A Prospective Study of the Accuracy of the Surgeonʼs Diagnosis and Significance of Positive Margins in Nonmelanoma Skin Cancers

Abstract

Even with a precise preoperative diagnosis, complete excision of nonmelanoma skin cancer is not always achieved. The conundrum remains the decision for appropriate secondary treatment. Many surgeons, regardless of the nature of the lesion, consider re-excision to be the only option. In a prior 4-year prospective study that ascertained the accuracy of our clinical diagnosis of skin lesions removed in an office setting, one-fifth were found to be malignant and 98 percent (n = 415) of the lesions were nonmelanoma skin cancer. Unfortunately, 65 (15.7 percent) of the malignant nonmelanoma skin cancer lesions had positive margins. The outcome of our management for these specific lesions was followed prospectively over the 7.5 years of this study to determine whether aggressive surgical intervention was justified in every case. Of 65 patients with lesions, early and complete re-excision of margin-positive nonmelanoma skin cancer was performed for 34 (52.3 percent), with residual tumor found in 11 (32.4 percent), followed by a later recurrence in one (2.9 percent). The remaining 31 patients agreed to semiannual office visits, with one (3.2 percent) recurrence in this group. Thus, the overall rate of recurrence for margin-positive nonmelanoma skin cancer was 3.1 percent, with a mean follow-up of 3.6 years (range, 0 to 7.5 years). There were no recurrences for basal cell carcinoma in either treatment group, suggesting that, at least for "simple" primary lesions without confounding risk factors, there is some validity to a "wait and see" attitude, in which treatment of a potential recurrence would be straightforward. Despite our observed infrequent local recurrences of squamous cell cancers (13.3 percent), the small risk of metastases still suggests the appropriateness of complete surgical eradication for these tumors whenever feasible.

Efficacy of narrow-margin excision of well-demarcated primary facial basal cell carcinomas

“…8 Similarly, a study by plastic surgeons found that 16% of 414 nonmelanoma skin cancers had positive surgical margins. 9 Perhaps more significantly, a study by ophthalmologists on 141 primary periocular BCCs found that 52% of excised tumors had involved histologic margins. 10 This is in contrast to a more recent study demonstrating that excision of periocular BCCs with a 2-mm margin results in positive surgical margins in only 18% of cases.…”

Infiltrating basal cell carcinoma of the neck 34 years after irradiation of an haemangioma in early childhood. A case-report

“…The standard treatment is surgical removal and histological control of the margins. Even in cases of correct clinical diagnosis of a basal cell carcinoma preoperatively, the pathology report reveals positive margins in 16.2% of the cases (Hallock and Lutz, 2001). The overall recurrence rate after surgical removal is up to 10% (Schubert, 2000).…”

“…In a prospective trial on the correct diagnosis of non-melanoma skin cancer, the correct diagnosis of basal cell carcinoma was found only in 66.7% of the cases (Hallock and Lutz, 2001). It is particularly difficult to assess the tumour's expansion.…”

Evaluation of The Diagnosis and Treatment of Non-Melanoma Skin Cancer and its Impacts on The Prevention Habits in a Specific Population of Southeastern Brazil

“…Incisional biopsy of the lesion, for suspicion of both BCC and SCC is indicated when there is diagnostic uncertainty (8,9); it can be time consuming, costly and sometimes crippling and painful for the patient, not being justified in most cases (7). The accuracy of the NMSC clinical diagnosis is approximately 60.2% (20); in relation to BCC it ranges from 59% to 88.93% (18,(20)(21)(22)(23) and for SCC it ranges from 25% to 67.4% (18,(20)(21)(22)(23). The diagnostic accuracy presented in this study is within the variation observed in the literature for both BCC and SCC.…”

“…In different series, the percentage of surgical margins compromised by SCC ranges from 3.9% to 15% (22,26), with a recurrence rate ranging from 4% to 50% of the cases (20). According to a recent guideline (9), if the surgical margins are compromised by SCC (incomplete excision), it is essential the re-excision with a 4-6 mm safety margin, and if this is not feasible, adjuvant treatment (radiotherapy or chemotherapy) may be an acceptable option (9).…”