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Lacerda PN, Lange EP, Luna NM, Miot HA, Abbade LPF. Efficacy of micrographic surgery versus conventional excision in reducing recurrence for basal cell carcinoma and squamous cell carcinoma: A systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2024; 38:1058-1069. [PMID: 38116955 DOI: 10.1111/jdv.19743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/17/2023] [Indexed: 12/21/2023]
Abstract
The standard of care for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) involves excision by conventional surgery (CS) with a predefined safety margin of resection or micrographic surgery (MS) with microscopic margin control. Previous studies have reported the superiority of MS in reducing recurrences for high-risk BCC and SCC. This systematic review aimed to assess MS and CS recurrence rates by including randomized clinical trials (RCTs) and cohort studies. A systematic review and meta-analysis were conducted for related studies in PubMed, LILACS, Embase, Scopus, Web of Science, CINHAL and Cochrane until May 2023. RCTs and cohorts involving patients with BCC or SCC submitted to MS and CS were included. Risk of bias assessment followed Cochrane-recommended tools for RCTs and cohorts, and certainty of evidence followed the GRADE approach. Pooled estimates were used to determine the relative risk (RR) and absolute risk difference (RD) using a random-effects model. Seventeen studies were included, two RCTs and fifteen cohorts. There were 82 recurrences in 3050 tumours submitted to MS, with an overall recurrence rate of 3.1% (95% CI 2.0%-4.7%). For CS, there were 209 recurrences in 3453 tumours, with a recurrence rate of 5.3% (95% CI 2.9%-9.3%). The combined estimate of RR was 0.48 (95% CI 0.36-0.63), without heterogeneity nor evidence of publication bias (p > 0.3). The RD resulted in 2.9% (95% CI 1.0%-4.9%; NNT = 35). Regarding subgroup analysis, the RR for BBC was 0.37 (95% CI 0.25-0.54), and RD was 3.7% (95% CI 0.8%-6.5%; NNT = 28). For SCC, RR was 0.57 (95% CI 0.29-1.13), and RD was 1.9% (95% CI 0.8%-4.7%; NNT = 53). Among primary tumours, RR was 0.39 (95% CI 0.28-0.54), and for recurrent tumours was 0.67 (95% CI 0.30-1.50). There is moderate evidence based on two RCTs, and low evidence based on 15 cohort studies that MS is superior to CS in reducing recurrences of BCCs and primary tumours. The development of protocols that maximize the cost-effectiveness of each method in different clinical scenarios is paramount.
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Affiliation(s)
- Priscila Neri Lacerda
- Department of Dermatology, Infectology, Imaging Diagnosis and Radiotherapy, Botucatu Medical School (FMB), São Paulo State University (UNESP - Universidade Estadual Paulista), Botucatu, Brazil
| | - Eloana Pasqualin Lange
- Department of Dermatology, Infectology, Imaging Diagnosis and Radiotherapy, Botucatu Medical School (FMB), São Paulo State University (UNESP - Universidade Estadual Paulista), Botucatu, Brazil
| | - Natália Miranda Luna
- Department of Dermatology, Infectology, Imaging Diagnosis and Radiotherapy, Botucatu Medical School (FMB), São Paulo State University (UNESP - Universidade Estadual Paulista), Botucatu, Brazil
| | - Hélio Amante Miot
- Department of Dermatology, Infectology, Imaging Diagnosis and Radiotherapy, Botucatu Medical School (FMB), São Paulo State University (UNESP - Universidade Estadual Paulista), Botucatu, Brazil
| | - Luciana Patrícia Fernandes Abbade
- Department of Dermatology, Infectology, Imaging Diagnosis and Radiotherapy, Botucatu Medical School (FMB), São Paulo State University (UNESP - Universidade Estadual Paulista), Botucatu, Brazil
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Verdaguer-Faja J, Toll A, Boada A, Guerra-Amor Á, Ferrándiz-Pulido C, Jaka A. Management of Cutaneous Squamous Cell Carcinoma of the Scalp: The Role of Imaging and Therapeutic Approaches. Cancers (Basel) 2024; 16:664. [PMID: 38339415 PMCID: PMC10854799 DOI: 10.3390/cancers16030664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Cutaneous squamous cell carcinoma (cSCC) is the second most common subtype of skin cancer. The scalp is one of the most frequently affected locations and is associated with a higher rate of complications, compared to other locations. In addition, it has a characteristic thickness and anatomical structure that may influence both growth pattern and treatment of primary cSCC; while clinical peripheral margins may be easily achieved during the surgery, vertical excision of the tumor is limited by the skull. Despite having a unique anatomy, current guidelines do not contemplate specific recommendations for scalp cSCC, which leads to inconsistent decision-making in multidisciplinary committees when discussing tumors with high risk factors or with close margins. This article provides specific recommendations for the management of patients with scalp cSCC, based on current evidence, as well as those aspects in which evidence is lacking, pointing out possible future lines of research. Topics addressed include epidemiology, clinical presentation and diagnosis, imaging techniques, surgical and radiation treatments, systemic therapy for advanced cases, and follow-up. The primary focus of this review is on management of primary cSCC of the scalp with localized disease, although where relevant, some points about recurrent cSCCs or advanced disease cases are also discussed.
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Affiliation(s)
- Júlia Verdaguer-Faja
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Spain; (J.V.-F.); (A.B.)
- Departament de Medicina, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
| | - Agustí Toll
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, 08036 Barcelona, Spain;
| | - Aram Boada
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Spain; (J.V.-F.); (A.B.)
- Departament de Medicina, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
| | - Álvaro Guerra-Amor
- Department of Dermatology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain;
| | - Carla Ferrándiz-Pulido
- Departament de Medicina, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
- Department of Dermatology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain;
| | - Ane Jaka
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Spain; (J.V.-F.); (A.B.)
- Departament de Medicina, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
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3
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McClure EM, Sedor G, Jin Y, Kattan MW. Image-guided superficial radiation therapy has superior 2-year recurrence probability to Mohs micrographic surgery. Clin Transl Radiat Oncol 2023; 43:100678. [PMID: 37781716 PMCID: PMC10539860 DOI: 10.1016/j.ctro.2023.100678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/10/2023] [Accepted: 09/14/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Non-melanoma skin cancers (NMSCs) are the most common cancers in the USA, and their incidence is rising. Mohs micrographic surgery (MMS) is commonly performed to excise NMSCs. MMS replaced superficial radiotherapy (SRT) as a first line treatment, given its superior efficacy. Image-guided superficial radiation therapy (IGSRT) was invented to improve the precision of SRT. This study investigates how the 2-year recurrence probability of IGSRT-treated NMSCs compares to that of MMS-treated lesions. Methods This retrospective cohort study compared the 2-year recurrence probability of early stage NMSCs (squamous and basal cell carcinomas (SCCs and BCCs)) treated by IGSRT (2,286 lesions) to data on NMSCs treated by MMS (5,391 lesions) via one sample proportion tests. Medical Subject Headings were used to search PubMed for reports of 2-year recurrence probability rates of NMSCs treated by MMS. Seventeen studies were screened; 14 studies were excluded for lack of 2-year time to event analysis, or irrelevant patient population (non-BCC/SCC study, advanced disease), leaving 3 studies for comparison. Results IGSRT-treated NMSCs have a statistically significantly improved 2-year recurrence probability than those treated by MMS, P < 0.001 for pooled data. Conclusion The 2-year recurrence probability IGSRT-treated NMSCs is superior to MMS-treated and supports IGSRT as an effective treatment option for individuals with early stage NMSCs.
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Affiliation(s)
- Erin M. McClure
- University of South Florida Morsani College of Medicine, 560 Channelside Dr, Tampa, FL 33602, United States
| | - Geoffrey Sedor
- Columbia University Irving Medical Center, Vagelos College of Physicians & Surgeons, 630 West 168th Street, New York, NY 10032, United States
| | - Yuxuan Jin
- Cleveland Clinic, Dept of Quantitative Health Sciences, Mail Code JJN3, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Michael W. Kattan
- Cleveland Clinic, Dept of Quantitative Health Sciences, Mail Code JJN3, 9500 Euclid Avenue, Cleveland, OH 44195, United States
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Stratigos AJ, Garbe C, Dessinioti C, Lebbe C, van Akkooi A, Bataille V, Bastholt L, Dreno B, Dummer R, Fargnoli MC, Forsea AM, Harwood CA, Hauschild A, Hoeller C, Kandolf-Sekulovic L, Kaufmann R, Kelleners-Smeets NW, Lallas A, Leiter U, Malvehy J, Del Marmol V, Moreno-Ramirez D, Pellacani G, Peris K, Saiag P, Tagliaferri L, Trakatelli M, Ioannides D, Vieira R, Zalaudek I, Arenberger P, Eggermont AMM, Röcken M, Grob JJ, Lorigan P. European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma: Part 2. Treatment-Update 2023. Eur J Cancer 2023; 193:113252. [PMID: 37708630 DOI: 10.1016/j.ejca.2023.113252] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 09/16/2023]
Abstract
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 Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV), and the European Organisation of Research and Treatment of Cancer (EORTC) was formed. Recommendations were based on an 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 first-line treatment is surgical excision with postoperative margin assessment or micrographically controlled surgery. Achieving clear surgical margins is the most important treatment consideration for patients with cSCCs amenable to surgery. Regarding adjuvant radiotherapy for patients with high-risk localised cSCC with clear surgical margins, current evidence has not shown significant benefit for those with at least one high-risk factor. Radiotherapy should be considered as the primary treatment for non-surgical candidates/tumours. For cSCC with cytologically or histologically confirmed regional nodal metastasis, lymph node dissection is recommended. For patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiotherapy, anti-PD-1 agents are the first-line systemic treatment, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drugs Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC, include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiotherapy. Multidisciplinary board decisions are mandatory for all patients with advanced cSCC, considering the risks of toxicity, the age and frailty of patients, and co-morbidities, including immunosuppression. Patients should be engaged in informed, shared decision-making on management and be provided with the best supportive care to improve symptom management and quality of life. The frequency of follow-up visits and investigations for subsequent new cSCC depends on underlying risk characteristics.
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Affiliation(s)
- Alexander J Stratigos
- First Department of Dermatology-Venereology, National and Kapodistrian University of Athens, Andreas Sygros Hospital, Athens, Greece.
| | - Claus Garbe
- Centre for Dermatooncology, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | - Clio Dessinioti
- First Department of Dermatology-Venereology, National and Kapodistrian University of Athens, Andreas Sygros Hospital, Athens, Greece
| | - Celeste Lebbe
- Université Paris Cite, Dermato-Oncology AP-HP Hôpital Saint Louis, Cancer Institute APHP. Nord-Université Paris Cite, INSERM U976, Paris, France
| | - Alexander van Akkooi
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Melanoma Institute Australia, Sydney, New South Wales, Australia
| | | | - Lars Bastholt
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Brigitte Dreno
- Nantes Université, INSERM, CNRS, Immunology and New Concepts in ImmunoTherapy, INCIT, UMR 1302/EMR6001, Nantes, France
| | - Reinhard Dummer
- Skin Cancer Centre at University Hospital, Zurich, Switzerland
| | - Maria Concetta Fargnoli
- Dermatology Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Ana Maria Forsea
- Carol Davila University of Medicine and Pharmacy Bucharest, Department of Oncologic Dermatology, Elias University Hospital Bucharest, Bucharest, Romania
| | - Catherine A Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Axel Hauschild
- Department of Dermatology, University Hospital (UKSH), Kiel, Germany
| | - Christoph Hoeller
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | | | - Roland Kaufmann
- Department of Dermatology, Venereology and Allergology, Frankfurt University Hospital, Frankfurt, Germany
| | - Nicole Wj Kelleners-Smeets
- GROW-School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Dermatology, Maastricht University Medical Centre+, Maastricht University, Maastricht, the Netherlands
| | - Aimilios Lallas
- First Department of Dermatology, Aristotle University, Thessaloniki, Greece
| | - Ulrike Leiter
- Centre for Dermatooncology, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | - Josep Malvehy
- Dermatology Department of Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBER de enfermedades raras, Instituto Carlos III, Barcelona, Spain
| | - Veronique Del Marmol
- Department of Dermatology, University Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - David Moreno-Ramirez
- Department of Medical and Surgical Dermatology Service, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | - Ketty Peris
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Dermatologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Philippe Saiag
- Department of General and Oncologic Dermatology, Ambroise-Paré hospital, APHP, and EA 4340 'Biomarkers in Cancerology and Hemato-oncology', UVSQ, Université Paris-Saclay, Boulogne-Billancourt, France
| | - Luca Tagliaferri
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Myrto Trakatelli
- Department of Dermatology, Papageorgiou Hospital, Aristotle University Department of Medicine, Thessaloniki, Greece
| | | | - Ricardo Vieira
- Department of Dermatology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Iris Zalaudek
- Department of Dermatology, University of Trieste, Trieste, Italy
| | - Petr Arenberger
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Alexander M M Eggermont
- University Medical Center Utrecht and Princess Máxima Center, Utrecht, the Netherlands; Comprehensive Cancer Center Munich, Technical University Munich and Ludwig Maximilian University, Munich, Germany
| | - Martin Röcken
- Centre for Dermatooncology, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | | | - Paul Lorigan
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, UK
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Navarrete-Dechent C, Mori S, Connolly K, Shah K, Dusza SW, Rossi AM, Lee EH, Busam KJ, Nehal KS. Staging System Performance and Clinical Outcomes for Cutaneous Squamous Cell Carcinoma of the Ear: A Single-Center Retrospective Study. Dermatol Surg 2023; 49:747-754. [PMID: 37235869 PMCID: PMC10524321 DOI: 10.1097/dss.0000000000003842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Cutaneous squamous cell carcinoma (cSCC) of the ear is associated with poor outcomes. No studies have evaluated current staging system performance in this specific location. OBJECTIVE Describe clinicopathologic characteristics and outcomes of ear cSCC and evaluate the performance of current staging systems. METHODS Retrospective study including cases diagnosed and treated at a cancer center from January 2000 to December 2014. Demographic, clinical, and pathologic data were collected from clinical records. Biopsy slides were rereviewed and patients were staged according to the American Joint Committee on Cancer (AJCC) seventh, eighth, and Brigham Women's Hospital (BWH) staging. RESULTS Of 125 patients, the mean age at diagnosis was 71.9 years (SD 12.5), with most men (89.6%, n = 112). Median follow-up was 22.3 months. Local recurrence and survival risk factors were similar to cSCC outside the ear. The Akaike's Information Criterion (AIC) estimates showed that the BWH system better predicted outcomes than the AJCC seventh, and the AJCC eighth, with AIC values of 189.9, 270.5, and 274.1, respectively. Limitations of the study include retrospective design, single center study, and no control group. CONCLUSION Current staging systems perform well at stratifying risk in ear cSCC.
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Affiliation(s)
- Cristian Navarrete-Dechent
- Department of Dermatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shoko Mori
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
| | - Karen Connolly
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kalee Shah
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stephen W. Dusza
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anthony M. Rossi
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Erica H. Lee
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Klaus J. Busam
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kishwer S. Nehal
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Lin A, Schmalbach CE. Surgery in the Era of Immunotherapy for Advanced Head and Neck Non-melanoma Skin Cancer. Curr Oncol Rep 2023; 25:735-742. [PMID: 37010785 DOI: 10.1007/s11912-023-01391-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE OF REVIEW Surgery remains the mainstay of treatment for non-melanoma skin cancer (NMSC). Immunotherapy (IO) has emerged as an alternative option. This review provides a contemporary summary of how to incorporate IO into the management of advanced NMSC. Evidence-based outcomes and recent clinical trials are provided with emphasis on the three most common NMSC diagnoses: cutaneous squamous cell carcinoma (cSCC), basal cell carcinoma (BCC), and merkel cell carcinoma (MCC). RECENT FINDINGS Surgical resection while preserving form and function remains the standard of care for the majority of NMSCs. In recalcitrant cases failing traditional surgery and/or primary radiation, patient ineligible for such treatments, or unresectable disease, IO has emerged as a promising alternative. In the majority of cases, it is a supplanting primary chemotherapy. Surgery remains the standard of care for NMSC. Immunotherapy has emerged as an alternative option for non-surgical candidates and as a neoadjuvant means to minimize morbidity.
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Affiliation(s)
- Alice Lin
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente School of Medicine, Pasadena, CA, USA
| | - Cecelia E Schmalbach
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
- Department of Otolaryngology-Head and Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
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7
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Zakhem GA, Pulavarty AN, Carucci J, Stevenson ML. Association of Patient Risk Factors, Tumor Characteristics, and Treatment Modality With Poor Outcomes in Primary Cutaneous Squamous Cell Carcinoma: A Systematic Review and Meta-analysis. JAMA Dermatol 2023; 159:160-171. [PMID: 36576732 PMCID: PMC9857763 DOI: 10.1001/jamadermatol.2022.5508] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/21/2022] [Indexed: 12/29/2022]
Abstract
Importance Primary cutaneous squamous cell carcinoma is usually curable; however, a subset of patients develops poor outcomes, including local recurrence, nodal metastasis, distant metastasis, and disease-specific death. Objectives To evaluate all evidence-based reports of patient risk factors and tumor characteristics associated with poor outcomes in primary cutaneous squamous cell carcinoma and to identify treatment modalities that minimize poor outcomes. Data Sources PubMed, Embase, and SCOPUS databases were searched for studies of the topic in humans, published in the English language, from database inception through February 8, 2022. Study Selection Two authors independently screened the identified articles and included those that were original research with a sample size of 10 patients or more and that assessed risk factors and/or treatment modalities associated with poor outcomes among patients with primary cutaneous squamous cell carcinoma. Data Extraction and Synthesis Data extraction was performed by a single author, per international guidelines. The search terms, study objectives, and protocol methods were defined before study initiation. A total of 310 studies were included for full-text assessment. Owing to heterogeneity of the included studies, a random-effects model was used. Data analyses were performed from May 25 to September 15, 2022. Main Outcomes and Measures For studies of risk factors, risk ratios and incidence proportions; and for treatment studies, incidence proportions. Results In all, 129 studies and a total of 137 449 patients with primary cutaneous squamous cell carcinoma and 126 553 tumors were included in the meta-analysis. Several patient risk factors and tumor characteristics were associated with local recurrence, nodal metastasis, distant metastasis, disease-specific death, and all-cause death were identified. Among all factors reported by more than 1 study, the highest risks for local recurrence and disease-specific death were associated with tumor invasion beyond subcutaneous fat (risk ratio, 9.1 [95% CI, 2.8-29.2] and 10.4 [95% CI, 3.0- 36.3], respectively), and the highest risk of any metastasis was associated with perineural invasion (risk ratio, 5.0; 95% CI, 2.3-11.1). Patients who received Mohs micrographic surgery had the lowest incidence of nearly all poor outcomes; however, in some results, the 95% CIs overlapped with those of other treatment modalities. Conclusions and Relevance This meta-analysis identified the prognostic value of several risk factors and the effectiveness of the available treatment modalities. These findings carry important implications for the prognostication, workup, treatment, and follow-up of patients with primary cutaneous squamous cell carcinoma. Trial Registration PROSPERO Identifier: CRD42022311250.
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Affiliation(s)
- George A. Zakhem
- The Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York
| | - Akshay N. Pulavarty
- The Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York
| | - John Carucci
- The Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York
| | - Mary L. Stevenson
- The Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York
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8
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Evidence from Clinical Studies Related to Dermatologic Surgeries for Skin Cancer. Cancers (Basel) 2022; 14:cancers14153835. [PMID: 35954498 PMCID: PMC9367341 DOI: 10.3390/cancers14153835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 01/20/2023] Open
Abstract
Simple Summary Although significant progress in pharmacotherapy for skin cancer has been made in the past several years, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgeries including lymph node dissection and skin graft can cause various complications, and these complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery. Abstract Despite the significant progress made in the past several years in pharmacotherapies for skin cancer, such as BRAF/MEK inhibitors, immune checkpoint inhibitors, and Hedgehog pathway inhibitors, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In cases of lymph node metastases with clinically palpable lymphadenopathy, lymph node dissection (LND) is typically performed for most skin cancers. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgery can cause various complications. Although skin graft is frequently used for reconstruction of the surgical defect, extensive graft necrosis may develop if optimal stabilization of the graft is not obtained. LND also sometimes causes complications such as intraoperative or postoperative bleeding and postoperative lymphoceles. Moreover, as in other types of surgery, surgical site infection, intraoperative anxiety, and intraoperative and postoperative pain may also develop. These complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.
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9
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Elleson KM, DePalo DK, Zager JS. An update on local and systemic therapies for non-melanoma skin cancer. Expert Rev Anticancer Ther 2022; 22:479-489. [PMID: 35412413 DOI: 10.1080/14737140.2022.2065987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Nonmelanoma skin cancers (NMSC) as a group exceed the incidence of all other malignancies combined. NMSC includes basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma. As the incidence continues to rise, it is important to appreciate the available treatment options. AREAS COVERED This article discusses the treatment of NMSC though surgical, topical, regional, and systemic modalities. EXPERT OPINION As there are many treatment options available for these diseases, selection of the appropriate method can be difficult. With time, we expect treatment decisions to become even more complex and personalized. The role of systemic immunotherapies and neoadjuvant therapies in the treatment of NMSC is still not well defined. Local treatment with intralesional injections and isolated limb infusion may prove to be promising alternative therapies.
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Affiliation(s)
- Kelly M Elleson
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | | | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
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10
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Hunt WTN, Earp E, Brown AC, Veitch D, Wernham AGH. A review of Mohs Micrographic Surgery for skin cancer: Part 3 - Squamous Cell Carcinoma. Clin Exp Dermatol 2022; 47:1765-1773. [PMID: 35315541 DOI: 10.1111/ced.15187] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 11/29/2022]
Abstract
This review is part three of a series assessing the evidence for Mohs micrographic surgery (MMS) for treatment of cutaneous malignancies. The evidence for using MMS to treat cutaneous squamous cell carcinoma (cSCC) is presented and discussed. Medline, Embase and Cochrane databases were searched and 39 papers were identified. We included all clinical trials and observational studies including retrospective reports. We excluded editorials and systematic reviews or meta-analyses. We categorised the evidence under the following headings: tumour recurrence, specific site outcomes (ear, lip, scalp and periocular), cSCC with PNI, and cost effectiveness. Whilst there are many observational studies indicating the potential benefits of MMS in the management of certain cSCCs, no randomised controlled trials (RCT) were identified. This evidence suggests that MMS has a lower recurrence rate than other treatments for cSCC, including standard excision. Many studies were single-armed, having no comparator but do demonstrate a low to very low recurrence rate of cSCC following MMS. Further methodologically robust studies with comparator arms are needed, including RCT evidence, given the overall quality of included studies was low and highly heterogeneous.
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Affiliation(s)
- William T N Hunt
- Department of Dermatology, University Hospitals Plymouth NHS Trust, UK
| | - Eleanor Earp
- Department of Dermatology, Lauriston Building, Lauriston Place, Edinburgh, UK
| | | | - David Veitch
- Department of Dermatology, Leicester University Hospitals NHS Trust, Leicester, UK
| | - Aaron G H Wernham
- Department of Dermatology, Walsall Healthcare NHS Trust, Walsall, UK.,Department of Dermatology, Leicester University Hospitals NHS Trust, Leicester, UK
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11
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Kofler K, Breuninger H, Eigentler T, Kofler L, Schaefer V, Blumenstock G, Häfner HM, Schnabl SM. Local Tumor Infiltration and Locoregional Recurrence in Desmoplastic Cutaneous Squamous Cell Carcinoma. Dermatol Surg 2022; 48:283-289. [PMID: 34966121 DOI: 10.1097/dss.0000000000003324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Perusal of the literature of cutaneous squamous cell carcinoma (SCC) reveals that the role of the desmoplastic subtype is indistinct. Data on local infiltration and recurrence are inconsistent dependent on surgical technique, histological method, and investigated collective. OBJECTIVE The aim of the study was to analyze local infiltration and locoregional recurrence of the desmoplastic subtype under a uniform procedure. METHODS AND MATERIALS Between 2005 and 2015, 320 SCCs were analyzed and histological sections of all tumors were examined. Data collection included locoregional recurrence, metastasis rate, and tumor-specific death. The median follow-up was 36.5 months. RESULTS The desmoplastic subtype required significant more re-excisions (70.0% vs 23.9%, p < .001), more interventions until tumor-free margins were achieved (maximal 6 vs 2; p < .001), showed more widespread tumor infiltration with larger excisional margins (median 9 mm, 2-51 mm vs median 4 mm, 1-10 mm; p < .001), and a 5-fold higher local recurrence rate (26.7% vs 5.0%, p < .001). The metastasis rate (16.6% vs 2.3%, p < .001) was increased. CONCLUSION The desmoplastic subtype is characterized by a widespread local infiltration associated with perineural infiltration. It seems to be a marker for decreased histological detectability with a high rate of locoregional recurrence and metastasis.
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Affiliation(s)
| | | | | | | | | | - Gunnar Blumenstock
- Clinical Epidemiology and Applied Biometry, University of Tuebingen, Tuebingen, Germany
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12
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Kim Y, Lehrer EJ, Wirth PJ, Khesroh EA, Brewer JD, Billingsley EM, Zaorsky NG, Lam C. Adjuvant radiotherapy may not significantly change outcomes in high-risk cutaneous squamous cell carcinomas with clear surgical margins: A systematic review and meta-analysis. J Am Acad Dermatol 2021; 86:1246-1257. [PMID: 34890701 DOI: 10.1016/j.jaad.2021.11.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 11/03/2021] [Accepted: 11/16/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The role of adjuvant radiotherapy for high-risk cutaneous squamous cell carcinomas (cSCC) after surgery with negative margins is unclear. OBJECTIVE To conduct a systematic review and meta-analysis examining the risk of poor outcomes for those treated with surgery vs. surgery and adjuvant radiotherapy. METHODS A comprehensive search of articles was executed in PubMed, Embase, and Cochrane Database. Random-effected meta-analyses were conducted. RESULTS Thirty-three studies comprised of 3,867 high-risk cSCC were included. There were no statistically significant differences in poor outcomes between the surgery vs. surgery and adjuvant radiotherapy groups. Estimates for local recurrence were 15.2% (95% confidence interval [CI]: 6.3%-27%) vs. 8.8% (CI: 1.6%-20.9%), regional metastases were 11.5% (CI: 7.2%-16.7%) vs. 4.4% (CI: 0%-18%), distant metastases were 2.6% (CI: 0.6%-6%) vs. 1.7% (CI: 0.2%-4.5%) and disease-specific deaths were 8.2% (CI: 1.2%-20.6%) vs. 19.7% (CI: 3.8%-43.7%) for the surgery group vs. surgery and adjuvant radiotherapy group respectively. LIMITATIONS Retrospective nature of most studies with a lack of sufficient patient-specific data. CONCLUSIONS For patients with high risk cSCC treated with margin-negative resection, there were no differences in poor outcomes between the surgery vs. surgery and adjuvant radiotherapy groups. Randomized-controlled trials are necessary to define the benefit of adjuvant radiotherapy in this setting.
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Affiliation(s)
- Yesul Kim
- Department of Dermatology, Penn State Health Hershey Medical Center, Hershey, Pennsylvania
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Paul J Wirth
- Department of Dermatology, Penn State Health Hershey Medical Center, Hershey, Pennsylvania
| | - Eiman A Khesroh
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jerry D Brewer
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | | | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve, Fairport Harbor, Ohio
| | - Charlene Lam
- Department of Dermatology, Penn State Health Hershey Medical Center, Hershey, Pennsylvania.
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13
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Mousa AK, Elshenawy AA, Maklad SM, Bebars SMM, Burezq HA, Sayed SE. Post-burn scar malignancy: 5-year management review and experience. Int Wound J 2021; 19:895-909. [PMID: 34535972 PMCID: PMC9013596 DOI: 10.1111/iwj.13690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/28/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022] Open
Abstract
The study spotlights a severe uncommon post‐burn complication, Marjolin's ulcer, in upper Egypt plastic and wound care centres. This problem is mainly related to inadequate medical care and awareness. No community or race is immune. The underlying malignant transformation mechanism remains unclear. The study aims, according to our experience, to review the prognostic factors through the management protocol of Marjolin's ulcers. This prospective study was conducted in the Aswan University Plastic & Burn surgery department in South Egypt between 2013 and 2020 and investigated 226 patients with chronic post‐burn ulceration. Nineteen cases were proved to have Marjolin's ulcer, and the other cases that had been excluded from being malignant went for reconstruction with split‐thickness skin graft with/without flap after adequate ulcer debridement. The surgical, oncologic, radiologic indications, and prognostic factors were reviewed according to our management outcome—the assessment with follow‐up period extended over 5 years. Histopathology of ulcers ranged among mild, moderate, and poorly differentiated squamous cell carcinoma. One scalp ulcer case showed basosquamous pathology. Most cases presented at age above 50, but no age was immune. The mean latent period was 29 years on average. The lesions' sites varied in their anatomic location where they involved the upper extremity, the scalp, and the lower extremity that had a predilection. Although surgical excision is the primary management line for tumour ablation, other factors may change the management course. During the follow‐up period, neoplasm recurrence in the form of lymph node enlargement and/or locoregional metastasis was detected in eight cases. Within 1 year after the intervention, six recurrent cases died, and two were saved. In addition to the case study, this paper reviewed the literature and provided our team a good experience in light of the NCCN protocol for non‐melanotic cutaneous carcinoma, although we suffered limited medical resources. It is concluded that early accurate diagnosis, low‐grade malignancy, and well‐planned individualised surgery with adjuvant radiotherapy were the best prognostic factors. The close follow‐up for an early sign of disease recurrence is paramount.
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Affiliation(s)
- Ahmed K Mousa
- Plastic & Reconstructive Surgery - Medical School of Aswan University, Aswan, Egypt
| | | | - Salah M Maklad
- Radiology Department, Medical School of Aswan University, Aswan, Egypt
| | - Shaimaa M M Bebars
- Department of Clinical Pathology, Medical School of Aswan University, Aswan, Egypt
| | - Hisham A Burezq
- Consultant Plastic & Reconstruction - Ibn Sina Hospitals - AlBabtain Center for Burn & Plastic Surgery, Kuwait City, Kuwait
| | - Sherif E Sayed
- Surgical Oncology, Medical School of Bany-Swif University, Bany-Swif, Egypt
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14
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Udkoff J, Beal BT, Brodland DG, Knackstedt T. Cost effectiveness of intermediate-risk squamous cell carcinoma treated with Mohs micrographic surgery compared with wide local excision. J Am Acad Dermatol 2021; 86:303-311. [PMID: 34363906 DOI: 10.1016/j.jaad.2021.07.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/07/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The efficacy of Mohs micrographic surgery (MMS) in treating cutaneous squamous cell carcinoma has been demonstrated. The cost effectiveness of MMS has rarely been studied to support the perceived higher cost. OBJECTIVE Perform a cost-effectiveness analysis to determine whether MMS is cost effective over wide local excision (WLE) for Brigham and Women's Hospital tumor stage T2a cutaneous squamous cell carcinoma over a 5-year period. METHODS A Markov model with a 5-year time horizon was created using variables from published data. Costs in United States dollars and quality-adjusted life-years (QALY) were calculated. RESULTS MMS was $333.83 less expensive ($4365.57 [95% CI, $3664.68-$6901.66] vs $4699.41 [95% CI, $3782.94-$10,019.31]) than WLE. MMS gained 2.22 weeks of perfect health (3.776 QALY [95% CI, 3.774-3.777] for MMS and 3.733 QALY [95% CI, 3.728-3.777]) over 5 years. The incremental cost-effectiveness ratio was -$7,822.19. MMS had a 99.9% probability of being more cost effective than WLE. Annualized savings of choosing MMS over WLE would be $200 million and over 25,000 QALY. MMS could cost 3.1 times its current rate and remain cost effective. LIMITATIONS Relied on data from external retrospective sources. CONCLUSION MMS is less costly and more effective than WLE and should be strongly considered for stage T2a cSCC, given improvements in costs and QALY.
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Affiliation(s)
- Jeremy Udkoff
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brandon T Beal
- Jacksonville Skin Cancer Specialists, Jacksonville, Florida; Zitelli and Brodland, PC, Pittsburgh, Pennsylvania; Departments of Dermatology, Otolaryngology, and Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David G Brodland
- Zitelli and Brodland, PC, Pittsburgh, Pennsylvania; Departments of Dermatology, Otolaryngology, and Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Thomas Knackstedt
- Case Western Reserve University, School of Medicine, Cleveland, Ohio; MetroHealth System, Department of Dermatology, Cleveland, Ohio.
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15
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New Developments in the Management of Cutaneous Squamous Cell Carcinoma. Plast Reconstr Surg 2021; 147:492-504. [PMID: 33620947 DOI: 10.1097/prs.0000000000007678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. List important prognostic features that affect cutaneous squamous cell carcinoma risk. 2. Summarize the changes to the AJCC Cancer Staging Manual, Eighth Edition, staging system for cutaneous squamous cell carcinoma. 3. Evaluate the draining nodal basin with appropriate imaging modalities. 4. Recommend adjuvant radiation therapy in the correct clinical setting for high-risk tumors. 5. Recognize the currently available treatments for advanced cutaneous squamous cell carcinoma. SUMMARY This continuing medical education article reviews the features, management, and prognosis of cutaneous squamous cell carcinoma with an emphasis on high-risk squamous cell carcinoma and data from the past 3 years. This review will discuss the primary tumor management, high-risk features of a squamous cell carcinoma, changes to the American Joint Committee on Cancer staging system, and the utility of sentinel lymph node biopsy, and critically review the evidence regarding adjuvant therapy.
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16
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González A, Etchichury D, Rivero JM, Adamo L. Squamous cell carcinoma of the external ear: 170 cases treated with Mohs surgery. J Plast Reconstr Aesthet Surg 2021; 74:2999-3007. [PMID: 33967017 DOI: 10.1016/j.bjps.2021.03.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/11/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Squamous cell carcinoma of the ear (SCC-E) shows high rates of local recurrence (LR) and lymph node metastases (NM). SCC-E is the leading cause of death from nonmelanoma skin cancer. OBJECTIVE To determine the LR and NM rates and survival after Mohs micrographic surgery (MMS). PATIENTS AND METHODS We treated 170 invasive SCC-E with MMS with a mean follow up of 48 months. Mean age was 76 years, 93.2% were male patients, mean size: 1.5 cm, and 61.8% of the tumours were well differentiated. RESULTS We observed 5 LRs, 2 locoregional recurrences, and 16 NMs in 23 patients. LR and NM rates were 4.1% and 10.6%, respectively. Only 3/25 recurrences occurred after 2 years of follow up. We observed 1(0.6%) distant metastasis (DM) in a patient who also presented LR + NM. Six out of seven cases with LR and 8/18 with NM died of disease, regardless of aggressive surgical rescue with or without adjuvant radiotherapy. Five-year overall survival, disease-free survival, and disease-specific survival were 81%, 82.6%, and 89.7%, respectively. CONCLUSIONS Undeniably, the outcome in SCC-E is determined by locoregional control. DM are sporadic and rarely the cause of death. Systematic reviews and retrospective studies show a solid trend in favor of MMS vs surgical excision. The LR rate of this series (4.1%) is one of the lowest published to date with regard to SCC-E, and confirms this assertion. We observed 10.6% NMs according to other series that treated the whole spectrum of SCC-E. Almost 2/3 of patients with NMs die after therapeutic rescue. We believe that it is essential to identify prognostic factors to select patients for one of the following: close surveillance (ultrasonography) during the first 2 years after surgery, sentinel node biopsy, or elective treatment of the nodes (surgery or radiotherapy).
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Affiliation(s)
- Abel González
- Angel H. Roffo Oncology Institute, Mohs Surgery Unit, Head and Neck Department, Alexander Fleming Institute, Skin Cancer Oncology, 1180 Cramer St., CABA (ZIP 1426), Buenos Aires, Argentina.
| | - Dardo Etchichury
- Angel H. Roffo Oncology Institute, Mohs Surgery Unit, Head and Neck Department, Alexander Fleming Institute, Skin Cancer Oncology, 1180 Cramer St., CABA (ZIP 1426), Buenos Aires, Argentina
| | - Juan Mario Rivero
- Angel H. Roffo Oncology Institute, Mohs Surgery Unit, Head and Neck Department, Alexander Fleming Institute, Skin Cancer Oncology, 1180 Cramer St., CABA (ZIP 1426), Buenos Aires, Argentina
| | - Lucia Adamo
- Angel H. Roffo Oncology Institute, Mohs Surgery Unit, Head and Neck Department, Alexander Fleming Institute, Skin Cancer Oncology, 1180 Cramer St., CABA (ZIP 1426), Buenos Aires, Argentina
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17
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Mohs micrographic surgery: a review of indications, technique, outcomes, and considerations. An Bras Dermatol 2021; 96:263-277. [PMID: 33849752 PMCID: PMC8178571 DOI: 10.1016/j.abd.2020.10.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/26/2020] [Accepted: 10/05/2020] [Indexed: 01/10/2023] Open
Abstract
Mohs micrographic surgery is a specialized form of skin cancer surgery that has the highest cure rates for several cutaneous malignancies. Certain skin cancers can have small extensions or “roots” that may be missed if an excised tumor is serially cross-sectioned in a “bread-loaf” fashion, commonly performed on excision specimens. The method of Mohs micrographic surgery is unique in that the dermatologist (Mohs surgeon) acts as both surgeon and pathologist, from the preoperative considerations until the reconstruction. Since Dr. Mohs’s initial work in the 1930s, the practice of Mohs micrographic surgery has become increasingly widespread among the dermatologic surgery community worldwide and is considered the treatment of choice for many common and uncommon cutaneous neoplasms. Mohs micrographic surgery spares the maximal amount of normal tissue and is a safe procedure with very few complications, most of them managed by Mohs surgeons in their offices. Mohs micrographic surgery is the standard of care for high risks basal cell carcinomas and cutaneous squamous cell carcinoma and is commonly and increasingly used for melanoma and other rare tumors with superior cure rates. This review better familiarizes the dermatologists with the technique, explains the difference between Mohs micrographic surgery and wide local excision, and discusses its main indications.
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18
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Massey PR, Gupta S, Rothstein BE, Konnikov N, Mahalingam M, Ruiz ES, Schmults CD, Waldman A. Total Margin-Controlled Excision is Superior to Standard Excision for Keratinocyte Carcinoma on the Nose: A Veterans Affairs Nested Cohort Study. Ann Surg Oncol 2021; 28:3656-3663. [PMID: 33742233 DOI: 10.1245/s10434-021-09604-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 12/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Keratinocyte carcinoma (KC), including basal and squamous cell carcinoma, is the most common human malignancy. Limited real-world data have compared surgical outcome or cost between total margin-controlled excision (TMCE) and standard excision (SE), the two most common treatments for invasive KC. We compared reconstruction, margin status, and cost between TMCE and SE for KC on the nose at a Veterans Affairs (VA) healthcare system. METHODS Randomly selected primary KCs on the nose ≤3 cm that were confined to soft tissue, without nerve or lymphovascular invasion, and treated with SE or TMCE between 2000 and 2010, were assessed. Utilization of flap or graft reconstruction and margin status following all surgical attempts were recorded. Costs were based on Current Procedural Terminology codes standardized to 2019 Medicare payments. RESULTS Overall, 148 cases were included in each treatment group. Baseline characteristics were similar between groups, although SE tumor median diameter was 1 mm larger. SE was associated with increased utilization of flap or graft reconstruction (odds ratio 2.05, 95% confidence interval 1.16-3.59, p = 0.01). Positive margins were present in 24% of SEs initially and remained positive after the final recorded excision in 9% of cases. No positive final margins were noted in TMCE cases. SE cost per tumor was significantly higher than TMCE ($429.03 ± 143.55; p = 0.003). CONCLUSIONS Surgical management of KC with SE is associated with increased reconstruction complexity, a significant risk of positive margins, and higher cost compared with TMCE. The 23% risk of positive margins supports National Comprehensive Cancer Network guidelines for the treatment of high-risk KC with TMCE, unless delayed reconstruction is employed.
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Affiliation(s)
- Paul R Massey
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sameer Gupta
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Nellie Konnikov
- Department of Dermatology, Veterans Affairs, Boston Healthcare System, Boston, MA, USA
| | - Meera Mahalingam
- Dermatopathology Section, Department of Pathology and Laboratory Medicine, Veterans Affairs, Boston Healthcare System, Boston, MA, USA
| | - Emily S Ruiz
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Dermatology, Veterans Affairs, Boston Healthcare System, Boston, MA, USA
| | - Chrysalyne D Schmults
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Abigail Waldman
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Dermatology, Veterans Affairs, Boston Healthcare System, Boston, MA, USA.
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Cogrel O. Quoi de neuf en dermatologie instrumentale en 2020 ? Ann Dermatol Venereol 2020; 147:12S9-12S14. [PMID: 33267944 DOI: 10.1016/s0151-9638(20)31102-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- O Cogrel
- Praticien hospitalier, Responsable de l'unité de dermatologie instrumentale, Service de Dermatologie, Hôpital Saint-André, CHU de Bordeaux.
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20
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Sidey K, Kobic A, Vidal NY. Identifying squamous cell carcinoma and cytokeratin-derived amyloid with pan-cytokeratin AE1/AE3 during Mohs micrographic surgery. JAAD Case Rep 2020; 6:776-779. [PMID: 32760776 PMCID: PMC7390831 DOI: 10.1016/j.jdcr.2020.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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21
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Barriera-Silvestrini P, Knackstedt T. In Reference to Prognostic Value of Tumor Staging: Predicting Nodal Metastases in Cutaneous Squamous Cell Carcinoma. Laryngoscope 2020; 131:E443. [PMID: 32770736 DOI: 10.1002/lary.28978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 11/05/2022]
Affiliation(s)
| | - Thomas Knackstedt
- Department of Dermatology, MetroHealth Hospital, Cleveland, Ohio, USA.,School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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22
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Beal BT, Xiong D, Rodriguez M, Varra V, Cundall H, Simmons L, Woody N, Koyfman SA, Vidimos AT, Knackstedt TJ. Noncompliance with surgical margin guidelines is associated with histologic margin positivity: A retrospective case-control study. J Am Acad Dermatol 2020; 84:1126-1128. [PMID: 32565212 DOI: 10.1016/j.jaad.2020.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/05/2020] [Accepted: 06/10/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Brandon T Beal
- Zitelli & Brodland PC, Jefferson Hills, Pennsylvania; Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David Xiong
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Marla Rodriguez
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Vamsi Varra
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Hannah Cundall
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Lanee Simmons
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Neil Woody
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Allison T Vidimos
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Thomas J Knackstedt
- School of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of Dermatology, MetroHealth Hospital, Cleveland, Ohio.
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