Effective excision of cutaneous squamous cell carcinoma of the face using analysis of intra-operative frozen sections from the whole specimen

Surgery for Cutaneous Squamous Cell Carcinoma and its Limits in Advanced Disease

Surgery remains the first-line therapeutic option for most patients with cutaneous squamous cell carcinoma (cSCC). However, in the current therapeutic landscape, surgery must attempt to the complete tumor resection (R0 resection) with the lowest risk of surgical complications. This double aim is usually accomplished through standard excision with clinical margins in patients with low-risk tumors or by some of the micrographically controlled surgery procedures for patients with tumors at high-risk of local recurrence and metastasis. Surgery is also a first-line treatment for nodal metastases of cSCC as well as an option to consider in patients who develop recurrences while receiving immunotherapy, or as a palliation procedure in patients with advanced tumors. Neoadjuvant immunotherapy, that is the use of a medical treatment before surgery, is under investigation in patients with cSCC. The decision-making process and guidelines recommendations regarding cSCC surgery are reviewed in this manuscript.

European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 2. Treatment

In order to update recommendations on treatment, supportive care, education and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Dermatology Forum, the European Association of Dermato-Oncology and the European Organization of Research and Treatment of Cancer was formed. Recommendations were based on evidence-based literature review, guidelines and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable) and distant metastatic cSCC. For common primary cSCC (the most frequent cSCC type), first-line treatment is surgical excision with postoperative margin assessment or microscopically controlled sugery. Safety margins containing clinical normal-appearing tissue around the tumour during surgical excision and negative margins as reported in the pathology report are necessary to minimise the risk of local recurrence and metastasis. In case of positive margins, a re-excision shall be done, for operable cases. Lymph node dissection is recommended for cSCC with cytologically or histologically confirmed regional nodal involvement. Radiotherapy should be considered as curative treatment for inoperable cSCC, or for non-surgical candidates. Anti-PD-1 antibodies are the first-line systemic treatment for patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiation, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drug Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiation therapy. Multidisciplinary board decisions are mandatory for all patients with advanced disease who require more than surgery. Patients should be engaged with informed decisions on management and be provided with best supportive care to optimise symptom management and improve quality of life. Frequency of follow-up visits and investigations for subsequent new cSCC depend on underlying risk characteristics.

Facial cutaneous squamous cell carcinoma - microscopic safety margins and their impact on developing local recurrences

OBJECTIVES

Surgical excision remains the treatment of choice for facial cutaneous squamous cell carcinoma (cSCC) despite there being no generally accepted diameter of clear margins. Therefore, the aim of this study was to evaluate the impact of microscopic clear margins diameter (mCMD) with respect to the development of local recurrences (LR).

MATERIALS AND METHODS

The medical records of 99 patients with a total of 142 cases of facial cSCC, who underwent surgical treatment between January 2010 and December 2015, were reviewed for demographic data and clinicopathological features.

RESULTS

100 cases were diagnosed as primary cSCC and 42 cases as secondary cSCC. Of these, nine (6.3%) developed LR. Mean time to LR was 20 months, with the cheek as the predominant site 55.5% (n = 5). Wound closure was either primary (56%) or secondary (44%), depending on the site. Although no significant correlation between mCMD and LR was found (r_Pearson = 0.029; r_Pearson = 0.015), >4.1 mm was shown to be a negative cut-off-value (horizontally and vertically) without LR (100% vs 0%).

CONCLUSIONS

Based on these results, however descriptive they are, the authors consider histological confirmation of clear margins to be necessary for reducing the formation of LR. Thus, consistent testing and histopathological reporting, in a multicentered effort, are needed to further clarify the role of mCMD in the development of cSCC-LR.

Local surgical treatment of cutaneous squamous cell carcinoma: deficits and controversies in the literature

The prognostic impact of primary excision in the treatment of cutaneous squamous cell carcinoma depends on certain tumor characteristics (risk factors), the surgical approach chosen and the subsequent histological examination. For the development of the AWMF (Association of Scientific Medical Societies in Germany) guidelines for squamous cell carcinoma, the most conclusive guidelines available were evaluated using the DELBI tool (German Instrument for the Methodological Appraisal of Guidelines). These were the Scottish and Canadian guidelines as well as the joint guidelines published by EDF, EADO and EORTC. The primary literature on the aforementioned topics that was used for these guidelines included 49 studies and 9 reviews. None of the studies had a prospective, randomized design; 19 studies contained prospective data; 30 studies provided retrospective data. Overall, the results were heterogeneous. Not only were there discrepancies in terms of the validity of the various risk factors for locoregional disease progression - such as dedifferentiation, desmoplasia and perineural invasion - but also with respect to tumor thickness and surgical consequences. Differences were also found regarding the histological processing method used. In general, there are two such methods: conventional histology (bread loaf technique) and complete histological assessment of excision margins. The latter was found to be associated both with low recurrence rates and low metastatic rates, possibly due to the fact that patients treated with the latter method had lower-risk tumors. Publications on bread loaf histology lacked precise information as to how the tissue was actually processed. Likewise, there was a lack of usable data in terms of the surgical margins used in the primary excision. Conclusion: The current literature is inconsistent and insufficient with regard to the various prognostic factors and the surgical approach to cutaneous squamous cell carcinoma.

Long-term recurrence rates of whole specimen intraoperative frozen section analysis in basal cell carcinomas of the face with WIFSA

BACKGROUND AND OBJECTIVES

Recent studies show that whole specimen intraoperative frozen section analysis (WIFSA) is a reliable method for margin analysis in basal cell carcinoma (BCC) and has low recurrence rates after five-years follow-up. There are no studies with longer follow-up. Our aim is to present long-term recurrence rates after WIFSA.

MATERIALS AND METHODS

All patients with a facial BCC receiving excision with WIFSA between 1992 and 2007 were evaluated. Recurrence rates were examined for primary BCC (pBCC), recurrent BCCs (rBCC), and the different histological subtypes. The accuracy of WIFSA was assessed by comparing with formalin-fixed paraffin-embedded section analysis.

RESULTS

A total of 1140 patients with 1265 BCCs underwent excision with WIFSA, with a median and maximum follow-up of 10 and 25.3 years, respectively. Of all tumors, 90.0% were primary. Excisions were radical after an average of 1.4 excision rounds;5, 10, and 15-year recurrence rates for pBCCs are 3.3%, 5.1%, and 7.3%, respectively. An aggressive growth pattern and rBCCs are associated with more recurrences. The accuracy of WIFSA is 98.4%.

CONCLUSIONS

WIFSA provides a highly accurate analysis and has a low recurrence rate for primary BCCs. The increasing recurrence rates over time imply 5 years of follow-up may be insufficient.