64-year-old woman presents with recurrence of left ear basal cell carcinoma. She has a history of sun lamp tanning and scuba diving with multiple sun burns. Basal cell carcinoma was first removed from left scapha and treated with a skin graft in July 2009. The area subsequently developed crusting and was treated with LN2 and 5-FU.
First recurrence appeared in 2016 in the ear helix and scapha and was treated with Mohs and a complex reconstruction of a large 2.2 x 1.5 cm defect. Second recurrence occurred in root of helix in July 2017 and was treated with Mohs and simple flap reconstruction. The third recurrence of BCC occurred in inferior scapha in November 2017 and was recently excised.
This case represents either field cancerization of multifocal basal cell carcinoma or a recurrence after a Mohs margins miss. Either way the extent and complexity of reconstruction presents the risk of having buried some carcinoma deep within the area. In the words of the SCARS Center Radiation Oncologist, Judith Harrison, MD, “You’ve had your chance”. Indeed, 4 excisions of BCC with persistence of carcinoma begs for a paradigm shift. Radiation of the region is the next logical options. This is not superficial radiotherapy (SRT). This would require a 3-D field of electrons of traditional radiation therapy machine. Both superficial and deeper root of helix penetration would be required.
Another option is wide local resection of the superior portion of the ear. Reconstructive options would be limited having already used the TPF fascia flap in a previous reconstruction. Prosthetic rehabilitation of the ear with bone osseointegrated implants could be an option.