The reconstruction after nasal skin cancer (NSC) resection is often practiced differently. The objective of this study is to evaluate the influence of patient-, tumor- and management-related factors on the role of surgery and choice of reconstruction.
This was a monocentric retrospective study of patients who were diagnosed with a NSC (squamous cell or basal cell carcinoma) and suffered from an extended defect after ablative surgery between 2003 and 2013. Twenty-five patients were included. Tumors were staged using the Union for International Cancer Control (eighth edition) TNM classification for primary cutaneous skin cancer of the head and neck. Preferred treatment was surgery in all patients. Health-related quality of life (HRQoL) measurement was evaluated by one generic (36-Item Short Form Health Survey [SF-36]) and two organ-specific questionnaires (Rhinoplasty Outcome Evaluation [ROE] and Functional Rhinoplasty Outcome Inventory 17 [FROI-17]) after therapy. Survival data were estimated by the Kaplan-Meier method and statistical analysis was performed by log-rank, analysis of variance, Levene’s and
According to the Union for International Cancer Control classification, 13 of 25 tumors were staged as pT1 (52%), four as pT2 (16%), seven as pT3 (28%) and one as pT4a (4%). Seventy-two percent of patients (n=18) chose plastic reconstruction, and for the remaining 28% (n=7) of the patients opted for an implant-retained prosthesis. The overall survival was 69.5% after 5 years, the 5-year recurrence-free survival was 90.9% and the 5-year disease-specific survival was 100%. There was no significant difference in the HRQoL outcome between both rehabilitation methods.
Surgery in NSC gives an excellent oncologic prognosis. Nasal reconstruction and prostheses are both very viable options depending on tumor stage and biology, the patient’s wishes as well as the experience of the surgeon.
Skin cancer is the most common malignant disease. Basal cell carcinomas (BCC) and cutaneous squamous cell carcinomas (cSCC) are the major histological types of nonmelanoma skin cancer. cSCC is more aggressive than BCC and is often locally recurrent and sometimes metastasizes to local and locoregional lymph nodes. In contrast, metastasis of BCC is very rare with an incidence of less than 0.01% [
BCC and cSCC are often highly aggressive and destructive, especially in the orbit and nose; therefore a combination of optimal tumor control and best possible cosmesis after surgery is very important. Therapies for BCC and cSCC of the nose include surgery with rehabilitation, primary radiochemotherapy, brachytherapy, or a combination of treatments [
To our knowledge, the different rehabilitation options in nasal skin cancer (NSC) patients with extensive multilayered defects have not been investigated alone so far. In this single center study, we compared patients’ Health-related quality of life (HRQoL) following the reconstruction of extended defects after nasal cancer resection by plastic reconstruction versus use of an implant-retained prosthesis.
This study was performed in accordance with the guidelines of the Declaration of Helsinki on biomedical research involving human subjects, and the study protocol was approved by the local Ethics Committee of Medical Faculty, Heidelberg University Hospital, and informed consent for study and publication was obtained from all individual participants included in the study.
Nasal cancer patients with newly diagnosed nonmelanoma NSC requiring ablative surgery resulting in extensive multilayered nasal defects at the Department of Otolaryngology, Head and Neck Surgery at the Heidelberg University Hospital between 2003 and 2013 were included in the study [
For all patients, clinical and follow-up data (sex, age, TNM classification, histopathological differentiation, treatment modalities, and outcome) were recorded. Tumors were staged according to the Union for International Cancer Control (eighth edition). Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were statistically estimated by the Kaplan-Meier method using IBM SPSS ver. 22.0 (IBM Corp., Armonk, NY, USA).
Patients completed one generic questionnaire (36-Item Short Form Health Survey [SF-36]) and two organ-specific questionnaires (Rhinoplasty Outcome Evaluation [ROE] and Functional Rhinoplasty Outcome Inventory 17 [FROI-17]) after treatment between 2013 and 2015. The SF-36 Health Survey is composed of eight subgroups: physical functioning, physical role functioning, bodily pain, general health, vitality, social functioning, emotional role functioning, and mental health (scales and scoring are reflected in the SF-36 Health Survey Manual and Interpretation Guide). The ROE is composed of six items and focuses more on aesthetic aspects. A higher ROE score indicates higher satisfaction. The FROI-17 contains 17 items and measures more functional aspects [
Twenty-five patients were included in the analysis. Baseline patient characteristics are presented in
All resections achieved a histopathological R0 resection. In one cSCC patient with suspected lymph node status (based on imaging), a concomitant bilateral neck dissection was performed and resulted in a pN0 classification. Two out of five cSCC patients (40%) had advanced stage tumors with infiltration of the upper lip and/or premaxillary bone, therefore received adjuvant radiation therapy.
The median follow-up time was 2.1 years (range, 0.5 to 12.3 years). Seven deaths were recorded. No deaths were related to NSC. Causes of death were second malignancies (non-Hodgkin lymphoma and non-small cell lung cancer) or cardiovasculary/pulmonary disease. One local relapse (4%) occurred in a T1 BCC patient 3.05 years after resection and reconstruction with a paramedian forehead flap. The patient declined further surgery and opted for definitive radiotherapy. To date, the patient is tumor free.
The 5-year OS was 69.5% for the entire cohort and no statistically significant differences were observed between the BCC and cSCC groups (5-year OS: 70.7% [BCC cohort] and 60% [cSCC cohort]; log-rank
CSCC patients (average ROE score, 81.3; standard deviation [SD], 20.6) had a higher HRQoL score than BCC patients (average ROE score, 70.8; SD, 20.1), but this difference was not significant. FROI-17 self-confidence subscales were very low for both tumor types, indicating a high degree of self-confidence. Regarding the SF-36 questionnaire, physical functioning scores were significantly lower in the BCC group (average FROI-17 score, 61.9; SD, 31.7) than the cSCC group (91.7; SD, 10.4;
The therapy of choice for NSC is surgery. However, the nose has a delicate and complex multilayered structure and prominent localization, which makes reconstruction of post-surgical defects challenging. Functional and aesthetic nasal problems may arise following surgery [
So far, only two studies have investigated HRQoL in patients after radical nasal tumor resection with prosthetic rehabilitation alone, and only two studies have evaluated patients after surgical nasal reconstruction alone [
However, the only validated HRQoL questionnaires for conventional rhinoplasty are the FROI-17 and the ROE [
Twenty-five patients with nonmelanoma NSC were included in this study. There may be some degree of referral bias, which cannot be completely controlled, but surgery is the treatment of choice in our institution. A detailed comparison of major advantages and disadvantages of both rehabilitation strategies is given in
The ROE scores ranged between 70.8 and 81.25, indicating that the aesthetic HRQoL was similar in all subgroups. Compared with average scores of 58.8–83.3 after conventional rhinoplasty, our subgroup ROE findings were high [
In contrast to the ROE, a higher FROI-17 score indicates lower satisfaction. The FROI-17 includes functional questions, which complement the aesthetic assessment of the ROE. For the subcohort analysis (cSCC vs. BCC; surgical reconstruction versus prosthesis rehabilitation; T1/2 vs. T3/4), the overall FROI-17 and the subscores general symptoms, nasal symptoms, and self-confidence did not differ significantly.
In the generic SF-36 questionnaire, physical functioning scores were higher in cSCC patients (91.7) than BCC patients (61.9). This might be partly due to different age distribution or different postoperative expectations. We compared our data with a normally distributed reference cohort (which was included in the validation of the SF-36). Physical functioning was good in our NSC patients, but significantly worse than the reference patient cohort. Although organ specific HRQoL were satisfactory, significantly low physical and social functioning scores may indicate restrictions in everyday life. Age and orthopedic disabilities may be responsible for the reduced HRQoL score for the NSC group compared to reference cohort. However, these were not examined due to the low number of the NSC cohort. We believe that the excellent organ-specific HRQoL outcome we observed is a result of our dedicated multidisciplinary approach with extensive rehabilitation counselling before ablative surgery is performed.
The strength of the study that it is the first to address HRQoL in advanced NSC patients. There are, of course, also limitations of this study. Obviously, the study cohort is small, which is due to the low incidence of patients with this particular tumor entity being that far locally advanced to require multilayered excision. There might be a referral bias to this study, as some patients might have been sent for radiotherapy, because they declined rhinectomy. However, we estimate that the proportion is minimal, because the institutional preference in this situation is surgery. Moreover, the assignment of patients the rehabilitation strategy was based on patients’ preference and oncological factors as stage, tumor biology and risk factors on histology, and not in a randomized controlled fashion. However, we believe that such a trial would be difficult to conduct, as these patients most likely declined randomization.
Overall oncological outcome is good for nonmelanoma NSC. However, extensive multilayer resections are sometimes necessary to cure the patient which may have high physiological impact on the patients and affect their HRQoL. Despite the worse overall HRQoL outcome (SF-36) than in the control cohort, in terms of organ-specific HRQoL (ROE and FROI-8), we observed a high degree of satisfaction. We believe that this might be a merit of our dedicated multidisciplinary approach with extensive counselling of all rehabilitation options before ablative surgery is performed. Interestingly, the HRQoL outcome between both rehabilitation methods had been comparable. Therefore patient’s preference and the experience of the surgeon should be considered when choosing the reconstruction method.
• Surgery in advanced nasal skin cancer patients results in an excellent prognosis.
• Quality of life is equal in nasal reconstruction and prosthetic rehabilitation for extensive skin cancer defects.
• Nasal reconstruction and prostheses are both very viable options depending on tumor stage and biology, patient’s wishes as well as the experience of the surgeon.
No potential conflict of interest relevant to this article was reported.
Conceptualization: PAF, KZ, MP, HMT. Data curation: MP, HMT, KZ. Formal analysis: MP, HMT, KZ, IB, PAF. Methodology: HMT, KZ, IB, PAF. Project administration: KZ, PAF. Visualization: MP, HMT, KZ. Writing - original draft: MP, KZ, PAF. Writing - review & editing: MP, KZ, PAF.
(A-C) Partial rhinectomy and reconstruction with a paramedian forehead flap, anterior based septal mucoperichondrious flap, and cartilage graft. (D-F) Total rhinectomy followed by reconstruction with an implant-retained nasal prosthesis (nasal plate of the Epiplating System by Medicon eG, Tuttlingen, Germany; anaplastologist Jörn Brom, Heidelberg, Germany).
Kaplan-Maier plots for overall survival (OS) and recurrence-free survival (RFS) depending on T1/2 vs. T3/4, basal cell carcinoma (BCC) vs. cutaneous squamous cell carcinoma (cSCC), prosthetic rehabilitation (PR) vs. surgical reconstruction (SR). Disease-specific survival was 100% (not shown).
Box-plot analysis showing the 36-Item Short Form Health Survey (SF-36) subscores (
Surgical and clinicopathological characteristics of the study population
Characteristics | Entire cohort (n=25) | Prosthesis cohort (PR, n=7) | Reconstruction cohort (SR, n=18) |
---|---|---|---|
Age (yr) | 73 (52–93) | 85 (74–92) | 68 (52–93) |
Sex | |||
Male | 15 (60.0) | 3 (42.9) | 12 (66.7) |
Female | 10 (40) | 4 (57.1) | 6 (33.3) |
Histology | |||
BCC | 20 (80) | 5 (71.4) | 15 (83.3) |
cSCC | 5 (20) | 2 (28.6) | 3 (16.7) |
T stage | |||
T1/2 | 17 (68.0) | 3 (42.9) | 14 (77.8) |
T3/4 | 8 (32.0) | 4 (57.1) | 4 (22.2) |
N stage | |||
N0 | 25 (100) | 7 (100) | 18 (100) |
M stage | |||
M0 | 25 (100) | 7 (100) | 18 (100) |
Questionnaire (FROI-17, ROE, and SF-36) | |||
No response | 7 (28.0) | 1 (14.3) | 6 (33.3) |
Response | 11 (44.0) | 2 (28.6) | 9 (50.0) |
Excluded due to death | 7 (28.0) | 4 (57.1) | 3 (16.7) |
5-Year overall survival rate (%) | 69.5 | 53.6 | 77.2 |
5-Year disease-specific survival rate (%) | 100 | 100 | 100 |
5-Year recurrence-free survival rate (%) | 90.9 | 100 | 85.7 |
Values are presented as mean (range) or number (%).
PR, prosthetic rehabilitation; SR, surgical reconstruction; BCC, basal cell carcinomas; cSCC, cutaneous squamous cell carcinomas; FROI-17, Functional Rhinoplasty Outcome Inventory 17; ROE, Rhinoplasty Outcome Evaluation; SF-36, 36-Item Short Form Health Survey.
FROI-17, ROE, and SF-36 scales
Variable | Prosthetic rehabilitation (n=7) | Surgical reconstruction (n=18) | |
---|---|---|---|
FROI-17 | |||
Overall score | 15.0±0.0 | 25.6±29.2 | 0.750 |
Nasal symptom | 10.0±12.4 | 22.2±20.8 | 0.610 |
General symptom | 20.0±14.4 | 21.4±29.1 | 0.965 |
Self-confidence | 0.0±0.0 | 20.0±32.7 | 0.588 |
ROE | 79.2±0.0 | 72.4±20.6 | 0.766 |
SF-36 | |||
Physical functioning | 55.0±35.4 | 73.3±30.4 | 0.469 |
Physical role functioning | 50.0±70.7 | 66.7±50.0 | 0.695 |
Bodily pain | 94.4±7.9 | 72.8±31.5 | 0.378 |
General health | 52.5±3.5 | 64.4±26.2 | 0.558 |
Vitality | 55.0±0.0 | 70.0±28.9 | 0.640 |
Social functioning | 43.8±8.8 | 50.0±11.6 | 0.503 |
Emotional role functioning | 66.7±47.1 | 79.2±39.6 | 0.707 |
Mental health | 72.0±0.0 | 69.0±16.0 | 0.864 |
FROI-17 | |||
Overall score | 25.8±29.1 | 13.8±0.0 | 0.717 |
Nasal symptom | 21.7±21.2 | 13.3±0.0 | 0.730 |
General symptom | 26.3±29.7 | 6.3±8.8 | 0.404 |
Self-confidence | 21.7±35.4 | 5.0±7.1 | 0.553 |
ROE | 70.8±20.1 | 81.3±20.6 | 0.541 |
SF-36 | |||
Physical functioning | 61.9±31.7 | 91.7±10.4 | 0.044 |
Physical role functioning | 62.5±51.8 | 66.7±57.7 | 0.910 |
Bodily pain | 72.2±33.6 | 88.9±11.1 | 0.248 |
General health | 57.1±25.5 | 73.3±17.6 | 0.352 |
Vitality | 63.3±30.9 | 78.3±20.2 | 0.478 |
Social functioning | 48.2±13.4 | 50.0±0.0 | 0.829 |
Emotional role functioning | 66.7±43.0 | 100.0±0.0 | 0.086 |
Mental health | 66.0±17.7 | 76.0±4.0 | 0.380 |
SF-36 | |||
Physical functioning | 70.0±30.3 | 84.2±23.8 | 0.049 |
Physical role functioning | 63.6±50.5 | 80.6±34.5 | 0.292 |
Bodily pain | 76.8±29.6 | 77.0±28.5 | 0.978 |
General health | 62.0±23.7 | 64.1±23.5 | 0.777 |
Vitality | 68.3±27.5 | 61.9±19.1 | 0.316 |
Social functioning | 48.8±10.9 | 87.7±19.5 | <0.001 |
Emotional role functioning | 76.7±38.7 | 87.7±29.0 | 0.228 |
Mental health | 69.3±15.0 | 72.9±17.2 | 0.541 |
Values are presented as mean±standard deviation.
FROI-17, ROE, and SF-36 scales after prosthetic rehabilitation (n=7) vs. surgical reconstruction (n=18) in all patients (T1-4), BCC (n=20) vs. cSCC patients (n=5), and NSC cohort (n=25) vs. the normally distributed SF-36 reference population (n=2,900). A higher ROE score indicates higher satisfaction. A higher FROI-17 score indicates lower satisfaction. P<0.05 were considered statistically significant.
FROI-17, Functional Rhinoplasty Outcome Inventory 17; ROE, Rhinoplasty Outcome Evaluation; SF-36, 36-Item Short Form Health Survey; SD, standard deviation; BCC, basal cell carcinomas; cSCC, cutaneous squamous cell carcinomas; NSC, nasal skin cancer.
Comparison of advantage and disadvantage in prosthetic rehabilitation versus surgical reconstruction
Variable | Prosthetic rehabilitation | Surgical reconstruction |
---|---|---|
Advantage | • Simple and fast surgical procedure for implant placeme (operating time approximately 20–30 minutes) | • Psychological benefit of using patient’s own tissue |
• No donor site morbidity/scars | • No need for maintenance or specialized care | |
• Short rehabilitation time (fitting after a healing period of 6 | • Defect is eliminated and no longer visible. | |
• Predictable cosmesis of prosthesis | • Follows color change of adjacent skin with temperature, emotion and sun exposure | |
• Prosthesis may be changed according to patient wishes. | ||
• Ease of oncological follow-up to detect local recurrence | ||
Disadvantage | • Prothesis is a “foreign body.” | • Multiple stages of surgical reconstruction under general anesthesia with longer operation time |
• Patients keep the defect. | • Longer healing time with three surgical stages of 3–6 months | |
• Risk of losing the prosthesis with inadvertent contact | • Possible surgical complications with reconstruction, especially in irradiated patients and smokers | |
• Prosthesis is removed for sleeping (patient wears a light bandage). | • Possible need for secondary refinement surgery | |
• Prosthesis may exhibit color mismatch with seasonal cha complexion or cigarette smoke. | • Additional scars outside the nasal region | |
• Necessity of a new prosthesis every 2 years due to degr and/or slight defect changes | • Malignant precursor lesion may be transposed (field cancerization with UV exposure). | |
• Cost for initial and repetitive manufacturing | • Cosmetic result less predictable | |
• Personal hygiene for percutaneous parts of implants (however minimal for nasal implants) | • Oncological follow-up less easy (may need endoscopy and imaging) | |
• Magnets have to be temporarily removed for MRI (titanium implants are MRI conditional). |
UV, ultraviolet; MRI, magnetic resonance imaging.