return is mandatory.
Follow up, to include full body skin examination, must be arranged for all diagnosed
individual skin cancers to assess for recurrence of the tumour or the development of a
new tumours at appropriate intervals (eg: three or six monthly for the first year and
annually for the next 4 years )
All patients need to be advised on photo protection and how to supplement with
Vitamin D.
Auditing of the clinicians NMSCs work is encouraged.
Doctors treating NMSCs should operate from an appropriate primary care based
surgical facility with adequate decontamination facilities, protected time, and an
assistant if required.
Training and experience in skin surgery is mandatory. A minimum of the ICGP minor
surgery course or equilivant should be completed, plus further skin surgery training in
techniques such as flaps, grafts, cryosurgery, PDT, etc, for the more advanced case
work is required .
Training and experience in skin lesion recognition.
Membership of a surgical professional association (eg: PCSA or ASPC), and
attendance at the PCSA annual meeting and online forum is encouraged.
Doctors carrying out NMSC work should have a good working relationship with a
local dermato-pathologist, dermatologist and plastic surgeon.
Draft V8

28.5.14

Primary Care Surgical Association Document (28/05/2014)

Page 2

PCSA Non Melanoma Skin Cancer Guidelines

Dr Colum Gavin, Dr Neil Healy, Dr David Buckley + Dr Tony O Sullivan.

On behalf of the Primary Care Surgical Association
E mail for correspondence : info@asctralee.com
Mob 087 2541000 ( David )
The standards and recommended practices for NMSC were developed as follows:
Extensive literature search.
Consideration of the opinion of experts knowledgeable in the subject.
Consideration of the available current best practice, both in Ireland and
internationally, that may impact on the management of suspicious pigmented lesions .
National workshops held with key stakeholder groups to provide an opportunity
for input into draft documents.
Development of draft standards and recommended practices for distribution to
key stakeholders and PCSA committee and members for consultation.
Feedback considered and where appropriate, incorporated into the current
version of the standards and recommended practices.

Primary Care Surgical Association Document (28/05/2014)

Page 3

PCSA Non Melanoma Skin Cancer Guidelines

Surgical Margins in the Management of NMSC in Primary care :

Discussion
The aim of the PCSA NMSC Guidelines is to identify optimal surgical margins in
management of Non Melanoma Skin Cancer in primary care. The author explores the
evidence for these guidelines after a thorough literature review of the evidence base.
Significant debate exists as to the optimal width of NMSC surgical margins across the
spectrum of disease encountered (11). The competing goals aim to achieve the best
oncological outcome while maintaining optimum functional and cosmetic results.
While excellent guidelines have been published (18) (19), there is a paucity of studies and
guidelines reporting optimal surgical excision margins for both BCC and SCC (and various
subtypes) in a single article for ease of reference for clinicians managing NMSC in primary
care.
Histologically, standard vertical section processing of excision specimens allows the
pathologist only to examine representative areas of the peripheral and deep surgical
margins, and it has been estimated that at best 44% of the entire margin can be examined
in this fashion, which may partly explain why tumours which appeared to have been fully
excised do occasionally recur (120). It must be understood, as pointed out by Kimayi-Asadi
et al (120), that less than half of the margin is actually studied using this standard method
and clinicians working in this area must appreciate this weakness when they are
considering the histological report and deciding on the adequacy of the surgical
treatment.
Basal Cell Carcinoma
Optimal management of BCC is increasingly relevant in an ageing population in which the
funding for treatment is a diminishing resource and in which the prevalence of BCC may
soon be greater than all other cancers combined (12). Housman et al estimate that BCC is
currently the fifth most costly cancer in the United States (5).
BCC clinical appearances and histological subtypes are diverse and also include pigmented
forms, morphoeic, micronodular, infiltrative and basosquamous variant which can be
aggressive and associated with perivascular and perineural invasion (39).
There are well described prognostic factors which allow the treating doctor to assign
individual BCC lesions into a low-risk category or into a high-risk category of tumour
recurrence following treatment (18).
It is worth emphasising that these prognostic factors apply in a similar fashion to
cutaneous SCC. These factors should strongly influence the management of NMSC, not only

Primary Care Surgical Association Document (28/05/2014)

Page 4

PCSA Non Melanoma Skin Cancer Guidelines

in terms of treatment selection, but also whether this treatment can be safely provided in
primary care versus referral to a suitable multi-disciplinary team.
BCC Prognostic factors

1. Tumour size - increasing size confers higher risk of recurrence. BCC

greater than 2 cm in diameter are consider high risk.
2. Tumour site - lesions on the central face, especially around the eyes,
nose, lips and ears, are at higher risk of recurrence.
3. Definition of clinical margins - poorly defined lesions are at higher
risk of recurrence.
4. Histological subtype - certain subtypes confer higher risk of
recurrence e.g., morphoeic and basosquamous subtypes.
5. Histological features of aggression - perineural and /or perivascular
involvement confers higher risk of recurrence.
6. Failure of previous treatment - recurrent lesions are at higher risk of
further recurrence.
7. Immunosuppression - confers increased risk of recurrence.
Nice provided clear guidance on the categorisation of low-risk and high-risk BCC in
2006 (7) and subsequently updated in 2010 (10) and further guidelines on the
identification of who can carry out this work is available in the Manual for cancer services
2008: skin measures (20).
While the range of treatment options has increased with the recent development of more
effective topical therapies for the management of low risk BCC, surgery maintains a
significant role here and remains the treatment of choice for the majority of high risk
lesions with the lowest overall failure rate (15).
In the surgical treatment of BCC, consideration needs to be given to the optimal surgical
margin across a spectrum of clinical scenarios including:

a. Primary basal cell carcinoma

b. Incompletely excised basal cell carcinoma
c. Recurrent basal cell carcinoma
Additionally, specific regions need a clear definition of optimal margins measured against
the competing need for best results from an oncological, functional and aesthetic
outcome:

a. Cervico-facial area
b. Noble areas such as lips, ears and eye-lids
c. Other areas including trunk, and limbs.

Primary Care Surgical Association Document (28/05/2014)

Page 5

PCSA Non Melanoma Skin Cancer Guidelines

a. Primary basal cell carcinoma
Surgical excision is a highly effective treatment for primary BCC with a recurrence rate of
< 2% reported five years following histological completed excision (30) (31) (32).
The basis of predetermined ideal resection margins is predominantly from retrospective
data and mainly from small case series. However, Gulleth et al, published a meta-analysis
of the literature, using data from 89 articles from a larger group of 973 articles selected
from the PubMed database. The total number of lesions analyzed was 16,066. Recurrence
rates for 5mm, 4mm, 3mm and 2 mm surgical margins were 0.39, 1.62, 2.56 and 3.96
percent, respectively. The group concluded that a 3 mm surgical margin can be safely
used for non-morpheaform basal cell carcinoma to attain 95% cure rates for lesions 2 cm
or smaller (36).
However, Cigna et al published a study looking at 1123 patients with BCC. Margins taken
were 3mm - 5mm on cervico-facial area, 2mm 3mm on noble areas (such as lips, ears,
and eyelid), and 5mm 10mm on other areas (37). In this study relapses occurred in 30
cases (2.67%), 90% of which were located in noble areas in which the initial peripheral
margin of excision was 3mm or less (37). They report that a margin of 3 mm or less
considerably increases the risk of relapse, even if the histology shows complete excision of
the lesion, and should be reserved as a minimum in sites such as nose, eyelid, and lips for
a better functional and aesthetic result. This is also supported by Kimyai-Asadi et al who
looked at a subgroup of primary, small, well-demarcated, facial nodular BCCs and a
sample size of 134, and found that narrow margin (1mm - 3mm) were inadequate and to
avoid repetitive operations and the risk of recurrence in anatomically sensitive areas, they
should be treated with standard 4 mm margins (35).
According to Madan et al, a 4mm 5mm surgical margin ensures peripheral clearance in
roughly 95% of well defined small basal cell carcinomas (122).
The size of lateral and deep margins should correlate with the prognostic factors for
recurrence listed above. In other words, advancing risks imply a widening of the surgical
margins.
The deep margin is often limited by underlying anatomical structures. According to
Griffiths et al who studied 1539 consecutive basal cell carcinomas excised by conventional
surgery, deep margin involvement occurred in 3.1% of cases, and 85% were excised with a
deep margin less than 5 mm (123). Only 12% had deep margin clearance greater than 5mm
(123). With regard to the deep margins this should include the subcutaneous fat where
possible, but will depend on local anatomical factors (37).
In well defined primary BCC lesions less than 20 mm in diameter, a 4 mm peripheral
margin will clear the lesion in 95% of cases, indicating that in < 5% of small, well defined
BCCs extend over 4 mm beyond their apparent clinical margins. (11) (35) (124).
In high risk locations, such as eyelids and lips, excision can be performed with a peripheral
margin of 3mm but in preserving tissue with suboptimal margin, longer term oncological
outcome is sacrificed (35) (37).
The treatment of morphoeic BCC is associated with high rates of incomplete excision and
recurrence (125). Morphoeic and large BCCs require wider surgical margins in order to
maximize the chance of complete histological resection. Morphoeic or sclerosing basal cell
carcinoma is the most aggressive subtype and because it spreads into the dermis beyond

Primary Care Surgical Association Document (28/05/2014)

Page 6

PCSA Non Melanoma Skin Cancer Guidelines

the clinically visible or palpable borders, it makes it very difficult to define an appropriate
margin.
For primary morphoeic lesions, the rate of complete excision with increasing peripheral
surgical margins is as follows: 3 mm margin, 66%; 5 mm margin, 82%; 13 -15 mm margin,
>95% (124). These histological subtypes are high risk as exampled in the study by Cigna et
al, where 63% of relapses were accounted for by the morphoeic-infiltrative subtype (37).
These require referral to a SSMDT as recommended in the NICE guidance on skin cancer
services and will often involve MMS (7).
Basosquamous basal cell carcinoma exhibits an infiltrative growth and stromal reaction
consistent with a relatively aggressive tumour (126). Studies have shown a higher
frequency of pulmonary metastasis than cutaneous SCC and excision using Mohs technique
required a greater number of stages when compared to BCC and SCC (127). It is reported
to have a high recurrence with standard wide excision and these should be managed in a
specialist setting ideally using MMS (128). There is a deficit of literature on optimum
margins of excision.

b. Incompletely excised basal cell carcinoma

The inclusion here is of utmost importance because in a large meta-analysis studying
margins in 16,066 cases, a positive pathological margin occurred with a mean of 14%
(range was 2% to 26%), and resulted in a recurrence rate of 27% (36).
Incomplete excision is where lateral and/or deep margins are involved with (or extremely
close to) tumour. This has been reported to occur in 4.7% and 7% of cases reported from
British specialist plastic surgical units (129) (130).
In a large study of 6881 BCC lesions, Hansen et al, found incomplete BCC excision rates to
be very favourable at 6.4% amongst Australian GPs with a special interest in skin cancer
and skin surgery (131). However there was substantial variation in frequency of
incomplete excision between clinics ranging from 3.3% to 24.7%.
Where histologically complete primary excision is confirmed a recurrence rate of less than
2% in a five year follow up has been reported (32).
In contrast, studies using 2 5 years of follow up have reported recurrence rates following
histological incomplete excision of between 30% and 41% (132) (133). So, prospective and
retrospective reviews of incompletely excised BCC suggesting that even where there is
margin involvement a significant proportion of these lesions will not recur (132) (133).
Liu et al further refined the risk of recurrence revealing that when only the lateral margin
was involved, a 17% recurrence risk could be expected, while when deep margins were
involved a 33% risk of recurrence ensued (134).
Re-excision of incompletely excised lesions revealed the presence of residual tumour in
45% and 54% of cases using standard tissue sectioning (135) (130).
There is good evidence to support a policy of re-treatment of incompletely excised lesions
(32) (135) (136).
If the decision is made to re-treat rather than observe, re-excision or MMS are the
treatments of choice. There were no published series providing good evidence on the
margin necessary in the further surgical excision of incompletely excised BCC. However,
Cigna et al suggested that in incompletely excised BCC, an additional excision of 3 mm
Primary Care Surgical Association Document (28/05/2014)

Page 7

PCSA Non Melanoma Skin Cancer Guidelines

surrounding the scars margin be performed (37). In their study of 1123 patients with BCC,
incompletely excised BCC occurred in 21 patients (1.87%) and these were treated by
further excision using a 3mm margin surrounding the scar. However, there was no data
presented on this subgroup follow up.

c. Recurrent basal cell carcinoma

In the management of recurrent BCC by surgical excision, all publishes series reveal cure
rates which are inferior to that of primary lesions (108).
Mosterd et al, in a prospective randomised controlled trial with five years follow up,
presented results for 204 recurrent BCCs. Results revealed that MMS was preferred over
surgical excision for the treatment of facial recurrent BCC on the basis of significantly
fewer recurrences (117).
Recurrent lesions require wider surgical margins than primary lesions. Peripheral excision
margins for recurrent BCC of 5 10 mm have been suggested (112), but while there is good
evidence base for the use of MMS in these circumstances, there is a deficit of literature to
provide guidance on optimum surgical margins where standard excision is used.
Primary Cutaneous Squamous Cell Carcinoma

There are widely varying malignant behaviours of tumours which fall within the
histological diagnostic category of primary cutaneous SCC. The majority of SCC cases are a
low risk for metastases but it is essential to identify those which are at high risk for
recurrence including metastatic potential. Bernstein et al reviewed common variants of
SCC (88) and these included:

1. Neurotrophic SCC
2. Bowens disease
3. SCC in transplant patients
4. Keratoacanthoma-like SCC
5. SCC of the lip
6. adenoid SCC
7. spindle cell SCC
8. radiation induced SCC
9. verrucous carcinoma
10. Marjolins ulcer.
They all have unique aetiologic, histologic, and clinical features that significantly
influence their diagnosis, treatment and subsequent management.

Emphasis has been placed on obtaining a diagnosis histologically in advance of definitive

therapy and this is supported by the NICE guidelines (7) (10). NICE provides a
recommendation that a preliminary biopsy may be necessary when a firm clinical diagnosis
cannot be made by inspection alone, or when a treatment other than surgical removal is
chosen for NMSC. Biopsy may also be needed before extensive surgery and in order to
confirm the diagnosis in cosmetically sensitive areas such as the face (7).

Primary Care Surgical Association Document (28/05/2014)

Page 8

PCSA Non Melanoma Skin Cancer Guidelines

Where a histological diagnosis of SCC is made, there are important factors to be reported
by the histopathologist which will impact on the risk categorisation and further treatment.
This includes

a. Histopathological subtype e.g. acantholytic, desmoplastic, spindle

verrucous or keratoacanthoma subtypes.
b. Degree of differentiation well, moderate, poorly or undifferentiated. Also
histological grading as described by Broders (137).
c. Tumour depth
d. The presence or absence of perineural, vascular or lymphatic invasion.
There are prognostic factors which allow the treating clinician to assign individual SCC
lesions into a low-risk category or into a high-risk category of tumour recurrence
following treatment (19).
As stated earlier, these are similar to the prognostic factors in BCC described above.
Primary cutaneous SCC Prognostic factors

1. Tumour size tumours greater than 2 cm in diameter are twice as likely to

recur locally and three times as likely to metastasize as smaller tumours
(17) (138).
2. Tumour site In order of increasing risk of metastatic potential, SCC arising
at sun exposed sites ( excluding lip and ear), SCC of the lip, SCC of the
ear, tumours arising in non sun-exposed sites e.g. perineum, sacrum, sole of
foot), SCC arising in areas of radiation or thermal injury, chronic draining
sinuses, chronic ulcers, chronic inflammation or BD (17).
3. Definition of clinical margins - Poorly defined lesions are at higher risk of
recurrence.
4. Histological subtype Poorly differentiated tumours have a poorer
prognosis, with more than double the local recurrence rate and triple the
metastatic rate of better differentiated SCC (17) (139). Acantholytic,
spindle and desmoplastic subtypes have a poorer prognosis, whereas the
verrucous subtype has a better prognosis.
5. Histological depth and features of aggression Tumours greater than 4 mm
in depth or extending into or beyond the subcutaneous tissue are more
likely to recur and metastasize at a rate of 45.7% compared with thinner
tumours. Tumours less than 2 mm in thickness rarely metastasise (17) (139).
Tumours with perineural involvement, lymphatic or vascular invasion are
more likely to recur and to metastasize (140) (141).
6. Failure of previous treatment the risk of local recurrence depends upon
the treatment modality and local recurrent disease itself is a risk factor for
metastatic disease (17).
7. Immunosuppression tumours arising in patients who are immunosuppressed
have a poorer prognosis (142).
Primary Care Surgical Association Document (28/05/2014)

Page 9

PCSA Non Melanoma Skin Cancer Guidelines

While there is a paucity of randomised controlled trials for the treatment of primary
cutaneous SCC, the goal of treatment is complete removal including micrometastases
preferably with histological confirmation.
In the management of primary cutaneous SCC, surgical excision (which may MMS where
appropriate) should be regarded as the treatment of first choice for primary cutaneous
SCC (19).

Surgical excision allows full characterisation of the tumour and provides a guide to the
adequacy of treatment through histological examination of the margins of the excised
tissue.
Weinstein et al in a literature review, provided evidence for optimal margins and
recommended again the classification of skin cancers as low-risk and high-risk based of
the factors described above already (44).

Low risk SCC

Weinsteins group recommend lateral excision margins of 4mm 6 mm for low risk SCCs
and MMS or resection with complete circumferential peripheral and deep margin
assessment (CCPDMA) for high risk SCCs (44).
Brodland recommended, in clinically well-defined, low risk tumours less than 2 cm in
diameter, surgical excision with a minimum 4 mm margin around the tumour border was
appropriate and would be expected to completely remove the primary tumour mass in 95%
of cases (43).

High risk SCC

Using the prognostic factors above tumours falling into a high risk category should be
considered for a wider margin of excision. In Brodlands paper, tumours greater than 2 cm
in diameter, tumours classified as moderately, poorly or undifferentiated, tumours
extending into the subcutaneous tissue and those on the ear, lip, scalp, eyelids or nose
should be removed with a margin of 6 mm or more (43).

However the more recent extensive literature review by Weinstein, SCC > 20mm in low
risk areas and no other risk factors, which are amenable to primary closure, 10 mm
margins are optimum (44).

There is good evidence that the incidence of local recurrent and metastatic disease are
low after MMS and it should therefore be considered in the surgical treatment of high risk
SCC (17). The best cure rates for high risk SCC are reported in series treated by Mohs
micrographic surgery (143-144).

Conclusion and Recommendations

Primary Care Surgical Association Document (28/05/2014)

Page 10

PCSA Non Melanoma Skin Cancer Guidelines

These recommendations for clinicians working in the area of NMSC pertain especially to
General Practitioners with appropriate training who perform surgery on NMSC.

The key to the successful management of NMSC is carrying out a thorough risk assessment
and categorising these lesions into low risk and high risk of recurrence (18) (19) (44).

While biopsy is generally recommended where there is diagnostic uncertainty, in

circumstances where treatment modality will not result in a histological specimen analysis
and prior to extensive surgery in cosmetically sensitive regions (7) (10), great care must be
used in the interpretation of this specimen and biopsy and final specimen concordance can
be as low as 60.9% (116).

Contrary to some NICE guidelines (7), low risk lesions may be safely and effectively
managed in primary care by a GPs with a special interest in skin cancer and skin.

In the management of NMSC by surgical excision, low risk NMSC, including BCC and
cutaneous SCC, a clinical margin of 4mm is required to secure a 95% 5 year cure rate.

Where margins less than 4mm are used, for example in cosmetically sensitive and
challenging anatomical regions, this will result in diminished long term oncological
outcome (35) (37).

Rowe demonstrated that only 50% of recurrences occurred within two years and 82% at
five years (17). Therefore, a minimum of 5 years follow-up is required to properly assess
the potential for recurrence in NMSC.

In circumstances of incomplete NMSC excision, there is good evidence to support a policy

of scar revision excision but further study is required to establish the surgical margins
required in such circumstances (32) (135) (136).

High risk NMSC should be referred to a specialist multidisciplinary team (7) (10).

The evidence base for the optimal margin for high risk NMSC suggests that the higher the
risk the greater the margin that is required and margins in excess of 6mm 10mm have
been recommended where wide excision surgery is performed by the specialist (37) (44)
(112) (124), but further study is required to establish optimal surgical margins in such
circumstances.

Primary Care Surgical Association Document (28/05/2014)

Page 11

PCSA Non Melanoma Skin Cancer Guidelines

There is good evidence to support a policy of MMS or CCPDMA for high risk NMSC (18) (19)
(117) (143-144).
Dr. Neil Healy. 14/05/2014

1. Flohil SC, Seubring I, Van Rossum MM, Coebergh JW, de Vries E, Nijsten T.
Trends in Basal Cell carcinoma Incidence Rates; A 37-Year Dutch
Observational Study. J Invest Dermatol. 2012 Nov 29.
2. Diepgen, T.L. and Mahler, V. (2002), The epidemiology of skin cancer.
British Journal of Dermatology, 146: 16.
3. Gloster HM Jr, Brodland DG. The epidemiology of skin cancer. Dermatologic
Surgery 1996,22(3):217-26.
4. South West Public Health Observatory Skin Cancer Hub.
www.swpho.nhs.uk/skincancerhub)
5. Housman TS, Feldman SR, Williford PM, et al. Skin cancer is among the most
costly of all cancers to treat for the Medicare population. J Amer Acad
Derm. 2003;48(3):425-429.
6. Schofield J, Grindlay D, Williams H (2009). Skin conditions in the UK: a
health care needs assessment, Centre of Evidence Based Dermatology.
University of Nottingham.
www.library.nhs.uk/COMMISSIONING/ViewResource.aspx.
7. NICE. Improving outcomes for people with skin tumours including melanoma:
the manual 2006 Feb; CSGSTIM: London: National Institute for Health and
Clinical Excellence.
8. Department of Health(2007).Guidance and competencies for the provision of
services using GPs with a special interest (GPwSIs): dermatology and skin
surgery.
9. National Cancer Registry of Ireland (NCRI). 2010.
10. NICE 2010. Improving Outcomes for People with Skin Tumours including
melanoma (update).
11. Wolf DJ, Zitelli JA. Surgical margins for basal cell carcinoma. Arch
Dermatol. 1987 Mar;123(3):340-4.
12. Karagas MR, Greenberg ER. Unresolved issues in the epidemiology of basal
cell and squamous cell skin cancer. In: Mukhtar H, editor. Skin
Cancer:Mechanisms and Human Relevance. Boca Raton, Fla, USA: CRC
Press;1995.pp.79-86.
13. Hendrix JD Jr, Parlette HL. Duplicitous growth of infiltrative basal cell
carcinoma : analysis of clinically undetected tumor extent in a paired casecontrol study. Dermatol Surg 1996;22:535-9.
14. Thissen MR, Neumann MH, Schouten LJ. A Systematic Review of Treatment
Modalities for Primary Basal Cell Carcinomas. Arch Dermatol.
1999;135(10):1177-1183.
15. Bath-Hextall F, Perkins W, Bong J, Williams H. Interventions for basal cell
carcinoma of the skin. Cochrane database Syst Rev 2007;1:CD003412.
16. Kuijpers DI, Thissen MR, Neumann MH. Basal cell carcinoma: treatment
options and prognosis, a scientific approach to a common malignancy. Am J
Clin Dermatology 2002; 3:247 -59.

Primary Care Surgical Association Document (28/05/2014)

Page 12

PCSA Non Melanoma Skin Cancer Guidelines

17. Rowe DE, Carroll Rj, Day CL. Prognostic Factors for local recurrence,
metastasis and survival rates in squamous cell carcinoma of the skin, ear
and lip. J Am Acad Dermatol 1992:26:976-90.
18. Telfer NR, Colver GB, Morton CA. Guidelines for the management of basal
cell carcinoma. British Journal of Dermatology 2008;159: 35-48.
19. Motley RJ, Preston PW, Lawrence CM. Multi-professional Guidelines for the
Management of the Patient with Primary Cutaneous Squamous Cell
Carcinoma. British Journal of Dermatology 2002; 146: 18-25.
20. National Cancer Peer Review Programme (2008) Manual for cancer services
2008: skin measures.
21. Department of Health(2007).Guidance and competencies for the provision of
services using GPs with a special interest (GPwSIs): dermatology and skin
surgery.
22. Rapini RP. Comparison of methods for checking surgical margins. J Am Acad
Dermatol 1990 Aug;23(2 Pt 1):288-94.
23. Dandurand M, Petit T, Martel P, Guillot B. Management of basal cell
carcinoma in adults Clinical practice guidelines. Eur J Dermatol. Jul- Aug
2006;16(4):394-401.
24. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines
in Oncology. Basal Cell and Squamous Cell Skin Cancers. 2011;v.1:Accessed
June 30, 2012. Available at
http://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdf)
25. Gilbody JS, Aitken J, Green A. What causes basal cell carcinoma to be the
commonest cancer? Aust J Public Health 1994;18:218-21.
26. Wolff K, Johnson R. Fitzpatricks Color Atlas and Synopsis of Clinical
Dermatology. 6th edition. P 232 -235.
27. Rowe DE, Carroll RJ, Day CL. Long-term recurrence rates in previously
untreated (primary) basal cell carcinoma: implications for patient follow-up.
J Dermatol Surg Oncol. 1989;15315-328.
28. Barry J, Oon SF, Watson R, Barnes L. The management of basal cell
carcinomas. Ir Med J. 2006 jun;99(6):179-81.
29. NICE. Referral guidelines for suspected skin cancer. Accessed July 1, 2012 at
www.nice.org.uk/CG027
30. Walker P, Hill D. surgical treatment of basal cell carcinomas using standard
postoperative histological assessment. Australas J Dermatol 2006; 47: 1-12.
31. Marchac D, Papadopoulos O, Duport G. Curative and aesthetic results of
surgical treatment of 138 basal-cell carcinomas. J Dermatol Surg Oncol
1982;8:379-87.
32. Griffiths RW, Suvarna SK, Stone J. Do basal cell carcinomas recur after
complete conventional surgical excision? Br J Plast 2005;58:795-805.
33. National Comprehensive Cancer Network(NCCN). Clinical practice guidelines
in oncology, basal cell and squamous cell skin cancers. V.1.2010 Available
at: www.nccn.org. Accessed 18/03/2013.
34. Thomas DJ, King AR, Peat BG. Excision margins for nonmelanotic skin
cancer. Plast Reconstr Surg. 2003 Jul ; 112(1):57-63.
35. Kimyai-Asadi A, Alam M, Goldberg LH, Peterson SR, Silapunt S, Jih MH.
Efficacy of narrow-margin excision of well-demarcated primary facial basal
cell carcinomas. J Am Acad Dermatol. 2005 Sep;53(3):464-8.
Primary Care Surgical Association Document (28/05/2014)

Page 13

PCSA Non Melanoma Skin Cancer Guidelines

36. Gulleth Y, Goldberg N, Silverman RP, Gastman BR. What is the best surgical
margin for a basal cell carcinoma: a meta-analysis of the literature. Plast
Reconstr Surg. 2010 Oct;126(4):1222-31.
37. Cigna E, Tarallo M, Maruccia M, Sorvillo V, Pollastrini A et al. Basal Cell
Carcinoma: 10 years of Experience. J Skin Cancer;2011:2011:476362.
38. Kraemer KH, Lee MM, Andrews Ad et al. The role of sunlight and DNA repair
in melanoma and nonmelanoma skin cancer. The xeroderma pigmentosum
paradigm. Arch Dermatol 1994;130;1018-1021.
39. Costantino D, Lowe L, Brown DL. Basosquamous carcinoma an underrecognized, high-risk cutaneous neoplasm: case study and review of the
literature. J Plast Reconstr Aesthet Surg 2006;59:424-8.
40. Bratsch K, Meisner C, Schonfish B, Trilling B, Wehner-Caroli J, Rocken M,
Breuninger H. Analysis of risk Factors determining prognosis of cutaneous
squamous-cell carcinoma : a prospective study. Lancet Oncol. 2008
Aug;9(8):713-20.
41. Eroglu A, Berberoglu U, Berberoglu S. Risk factors related to locoregional
recurrence in squamous cell carcinoma of the skin. J Surg Oncol
1996;61:124-30.)
42. Green AC, McBride P. Squamous cell carcinoma of the skin (nonmetastatic).
Clin Evid. 2010;2010:1709.
43. Brodland DG, Zitelli JA. Surgical margins for excision of primary cutaneous
squamous cell carcinoma. J Am Acad Dermatol 1992:27:241-8.
44. Weinstein MC, Brodell RT, Bordeaux J, Honda K. The art and science of
surgical margins for the dermatopathologist. Am J dermatopathol. 2012
Oct;34(7):737-745.
45. Bovill ES, Cullen KW, Barrett W, Banwell PE. Clinical and histological
findings in re-excision of incompletely excised cutaneous squamous cell
carcinoma. J Plast Reconstr Aesthet Surg. 2009 Apr;62(4):457-61.
46. Bovill ES, Banwell PE. Re-excision of incompletely excised cutaneous
squamous cell carcinoma: histological findings influence prognosis. J Plast
Reconstr Aesthet Surg. 2012 Oct;65(10):1390-5.
47. Tan P, Ek E, Su S, et al. incomplete excision of squamous cell carcinoma of
the skin: a prospective observational study. Plast Reconstr
Surg.2007;120:910-916.
48. Authors omitted. Management of Bowens disease of the skin. Drug Ther
Bull. 2004Feb;42(2):13-6.
49. Cox NH, Eedy DJ, Morton CA. Guidelines for management of Bowens
disease: 2006 update. British Journal of Dermatology 2007 156, 11 -21.
50. Bowen JT. Precancerous dermatoses: a study of two cases of chronic
atypical epithelial proliferation. J Cutan Dis 1912;30:241-255.
51. Eedy DJ, Gavin AT. Thirteen year retrospective study of Bowens disease in
Northern Ireland. Br J Dermatol 1987;117:715-720.
52. Cox NH. Body site distribution of Bowens disease. Br J Dermatol
1994;130:714-716.
53. Quereux G, NGuyen JM, Dreno B. Human papillomavirus and extragenital in
situ carcinoma. Dermatology 2004;209:40-45.
Primary Care Surgical Association Document (28/05/2014)

Page 14

PCSA Non Melanoma Skin Cancer Guidelines

54. Chute CG, Chuang TY, Bergstralh EJ, Su WP. The subsequent risk of internal
cancer with Bowens disease. A population-based study. JAMA 1991;266:816819.
55. Marcil I, Stern RS. Risk of developing a subsequent nonmelanoma skin cancer
in patients with a history of nonmelanoma skin cancer: a critical review of
the literature and meta-analysis. Arch Dermatol 2000;136:1524-1530.
56. Kao GF. Carcinoma arising in Bowens disease. Arch Dermatol
1986;122:1124-1126.
57. Tsur H, Borenstein A, Seidman DS. Full thickness skin damage due to topical
administration of 5-fluorouracil. European Journal of Plastic Surgery. (Case
Report). 1990 November, 1990; Volume 13(Number 6):263-4.
58. Patel GK, Goodwin R, Chawla M et al. Imiquimod 5 % cream monotherapy for
cutaneous squamous cell carcinoma in situ (Bowens disease): a randomised,
double blind, placebo-controlled trial. J Am Acad Dermatol 2006;54:102532.
59. Ball SB, Dawber RP. Treatment of cutaneous Bowens disease with particular
emphasis on the problem of lower leg lesions. Australas J Dermatol. 1998
May;39(2):63-8.
60. Moreno G, Chia AL, Lim A, Shumack S. Therapeutic options for Bowens
disease. Australas J Dermatol.2007Feb;48(1)1-8.
61. Graham JH, Helwig EB. Bowens disease and its relationship to systemic
cancer. Arch Dermatol 1961;83:76-96.
62. Bell HK, Rhodes LE. Bowens disease a retrospective review of clinical
management. Clin Exp Dermatol 1999;24:338-9.
63. Marchesa P, Fazio VW, Oliart Set al. Perinal Bowens disease: a
clinicopathological study of 47 patients. Dis Colon Rectum 1997;40:1286-93.
64. Cleary Rk, Schaldenbrand JD Fowler JJ et al. Treatment options for perianal
Bowens disease:survey of American Society of Colon and Rectal Surgeons
Members. Am Surg 2000;66:686-8.
65. Meijer BU, de Waard-Vander Spek FB. Allergic contact dermatitis because of
topical use of 5-fluorouracil (Efudix cream). Contact Dermatitis. 2007
Jul;57(1):58-60.
66. Mackenzie-Wood A, Kossard S, de Launney J et al. Imiquimod 5% cream in
the treatment of Bowens disease. J Am Acad Dermatol 2001;44:462-70.
67. Ahmed I, Berth-Jones J, Charles-Holmes S et al. Comparison of cryotherapy
with curettage in the treatment of Bowens disease: a prospective study. Br
J Dermatol 2000;143:759-766.
68. Morton CA, Whitehurst C, Moseley H et al. Comparison of photodynamic
therapy with cryotherapy in the treatment of Bowens disease. Br J
Dermatol 1995 ; 135 :766-771.
69. Lui H, Hobbs L, Tope WD et al. Photodynamic therapy of multiple
nonmelanoma skin cancers with verteporfin and red light-emitting diodes:

Primary Care Surgical Association Document (28/05/2014)

Page 15

PCSA Non Melanoma Skin Cancer Guidelines

two-year results evaluating tumour response and cosmetic outcomes. Arch
Dermatol 2004;140:26-32.
70. Cox NH, Dyson P. Wound healing on the lower leg after radiotherapy or
cryotherapy in the treatment of Bowens disease and other malignant skin
lesions. Br J Dermatol 1995;135:766-71.
71. Dupree MT, Kiteley RA, Weismantle Ket al. Radiation therapy for Bowens
disease: lessons for lesions of the lower extremity. J Am Acad Dermatol
2001;45:401-4.
72. Dave R, Monk B, Mahaffey P. Treatment of Bowens disease with carbon
dioxide laser. Lasers Surg Med 2003;32:335.
73. Hansen JP, Drake Al, Walling HW. Bowens Disease: a four-year
retrospective review of epidemiology and treatment at a university center.
Dermatol Surg.2008 Jul;34(7):878-83.
74. Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Cutaneous squamous
carcinoma in situ (Bowens disease): treatment with Mohs micrographic
surgery. J Am Acad Dermatol.2005 Jun;52(6):997-1002.
75. Schwartz RA. Keratoacanthoma: a clinic-pathologic enigma. Dermatol Surg.
2004 Feb;30:326-33.
76. Jackson R. Early clinical descriptions of skin cancer. Can Med Assoc J. 1973
Nov 3;109(9);9.6-8.
77. Chuang TY, Reizner GT, Elpern DJ, Stone JL, Farmer ER. Keratoacanthoma
in Kauai, Hawaii. The first documented incidence in a defined population.
Arch Dermatol. Mar 1993;129(3):317-9.
78. Chuang TY, Reizner GT, Elpern DJ, Stone JL, Farmer ER.Squamous cell
carcinoma in Kauai, Hawaii. Int J Dermatol. Jun 1995;34(6):393-7.
79. Letzel S, Drexler H. Occupationally related tumors in tar refinery workers. J
Am Acad Dermatol. Nov 1998;39:712-720.
80. Miot HA, Miot LD,daCosta AL, et al. Association between solitary
Keratoacanthoma and cigarette smoking: a case control study. Dermatol
Online J. Feb 28 2006;12(2):2.
81. Ponti G, Ponz de leon M. Muir-Torre syndrome. Lancet Oncol. 2005
Dec;6(12):980-7.
82. Griffiths RW. Keratoacanthoma observed. Br J Plast Surg. 2004
Sep;57(6):485-501.
83. Gray RJ, Meland NB. Topical 5-fluorouracil as primary therapy for
keratoacanthoma. Ann Plast Surg.2000 jan;44(1):82-5.
84. Dendorfer M, Oppel T, Wollenberg A, Prinz JC. Topical treatment with
imiquimod may induce regression of facial Keratoacanthoma. Eur J
Dermatol. 2003 Jan-Feb;13(1):80-2.
85. Magalhaes RF, Cruvinel GT. Diagnosis and follow-up of keratoacathomas-like
lesions: clinical-histologic study of 43 cases. J Cutan Med Surg. 2008 JulAug;12(4):163-73.

Primary Care Surgical Association Document (28/05/2014)

Page 16

PCSA Non Melanoma Skin Cancer Guidelines

86. Stanc MF, Robertson GA. Conservative treatment of keratoacanthoma. Ann
Plat Surg. 1979 Jun;2(6):525-30.
87. Annest NM, VanBeek MJ, Arpey CJ, Whitaker DC. Intralesional methotrexate
treatment for keratoacnthoma tumors: a retrospective study and review of
the literature. J Am Acad Dermatol 2007 jun;56(6):989-93.
88. Bernstein SC, lim KK, Brodland DG, Heidelberg KA. The many faces of
squamous cell carcinoma. Dermatol Surg. 1996 mar;22(3):243-54.
89. Kossard S, Tan KB, Choy C. Keratoacanthoma and infundibulocystic
squamous cell carcinoma. Am J Derrmatopathol. 2008 Apr;30(2):127-34.
90. Beham A, Regauer S, Soyer HP, Beham-Schmid C. Keratoacnthoma: a
clinically distinct variant of well differentiated squamous cell carcinoma.
Adv Anat pathol. 1998 Sep;5(5):269-80.
91. Hodak E, Jones RE, Ackerman AB. Solitary Keratoacanthoma is a squamouscell carcinoma: three examples with metastases. Am J Dermatopathol. 1993
Aug;15(4):332-42.
92. Mandrell JC, Santa Cruz D. Keratoacanthoma: hyperplasia, benign neoplasm,
or a type of squamous cell carcinoma? Semin Diagn Pathol. 2009
Aug;26(3):150-63.
93. Barnetson RS, Halliday GM. Regression in skin tumours: a common
phenomenon. Australas J Dermatol. 1997 Jun;38Suppl 1:S63-5.
94. Cribier B, Asch P, Grosshans E. Differentiating squamous cell carcinoma
from Keratoacanthoma using histopathological criteria. Is it possible? A
study of 296 cases. Dermatology.1999;199(3):208-12.
95. Sanders S, Busam KJ, Halpern AC, Nehal KS. Intralesional corticosteroid
treatment of Multiple eruptive keratoacanthomas: Case report and review of
a controversial therapy. Dermatologic Surgery. 28:954-958.
96. Sayama S, Tagami H. Treatment of keratoacnthoma with Intralesional
bleomycin. Br J Dermatol. 1983 Oct;109(4):449-52.
97. Kirby JS, Miller CJ. Intralesional chemotherapy for nonmelanoma skin caner:
a practical review. J Am Acad Dermatol. 2010 Oct;63(4):689-702.
98. Martorell-Calatayud A et al. Intralesional infusion of methotrexate as
neoadjuvant therapy improves the cosmetic and functional results of surgery
to treat keratoacnthoma: results of a randomized trial. Actas Dermosifiliogr.
2011 oct;102(8):605-15.
99. Aubut N, Alain J, Claveau J. Intralesional methotrexate treatment for
keratoacnthoma tumors: a retrospective case series. J Cutan Med Surg. 2012
May-Jun;16(3):212-7.
100.
Jackson JE, Kelly B, Petitt M, Uchida T, Wagner RF. Predictive value
of margins in diagnostic biopsies of nonmelanoma skin cancers. J Am Acad
Dermatol. 2012 Jul;67(1):122-7.
101.
Lalla M, Thomas BA. Periorbital keratoacanthoma. Br J Ophthalmol
1968;52:876-881.

Primary Care Surgical Association Document (28/05/2014)

Page 17

PCSA Non Melanoma Skin Cancer Guidelines

102.
Leibovitch L, Huilgol SC, James CL, Hsuan JD, Davis G, Selva D.
Periocular keratoacanthoma: can we rely on the clinical diagnosis? Br J
Ophthalmol. 2005 September;89(9):1201 -1204.
103.
Boniuk M, Zimmerman LE. Eyelid tumors with reference to lesions
confused with squamous cell carcinoma.III. Keratoacanthoma. Arch
Ophthalmol 1967;77:29-40.
104.
Donaldson MJ, Sullivan TJ, Whitehead KJ, Williamson RM. Periocular
keratoacanthoma: clinical features, pathology, and management.
Ophthalmology. 2003 Jul;110(7):1403-7.
105.
Karagas MR. Occurrence of cutaneous basal cell and squamous cell
malignancies among those with a prior history of skin cancer. The Skin
Cancer Prevention Study Group. J Invest Dermatol. Jun 1994;102(6):10S-13S.
106.
Quirk C, Gebauer K, DeAmbrosis B, Slade HB, Meng TC. Sustained
clearance of superficial basal cell carcinomas treated with imiquimod cream
5%: results of a prospective 5-year study. Cutis. 2010 Jun;85(6):318-24.
107.
Ruiz-Villaverde R, Sanchez-Cano D, Burkhardt-Perez P, Sintes RN. Has
imiquimod 5% cream a role in the management of recurrent basal cell
carcinoma? Eur J Dermatol. 2009 Sep-Oct;19(5):481-3.
108.
Rowe DE, Carroll RJ, Day CL. Mohs surgery is the treatment of choice
for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg
Oncol 1989;15:424-31.
109.
Kuflik EG, Gage AA. Recurrent basal cell carcinoma treated with
cryosurgery. J Am Acad Dermatol 1997;37:82-4.
110.
Smeets NW, Krekels GA, Ostertag JU et al. Surgical excision vs Mohs
micrographic surgery for basal-cell carcinoma of the face: randomised
controlled trial. Lancet 2004;364:1766-72.
111.
Otley CC. Mohs micrographic surgery for basal-cell carcinoma of the
face. Lancet 2005;365:1226-7.
112.
Burg G, Hirsch RD, Kronz B, Braun-Falco O. Histographic surgery:
accuracy of visual assessment of the margins of basal-cell epithelioma. J
Dermatol Surg Oncol 1975;1:21-4.
113.
Nguyen TH, Ho DQ. Nonmelanoma skin cancer. Curr Treat Options
Oncol.2002 Jun;3(3):193-203.
114.
Kaur P, Mulvaney M, Carlson JA. Basal cell carcinoma progression
correlates with host immune response and stromal alterations: a histologic
analysis. Am J Dermatopathol 2006Aug; 28(4):293-307.
115.
Boulinguez S, Grison-Tabone C, Lamant L et al. Histological evolution
of recurrent basal cell carcinoma and therapeutic implications for
incompletely excised lesions. Br J Dermatol 2004 Sep;151(3):623-6.
116.
Roozeboom MH, Mosterd K, Winnepenninckx VJ, Nelemans PJ,
Kelleners-Smeets NW. Agreement between histological subtype on punch
biopsy and surgical excision in primary basal cell carcinoma. J Eur Acad
Dermatol Venereal. 2012 Jun 13.
Primary Care Surgical Association Document (28/05/2014)

Page 18

PCSA Non Melanoma Skin Cancer Guidelines

117.
Mosterd K, Krekels GA, Nieman FH et al. Surgical excision versus
Mohs micrographic surgery for primary and recurrent basal cell carcinoma
of the face: a prospective randomised controlled trial with 5-years follow
up. Lancet Oncol. 2008Dec;9(12):1149-56.
118.
Cataldo PA, Stoddard PB, Reed WP. Use of frozen section analysis in
the treatment of basal cell carcinoma. Am J Surg. 1990jun;159(6):561-3.
119.
Breuninger H, Schippert W, Black B, Rassner G. The margin of safety
and depth of excision in surgical treatment of basalioma. Use of 3dimensional histologic study of 2016 tumours. Hautarzt. 1989
Nov;40(11):693-700.
120.
Kimyai-Asadi A, Goldberg LH, Jih MH. Accuracy of serial transverse
cross-sections in detecting residual basal cell carcinoma at the surgical
margins of an elliptical excision specimen. J Am Acad Dermatol 2005;
53:469-74.
121.
Ceilley RI, Del Rosso JQ. Current Modalities and new advances in the
treatment of basal cell carcinoma. Int J Dermatol 2006;45:489-98.
122.
Madan V, Lear JT, Szeimies RM. Non-melanoma skin cancer. Lancet.
2010 Feb 20;375(9715):673-85.
123.
Griffiths Rw, Suvarna SK, Stone J. Basal cell carcinoma histological
clearance margins: an analysis of 1539 conventionally excised tumours.
Wider still and deeper? Journal of plastic, reconstructive and Aesthetic
Surgery. 2007;60(1):41-47.
124.
Breuninger H, Dietz K. Prediction of subclinical tumour infiltration in
basal cell carcinoma. J Dermatol Surg Oncol 1991;17:574-8.
125.
Erba P, farhadi J, Wettstein R, Arnold A, Harr T, Pierer G. Morphoeic
basal cell carcinoma of the face. Scand J Plastic Surg Hand Surg.
2007;41(4):184-8.
126.
Betti R, Crosti C, Ghiozzi S et al. Basosquamous cell carcinoma: a
survey of 76 patients and a comparative analysis of basal cell carcinomas
and squamous cell carcinomas.. Eur J Dermatol. 2012 Dec 14.
127.
Bowman PH, Ratz JL, Knoepp TG, Barnes CJ, Finley EM.
Basosquamous carcinoma. Dermatol Surg.2003Aug;29(8):830-2.
128.
Leibvitch I, Huilgol SC, Selva D, Richards S, Paver R. Basosquamous
carcinoma: treatment with Mohs micrographic surgery. Cancer.2005 Jul
1;104(1):170-5.
129.
Kumar P, Orton CI, McWilliam LJ, Watson S. Incidence of incomplete
excision in surgically treated basal cell carcinoma: a retrospective clinical
audit. Br J Plast Surg 2000;35:563-6.
130.
Griffiths RW. Audit of histologically incompletely excised basal cell
carcinomas: recommendations for management by re-excision. Br J Plast
Surg 1999;52:24-8.

Primary Care Surgical Association Document (28/05/2014)

Page 19

PCSA Non Melanoma Skin Cancer Guidelines

131.
Hansen C, Wilkinson D, Hansen M, Soyer HP. Factors contributing to
incomplete excision of nonmelanoma skin cancer by Australian general
practitioners. Arch Dermatol 2009 Nov;145(11):1253-60.
132.
Sussman LA, Liggins DF. Incompletely excised basal cell carcinoma: a
management dilemma? Aust NZ Surg 1996;66:276-8.
133.
De silva Sp, Dellon AL. Recurrence rate of positive margin basal cell
carcinoma: results of a five year prospective study. J Surg Oncol
1985;28:72-4.
134.
Liu FF, Maki E, Warde P et al. A management approach to
incompletely excised basal cell carcinoma of skin. Int J Radiat Oncol Biol
Phys 1991:20:423-8.
135.
Wilson AW, Howsam G, Santhanam Vet al. Surgical management of
incompletely excised basal cell carcinomas of the head and neck. Br J Oral
Maxillofac Surg 2004;42:311-14.
136.
Berlin J, Katz KH, Helm KF, Maloney ME. The significance of tumor
persistence after incomplete excision of basal cell carcinoma. J Am Acad
Dermatol 2002;46:549-53.
137.
Broders AC. Squamous cell epithelioma of the Lip. A study of five
hundred and thirty-seven cases. JAMA. 1920;74(10):656-664.
138.
Clayman GL, Lee JJ, Holsinger C et al. Mortality risk from squamous
cell carcinoma. J Clin Oncol 2005;23:759-65.
139.
Breuninger H, Black B, Rassner G. Microstaging of squamous cell
carcinomas. Am J Clin pathol 1990;94:624-7.
140.
Mendenhall WM, Parsons JT, Mendenhall NP, Brant TA, Stringer SP,
Cassisi NJ, Million RR. Carcinoma of the skin of the Head and Neck with
perineural invasion. Head Neck 1989;11:301-8.
141.
Cottel WI. Perineural invasion by squamous cell carcinoma. J
Dermatol Surg Oncol 1982;8:589-600.
142.
Barksdale SK, OConnor N, Barnhill R. Prognostic factors for
cutaneous squamous cell and basal cell carcinoma. Determinants of risk of
recurrence, metastasis and development of subsequent skin cancers. Surg
Oncol Clin N Am 1997;6:625-38.
143.
Leibovitch I, Huilgol SC, Selva D et al. Cutaneous squamous cell
carcinoma treated with Mohs micrographic surgery in Austrailia I.
Experience over 10 years. J Am Acad Dermatol 2005;53:253-6.
144.
Leibovitch I, Huilgol SC, Selva D et al. Cutaneous squamous cell
carcinoma treated with Mohs micrographic surgery in Austrailia II. Perineural
invasion. J Am Acad Dermatol 2005;53:261-6.

Primary Care Surgical Association Document (28/05/2014)

Page 20