From the Guidelines
For a painless lesion on Darwin's tubercle that is probably a basal cell carcinoma (BCC), Mohs micrographic surgery (option C) would be the best treatment choice. This recommendation is based on the guidelines of care for the management of basal cell carcinoma, which suggest that Mohs micrographic surgery is recommended for high-risk BCC 1. Given that the location of BCC in the H-zone constitutes high risk, independent of size, and Darwin's tubercle is located on the helix of the ear, which can be considered a high-risk area due to its cosmetic and functional importance, Mohs surgery is particularly suitable.
The advantages of Mohs surgery include its high cure rate for BCC, preservation of the maximum amount of healthy tissue, and minimal damage to surrounding structures 1. This technique involves removing the cancer layer by layer and examining each layer microscopically until no cancer cells remain, ensuring complete removal with minimal damage.
While excision with advancement flap (option A) or skin graft (option B) are valid surgical options, they may remove more healthy tissue than necessary and could result in greater deformity of the ear. According to the guidelines, surgical excision with 4-mm clinical margins and histologic margin assessment is recommended for low-risk primary BCC, but for high-risk tumors like those potentially located on Darwin's tubercle, Mohs micrographic surgery offers the best outcomes in terms of recurrence rate and preservation of function and cosmetic appearance 1.
Key points to consider in the decision include:
- The location of the BCC on Darwin's tubercle, which may be considered high-risk due to its location on the ear
- The importance of tissue conservation in this area for cosmetic and functional outcomes
- The high cure rate and tissue-sparing nature of Mohs micrographic surgery
- The recommendation of Mohs surgery for high-risk BCC in the guidelines of care for the management of basal cell carcinoma 1
From the Research
Treatment Options for Basal Cell Carcinoma
- Excision advancement flap
- Excision skin graft
- MOHS (Mohs surgery)
Mohs Surgery for Basal Cell Carcinoma
Mohs surgery is considered a highly effective treatment for basal cell carcinoma (BCC), especially for high-risk or cosmetically important sites 2, 3, 4. The procedure involves the examination of the entire excision margin to ensure complete tumor removal, resulting in a higher chance of cure and better cosmetic outcomes.
Advantages of Mohs Surgery
Considerations for Treatment Choice
The choice of treatment for BCC depends on various factors, including tumor location, size, and risk of recurrence, as well as patient condition and preferences 5, 6. Mohs surgery is often recommended for high-risk or poorly demarcated tumors, while other treatment options may be preferred for smaller or lower-risk lesions.
Evidence for Mohs Surgery
Studies have shown that Mohs surgery results in lower recurrence rates and better cosmetic outcomes compared to standard excision 2, 3, 4. However, the procedure can be more time-consuming and may require specialized training and equipment.