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Incomplete Surgical Excision of Keratinocyte Skin Cancers
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In this systematic review and meta-analysis, the authors included 110 studies of excision specimens of nonmelanoma skin cancers (Mohs surgeries, frozen sections, and biopsies excluded), which included 106,832 basal cell carcinomas (BCC) and 21,569 squamous cell carcinomas (SCC). Incomplete excision rates of BCC and SCC were 6.2% and 4.7%, respectively, for dermatologists; 9.4% and 8.2%, respectively, for plastic surgeons; and 20.4% and 18.9%, respectively, for general practitioners. Plastic surgeons excised more skin cancers from the head and neck than did dermatologists and general practitioners and also performed a larger number of complex closures, perhaps indicating that these surgeries were more complex or for larger lesions.
- The proportions of incomplete excision overall were 11% for BCC and 9.4% for SCC and varied by specialty of the physician performing the surgery. The risk of incomplete excision by general practitioners was nearly four times higher than that seen for dermatologists and more than double that for plastic surgeons. The rates of incomplete excision were much higher in this study than have been previous published, indicating the need for further study and efforts to improve excision outcomes for nonmelanoma skin cancers.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Keratinocyte or nonmelanoma skin cancer (NMSC) is the commonest malignancy worldwide. The usual treatment is surgical excision. Current guidelines underestimate incomplete excision rates.
OBJECTIVES
We aimed to determine the risk of incomplete excision of NMSCs through a systematic review and meta-analysis of primary clinical studies.
METHODS
A PRISMA-compliant systematic review and meta-analysis was performed using methodology proposed by Cochrane (PROSPERO CRD42019157936). A comprehensive search strategy was applied to MEDLINE, Embase, Scopus, CINAHL, EMCare, Cochrane Library and the grey literature (January 2000-27 November 2019). All studies were included except those on Mohs micrographic surgery, frozen section or biopsies. Abstract screening and data extraction were performed in duplicate. Risk of bias was assessed using a tool for prevalence/incidence studies. The primary outcome was the proportion of incomplete surgical excisions. A random-effects model for pooling of binomial data was used. Differences between proportions were assessed by subgroup meta-analysis and meta-regression, which were presented as risk ratios (RRs).
RESULTS
Searching identified 3477 records, with 110 studies included, comprising 53 796 patients with 106 832 basal cell carcinomas (BCCs) and 21 569 squamous cell carcinomas (SCCs). The proportion of incomplete excisions for BCC was 11·0% [95% confidence interval (CI) 9·7–12·4] and for SCC 9·4% (95% CI 7·6–11·4). Proportions of incomplete excisions by specialty were: dermatology, BCCs 6·2% and SCCs 4·7%; plastic surgery, BCCs 9·4% and SCCs 8·2%; general practitioners, BCCs 20·4% and SCCs 18·9%. The risk of incomplete excision for general practitioners was four times that of dermatologists for both BCCs (RR 3·9, 95% CI 2·0–7·3) and SCCs (RR 4·8, 95% CI 1·0–22·8). Studies were heterogeneous (I2 = 98%) and at high risk of bias.
CONCLUSIONS
The proportion of incomplete excisions is higher than previously reported. Excisions performed by specialists may lower the risk of incomplete excision.
Additional Info
Incomplete Surgical Excision of Keratinocyte Skin Cancers: A Systematic Review and Meta-Analysis
Br J Dermatol 2020 Oct 31;[EPub Ahead of Print], GS Nolan, AL Kiely, JP Totty, JCR Wormald, RG Wade, M Arbyn, A JainFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Dermatology
This study reports an overall increase in the proportion of incomplete nonmelanoma skin cancer (NMSC) excisions with significant specialty-specific variation compared with existing literature. Additionally, many of the incompletely excised tumors were located on the head and neck, which can result in significant morbidity. These findings are particularly concerning when compared with the virtually nonexistent risk of incomplete excision associated with Mohs surgery and further support the use of Mohs surgery for treatment of NMSCs.
Standard surgical excision of NMSC primarily relies upon selection of appropriate tumors for surgical excision, accurate estimation of tumor borders prior to excision, and adherence to excision margin guidelines. It is often a viable treatment option for clinically and histologically low-risk tumors that can be closed linearly. However, there is an inherent risk for incomplete excision as the margins are not histologically examined prior to closure. It is extraordinarily difficult to make oneself take adequate (4 mm) margins on cosmetically sensitive areas, but complete tumor clearance is essential prior to closure. Incomplete excision of NMSCs that have been repaired with more complex closures, such as flaps or grafts, is particularly challenging as it requires re-excision of the entire area to ensure tumor clearance. Therefore, it is important to identify high-risk clinical and histologic features that may warrant treatment with Mohs surgery, margins with frozen sections, or delayed closure to ensure complete tumor clearance.