Aggressive subtypes in basal cell carcinomas might need different treatment and follow-up due to the higher risk of surgically uncontrollable recurrences.

Purpose: Basal cell carcinoma (BCC) is the most frequent malignant tumor of the eyelid and recurrences of BCC may lead to massive destruction of the orbital region. The objective of this study was to evaluate predictors for surgically difficult-to-control or uncontrollable recurrences.

Methods: All BCCs of the periorbital region treated in the Department of Dermatology or Ophthalmology between 2011 and 2021 were included in a retrospective single center study and divided into a group of primary BCCs (pBCCs) and a group of recurrent BCCs (rBCCs). The following risk factors were compared between the two groups using the Chi² test: tumor localization, histological subtype and presence of R1 situation. Furthermore, difference in severity of reconstruction between pBCCs and rBCCs was analyzed. P-value < 0.05 was considered statistically significant.

Results: Data from 474 pBCCs and 33 rBCCs were included in this retrospective analysis. Both R1 status (p < 0.001) and aggressive subtype (p = 0.028) were significant risk factors for recurrence. The two most frequent reasons for R1 were the patient's rejection of further surgical intervention (n = 4) and the fact that the surgery was not performed at a specialized center (n = 6). In 10 of the 33 rBCCs, a further recurrence occurred despite R0 status and all 10 cases showed an aggressive subtype (p = 0.020). In all BCCs with R1 status, there was no significant difference in the recurrence rate regarding the subtype.

Conclusion: Our results show the impact of incomplete tumor resection and aggressive subtype on patient outcome after BCC surgery. We suggest that the aggressiveness of the BCC may be the precondition for multiple recurring BCCs. Furthermore, especially patients who underwent surgery outside our Departments showed R1 situations and rBCCs. Therefore, personalized treatment and follow-up care as well as efforts to avoid high-risk recurrences with aggressive subtypes are necessary to improve long-term success after surgery and should be conducted by a specialized center.