From the Guidelines
For nodulocystic basal cell carcinoma (BCC), a surgical margin of at least 5 mm is recommended to achieve clear margins, considering the high risk of recurrence and the need for wider margins in aggressive variants. This recommendation is based on the understanding that recurrent BCC, which can be more challenging to treat than primary disease, often requires wider peripheral surgical margins, as suggested by guidelines for the management of basal cell carcinoma 1. While specific margin recommendations for nodulocystic BCC are not detailed in the provided evidence, the principle of using wider margins for high-risk or recurrent lesions can be applied to this aggressive subtype.
Key considerations for determining the appropriate margin include:
- The size of the lesion, with larger lesions potentially requiring wider margins
- The location of the lesion, with areas like the face, especially the "H-zone" (nose, periorbital areas, and ears), possibly necessitating more conservative approaches
- The use of Mohs micrographic surgery, which offers high cure rates and tissue preservation, particularly in cosmetically sensitive areas
Given the aggressive nature of nodulocystic BCC and its potential for subclinical extension, ensuring clear margins is crucial to minimize the risk of recurrence. Although the provided study from 2008 1 discusses recurrent BCC and suggests margins of 5–10 mm for such cases, the application of this principle to primary nodulocystic BCC lesions, considering their aggressive potential, supports the use of a margin of at least 5 mm to balance the need for complete tumor removal with the preservation of normal tissue.
From the Research
Nodulocystic Basal Cell Carcinoma Margin Recommendations
- The recommended margin for clear margins in nodulocystic basal cell carcinoma (BCC) is not explicitly stated in the provided studies, but we can look at the recommendations for nodular BCC, which is a similar subtype.
- A study from 2010 2 suggests that a 3-mm surgical margin can be safely used for non-morpheaform basal cell carcinoma, including nodular BCC, to attain 95% cure rates for lesions 2 cm or smaller.
- Another study from 2019 3 recommends that nodular, superficial, and mixed non-infiltrative BCC can usually be safely excised with a cuff of fat alone, implying a margin of at least 1-2 mm.
- A 2025 study 4 found that a 2-mm margin allows for the safe excision of primary lesions with well-pigmented and well-defined basal cell carcinoma in Japanese patients.
- However, a 2005 study 5 suggests that narrow margins (1-3 mm) are inadequate for the excision of small, well-demarcated, primary nodular BCCs of the face, and recommends standard wide margins (e.g., 4 mm) or Mohs micrographic surgery for histologic margin control.
- A 2024 study 6 found that narrow histopathological margins are acceptable in surgical resection of basal cell carcinoma in Japanese patients, with a recurrence rate of only 0.5% in 198 cases with 2-mm, 3-mm, or 5-mm margins.
Margin Size and Recurrence Rate
- The recurrence rate for nodular BCC with different margin sizes is as follows:
- However, the 2025 study 4 found that a 2-mm margin was sufficient for primary lesions with well-pigmented and well-defined basal cell carcinoma in Japanese patients, with no recurrences reported.
- The 2024 study 6 found that histopathological margin was not associated with recurrence rate, even when it was less than 1,000 μm.