Risk Factors and Rate of Recurrence after Mohs Surgery in Basal Cell and Squamous Cell Carcinomas: A Nationwide Prospective Cohort (REGESMOHS, Spanish Registry of Mohs Surgery)

Clinical Characteristics of Local Recurrent Basal Cell Carcinoma After Surgical Excision: A Retrospective Study of the Patients From a Tertiary Clinical Center

BACKGROUND

Basal cell carcinoma (BCC) is the most frequent form of skin cancer. The etiology of recurrent BCC is multifactorial, and the recurrence rate is variable.

OBJECTIVE

The aim of the study was to identify the risk factors of local recurrence after surgical excision in primary BCC.

MATERIALS AND METHODS

 In our study, 934 patients histopathological diagnosed with BCCs between January 2017 and June 2022 were evaluated retrospectively. Among these, patients who were regularly followed up for at least three years were included in the study. Patients who underwent non-excision treatment were excluded. All the patients who had pathologically confirmed, surgically excised BCCs with safety margins and those with a clinicopathological diagnosis of recurrent BCCs. Demographic and clinical features of 78 patients with non-recurrent primary BCC and 55 patients with local recurrent BCC were compared.

RESULTS

The mean age was 69.7±11.7 years. The gender distribution was M/F:1.3. The time from diagnosis to total surgical excision was 2.3±1.4 months, and the time of recurrence was 27.5±23.3 months. The age of the patients, the time from diagnosis to total excision, the lesion size > 2 cm, and the presence of risk factors (such as radiotherapy, malignancy, and immunosuppression) were higher in the recurrent group than in the non-recurrent group (p < 0.05). Location (high/medium/low-risk area) and the presence of multiple lesions did not differ significantly between the recurrent and non-recurrent groups.

CONCLUSION

In patients with BCC, recurrence is often detected in the first three years after diagnosis. Our study determined age, lesion size, accompanying risk factors, and the length of time until total excision as risk factors for recurrence in BCC patients. The histological subtype and lesion localization did not differ between the group with and without recurrence.

Efficacy of micrographic surgery versus conventional excision in reducing recurrence for basal cell carcinoma and squamous cell carcinoma: A systematic review and meta-analysis

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.

Mohs micrographic surgery in immunosuppressed vs immunocompetent patients: Results of a prospective nationwide cohort study (REGESMOHS, Spanish registry of Mohs surgery)

BACKGROUND

Immunosuppressed (IS) patients, particularly solid organ transplant recipients and those on immunosuppressive therapy, face a higher incidence and recurrence of nonmelanoma skin cancers (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Mohs micrographic surgery (MMS) is the preferred treatment for high-risk NMSC due to its high cure rate and margin examination capabilities. However, IS patients may experience more complications, such as surgical site infections, and a greater risk of recurrence, making their outcomes a subject of interest.

OBJECTIVES

This study aimed to compare IS and immunocompetent (IC) patients undergoing MMS for NMSC in terms of baseline characteristics, intra- and post-surgical complications, and postoperative recurrence rates.

METHODS

The study utilized data from the REGESMOHS registry, a 7-year prospective cohort study in Spain. It included 5226 patients, categorizing them into IC (5069) and IS (157) groups. IS patients included solid organ transplant recipients, those on immunosuppressive treatments, individuals with haematological tumours and HIV-positive patients. Patient data, tumour characteristics, surgical details and outcomes were collected and analysed.

RESULTS

IS patients demonstrated a higher proportion of SCC, multiple synchronous tumours and tumours invading deeper structures. Complex closures, unfinished MMS and more surgical sections were observed in the IS group. Although intra-operative morbidity was higher among IS patients, this difference became non-significant when adjusted for other variables such as year of surgery, antiplatelet/anticoagulant treatment or type of closure. Importantly, IS patients had a substantially higher recurrence rate (IRR 2.79) compared to IC patients.

CONCLUSIONS

This study suggests that IS patients may be at a higher risk of development of AE such as bleeding or tumour necrosis and are at a higher risk of tumour recurrence. Close follow-up and consideration of the specific characteristics of NMSC in IS patients are crucial. Further research with extended follow-up is needed to better understand the long-term outcomes for this patient group.

Comparative Analysis of Slow Mohs Surgery in Melanoma and Mohs Micrographic Surgery in Squamous Cell Carcinoma and Basal Cell Carcinoma

Skin cancer is one of the most common types of cancer worldwide, and it can affect people of all ages, races, and genders. Mohs micrographic surgery (MMS), a specialized type of skin cancer surgery, boasts the highest cure rates for various types of skin malignancies. Slow Mohs surgery (SMS) is a methodical and meticulous approach to MMS that involves careful and deliberate examination of tissue samples to ensure the complete removal of skin cancer while preserving as much healthy tissue as possible. Both SMS and MMS have been indicated to be effective treatment options for skin cancer, depending on the type and stage of cancer. This case-control study analysis compares the efficacy of SMS for melanoma with that of MMS for squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). We analyzed data from the past two decades to assess recurrence rates and treatment-related complications. Our findings suggest that SMS for melanoma achieves comparable outcomes to MMS in SCC and BCC. Both approaches demonstrated similar cure rates and complication profiles. However, further prospective studies are necessary to solidify these findings and refine the specific role of SMS in melanoma therapy.

Implications of Malignancy, Radiation, and Timing of Major Nasal Reconstruction

Owing to the complex, multilayered anatomy of the nose in the central face, major nasal reconstruction can pose a significant challenge for reconstructive surgeons. It is the responsibility of reconstructive surgeons to have an understanding of the most common cutaneous malignancies and excisional techniques that may lead to complex nasal defects. The purpose of this article is to discuss these malignancies, excisional techniques, and impacts of radiation on tissue that has implications for reconstructive surgeons.

Management of Cutaneous Squamous Cell Carcinoma of the Scalp: The Role of Imaging and Therapeutic Approaches

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.

Image-guided superficial radiation therapy has superior 2-year recurrence probability to Mohs micrographic surgery

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.

[Translated article] Basal Cell Carcinoma in the Southern Health Area of Tenerife: Key Clinical and Pathological Factors and Margin Status After Excision

BACKGROUND AND OBJECTIVE

Surgical excision is the treatment of choice for basal cell carcinoma (BCC). Complete excision with clear margins is important for reducing the risk of recurrence. The aims of this study were to describe the characteristics of BCCs in our health care area, calculate the percentage of positive margins after surgical excision, and determine the risk factors for incomplete excision.

MATERIAL AND METHODS

Retrospective observational study of BCCs that were surgically removed at Hospital Universitario Nuestra Señora de Candelaria, in Santa Cruz de Tenerife, Spain, between January 1, 2014 and December 31, 2014. Information was collected on demographic, clinical, and histologic variables, surgical approach, margin status, and the department responsible.

RESULTS

In total, 966 BCCs were diagnosed in 776 patients. Nine percent of tumors with complete data were biopsied, 89% were surgically excised, and 2% were removed by shave excision. The median age of patients with excised tumors was 71 years and 52% were men. BCCs were most often located on the face (59.1%). Surgical margins were analyzed in 506 cases, 17% of which had positive margins. Incomplete excision was significantly more common in tumors located on the face (22% vs. 10% for other locations) and in high-risk subtypes according to the World Health Organization classification (25% vs. 15% for low-risk subtypes).

CONCLUSIONS

The characteristics of BCCs in our health care area are similar to those described elsewhere. Facial location and histologic subtype are risk factors for incomplete excision. Careful surgical planning is therefore important in the initial management of BCCs with these characteristics.

Basal Cell Carcinoma in the Southern Health Area of Tenerife. Key Clinical and Pathological Factors and Margin Status After Excision

BACKGROUND AND OBJECTIVE

Surgical excision is the treatment of choice for basal cell carcinoma (BCC). Complete excision with clear margins is important for reducing the risk of recurrence. The aims of this study were to describe the characteristics of BCCs in our health care area, calculate the percentage of positive margins after surgical excision, and determine the risk factors for incomplete excision.

MATERIAL AND METHODS

Retrospective observational study of BCCs that were surgically removed at Hospital Universitario Nuestra Señora de Candelaria, in Santa Cruz de Tenerife, Spain, between January 1, 2014 and December 31, 2014. Information was collected on demographic, clinical, and histologic variables, surgical approach, margin status, and the department responsible.

RESULTS

In total, 966 BCCs were diagnosed in 776 patients. Nine percent of tumors with complete data were biopsied, 89% were surgically excised, and 2% were removed by shave excision. The median age of patients with excised tumors was 71 years and 52% were men. BCCs were most often located on the face (59.1%). Surgical margins were analyzed in 506 cases, 17% of which had positive margins. Incomplete excision was significantly more common in tumors located on the face (22% vs. 10% for other locations) and in high-risk subtypes according to the World Health Organization classification (25% vs. 15% for low-risk subtypes).

CONCLUSIONS

The characteristics of BCCs in our health care area are similar to those described elsewhere. Facial location and histologic subtype are risk factors for incomplete excision. Careful surgical planning is therefore important in the initial management of BCCs with these characteristics.

A review of the evidence for Mohs micrographic surgery in the treatment of basal cell carcinoma

MMS is considered the gold standard treatment for basal cell carcinoma (BCC) particularly for sites with a high-risk of incomplete excision such as the central face, tumours with an aggressive growth pattern and consequent unpredictable sub-clinical extension and recurrent tumours. However, the process is more time consuming and the magnitude of benefit is uncertain. This article aims to provide a more complete picture of current evidence, including a review of cosmetic outcomes, tissue sparing ability and cost-effectiveness of MMS. Whilst robust evidence is lacking, there is a large volume of observational data supporting a low recurrence rate after MMS. The risk of incomplete excision and higher recurrence rate of standard excision favours the use of MMS at high-risk sites. There is some low certainty evidence that MMS results in a smaller defect size than SE and that incomplete excision with SE results in larger defects. Larger defects may affect cosmetic outcome but there is no direct evidence that MMS improves cosmetic outcome compared to SE. There is conflicting evidence regarding the cost of MMS in comparison to SE with some studies recognising MMS as less expensive than SE and others more which may reflect the healthcare setting. A multi-centre 10 year RCT comparing MMS and SE in the treatment of high-risk BCC would be desirable, but is unlikely to be feasible or ethical. Collection of robust registry data capturing both MMS and SE outcomes would provide additional long-term outcomes.