MIAMI BEACH – Observation or a "watchful waiting" approach is an acceptable option vs. re-excision for patients with positive margins remaining after removal of head and neck skin cancers, according to a retrospective study.
"A lot of times we take these lesions off and they appear to be benign, not really knowing what the preoperative histologic diagnosis is. [Then we] find out the diagnosis is cancer, and not only that, but they have a positive margin." Dr. Justin Douglas said at the Triological Society Combined Sections meeting.
The question is, he said, "Do you have to rush them back in [and re-excise] or can you sit on them for a while?"
"Dr. Douglas addresses an interesting question," said session moderator Dr. Jeffrey H. Spiegel, chief of the division of facial plastic and reconstructive surgery at Boston University Medical Center and otolaryngology faculty member at Boston University. "I see a lot of people who had squamous cells and basal cells excised sent back for re-excision ... and he’ll help us understand if I even need to be doing that."
Dr. Douglas and his colleagues studied 492 patients at the Clarksburg Veterans Affairs Hospital in Morgantown, W.Va. All had skin cancers removed from their head or neck, including 387 basal cell carcinomas and 105 squamous cell carcinomas, over 5 years.
"Do you have to rush them back in [and re-excise] or can you sit on them for a while?"
About 40% or 197 lesions had a negative margin after wide local excision. The remaining 295 lesions featured a positive margin on permanent section analysis. The positive lesions included 232 basal cell carcinomas (BCCs) and 63 squamous cell carcinomas (SCCs).
"In the group of 232 positive basal cell lesions, everybody was offered re-excision. A total 105 chose re-excision and 127 decided to just watch it, despite our best judgment," said Dr. Douglas, an otolaryngologist at the Morgantown V.A.
"Even of the squamous cell patients, 26 still said they wanted to watch it," Dr. Douglas said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons.
Of the positive margin group, none of the BCC and four (3.8%) of the SCC lesions recurred within a median follow-up of 3.7 years. This finding suggests a role for clinical observation of low-risk, nonmelanomatous cancers, Dr. Douglas said.
The four SCC lesions that recurred included one lesion in the observation-only group and three in the re-excision group. Some of these patients likely had a more aggressive form of cancer, Dr. Douglas said.
"Essentially, we feel what we learned from this study is that ... given the fact that you can handle any recurrence of these lesions if they occur, you can watch the basal cells, even with positive margins," Dr. Douglas said. "We still feel all squamous cell lesions should be taken out until you get a clear margin."
Why the majority of positive margin patients who chose observation did not experience recurrence is poorly understood, Dr. Douglas said. However, it could be the patient’s immune system, secondary to the wound healing process, comes in and cleans up any residual cells. Another possibility is that patients die from other causes before recurrence can occur. "The truth of the matter is: We don’t know. We need more studies to figure this out."
The nose was the most common site for the T1, nonmelanoma lesions. The average size was 1.2 cm. Mean patient age was 61 years and 484 (98%) were men. Patients were excluded from the study if their lesion was previously treated or they chose an option other than re-excision or observation.
Although initial excision by a Mohs surgeon would be ideal, Dr. Douglas said, in his study dermatologists and otolaryngologists removed the lesions at one of the hospital ambulatory clinics. This strategy reflects some real-world limitations. "The problem is, at least in West Virginia, Mohs surgeons are very sparse. There are probably only a handful in the state." Operating room time and scheduling (particularly for patients with many lesions), availability of a pathologist to read frozen sections, and costs are additional challenges.
Dr. Douglas and Dr. Spiegel said that they had no relevant financial disclosures.
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