Management of a Large Basal Cell Carcinoma on the Nose in an Elderly Patient
An 82-year-old man presents with a 2.5-cm basal cell carcinoma on the tip of his nose. He has a history of hypertension, type 2 diabetes, and atrial fibrillation on warfarin. He lives independently and is cognitively intact. He is concerned about the cosmetic outcome and wants to avoid a large scar. He has a history of multiple non-melanoma skin cancers treated with excision and Mohs surgery. The tumor is biopsy-proven nodular basal cell carcinoma. The patient is on warfarin with an INR of 2.5. He has a cardiology appointment in 2 weeks. The surgeon is considering Mohs micrographic surgery versus wide local excision with reconstruction.
1. Compare the options of Mohs surgery versus wide local excision with reconstruction for this patient, considering his age, comorbidities, and preferences.
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Mohs surgery offers the advantage of tissue conservation and high cure rates for basal cell carcinoma, especially in cosmetically sensitive areas like the nose. It allows for immediate reconstruction and confirmation of clear margins. However, it requires multiple stages and may be time-consuming, which can be challenging for an elderly patient. Wide local excision with reconstruction may be performed in one stage but may require larger margins (4-5 mm for basal cell carcinoma) and may result in a larger defect. For an 82-year-old with comorbidities, the goals are complete excision with minimal morbidity and acceptable cosmesis. Mohs is preferred for recurrent or large tumors in cosmetically sensitive areas. Given the patient's concern about scarring, Mohs likely offers better cosmetic outcome. However, the patient's anticoagulation with warfarin increases bleeding risk; Mohs is typically performed under local anesthesia, which is safer. Wide local excision may require general anesthesia. The patient's cognitive status and independence suggest he can tolerate Mohs. Shared decision-making should include discussion of time commitment and potential need for multiple visits.
2. How should the surgeon manage the patient's warfarin perioperatively?
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For Mohs surgery, which is a minor procedure with local anesthesia, warfarin can often be continued. The risk of bleeding is low, and the risk of thromboembolism from holding warfarin may outweigh the bleeding risk. However, if the surgeon prefers to hold warfarin, the INR should be checked, and the patient should be bridged with low-molecular-weight heparin if at high thrombotic risk (e.g., mechanical heart valve, recent stroke). For this patient with atrial fibrillation, the CHA2DS2-VASc score likely indicates moderate risk. The decision should be made in consultation with the cardiologist. For wide local excision, if performed under local anesthesia, warfarin can also be continued. If general anesthesia is planned, warfarin may need to be held for 5 days with bridging. The surgeon should coordinate with the cardiologist and consider the timing of the cardiology appointment.