John A. Zitelli

Surgical margins for excision of primary cutaneous squamous cell carcinoma

BACKGROUND No guidelines for the margin of resection of cutaneous squamous cell carcinoma have been based on data measuring subclinical tumor extension, as have been formulated for basal cell carcinoma. OBJECTIVE AND METHODS Guidelines for appropriate margins of excision of primary cutaneous squamous cell carcinoma were formulated on the basis of a prospective study of subclinical microscopic tumor extension. RESULTS Four millimeter margins were adequate for most squamous cell carcinomas. However, certain tumor characteristics were associated with a greater risk of subclinical tumor extension and included size of 2 cm or larger, histologic grade 2 or higher, invasion of the subcutaneous tissue, and location in high-risk areas. CONCLUSION Minimal margins of excision of 4 mm around the clinical borders of the squamous cell carcinoma are proposed for all but the high-risk tumors, in which at least a 6 mm margin is recommended.

Mohs micrographic surgery: A cost analysis

BACKGROUND The incidence of skin cancer is increasing significantly, and many people have declared the increase an epidemic. It was estimated that 900,000 to 1.2 million cases of nonmelanoma skin cancer occurred in the United States in 1994. With increasing pressure to deliver cost-effective medical care, physicians must understand the cost and value of the various methods to treat skin cancer. OBJECTIVE Our purpose was to define the true cost of treating a series of skin cancers with the Mohs micrographic technique and compare our costs with calculated estimates of the costs to treat the same cancers with traditional methods of surgical excision. METHODS A group of 400 consecutive tumors was selected. The cost of treatment in the reference group included diagnosis, Mohs micrographic surgery, reconstruction (if applicable), follow-up, and the cost to treat disease recurrence. These costs were then compared with traditional methods of surgical excision: excision with permanent section margin control, excision with frozen section margin control, and excision with frozen section margin control in an ambulatory surgical facility. For cost comparisons, it was assumed that all tumors in the comparison groups would be excised with standard surgical margins and the resultant surgical defects would be reconstructed with the simplest method possible. The costs of diagnosis, excision, pathology, reconstruction, and the cost to treat disease recurrence were then calculated and compared with the costs of treating the lesions with Mohs micrographic surgery. RESULTS Our calculation of costs documents that Mohs micrographic surgery is similar in cost to office-based traditional surgical excision and less expensive than ambulatory surgical facility-based surgical excision. The average cost of Mohs micrographic surgery was

Mohs micrographic surgery for the treatment of primary cutaneous melanoma

1243 versus

Wound healing by secondary intention: A cosmetic appraisal

1167 for excision with permanent section margin control,

Surgical margins for excision of dermatofibrosarcoma protuberans

1400 for excision in the office with frozen section margin control, and

The reliability of frozen sections in the evaluation of surgical margins for melanoma

1973 for excision with frozen section margin control in an ambulatory surgical facility. Analysis based on anatomic location yielded similar results. CONCLUSION Mohs micrographic surgery is a method of surgical excision with high intrinsic value that is cost-effective in comparison to traditional surgical excision.

Surgical margins for excision of primary cutaneous melanoma

BACKGROUND Mohs micrographic surgery is thought to be a useful therapy for cutaneous melanoma. Controversy persists, however, because there are few published reports that document its safety and efficacy. OBJECTIVE Our purpose was to determine the safety and efficacy of Mohs micrographic surgery for the treatment of cutaneous melanoma. METHODS A consecutive sample of 535 patients referred for treatment of 553 primary cutaneous melanomas was entered into the study. Of this sample, 99.5% of patients completed their first 5 years of follow-up. All melanomas were excised by means of fresh-tissue Mohs micrographic surgery with frozen-section examination of the margin. The 5-year Kaplan-Meier melanoma mortality, metastasis, and local recurrence rates were compared with historical control cases. RESULTS Mohs micrographic surgery provided 5-year survival and metastatic rates equivalent to or better than historical controls that were treated by standard wide-margin surgery. Satellite metastases were not more common with the narrow margins used with Mohs micrographic surgery. Local recurrences from inadequate excision of the primary tumor were infrequent (0.5%). The majority of melanomas were successfully excised with a narrow margin (83% were excised with a 6 mm margin). CONCLUSION Mohs micrographic surgery is an effective therapy for primary cutaneous melanoma. It may be particularly useful to conserve tissue for melanomas on the head, neck, hands, or feet or for melanomas with indistinct clinical margins.

Surgical margins for melanoma in situ

Secondary intention healing is a simple method of wound management that can provide excellent cosmetic results. Wounds located on concave surfaces of the skin heal with a better cosmetic result than those on convex surfaces. The technic of wound care is reviewed and a set of guidelines is presented that helps one to predict the final appearance of healed cutaneous wounds.

Histologic patterns of congenital nevocytic nevi and implications for treatment

BACKGROUND Dermatofibrosarcoma protuberans (DFSP) commonly recurs after standard surgical excision with a wide margin. No studies have been undertaken to objectively determine the appropriate surgical margins by measuring the extension of the subclinical tumor. OBJECTIVE Our purpose was to measure the subclinical extent of tumor in 20 patients with DFSP to determine appropriate surgical margins. METHODS We mapped the subclinical tumor extension with Mohs micrographic surgery and measured the surgical margins required to clear the tumor completely. RESULTS We found that a 2.5 cm surgical margin through the deep fascia (nonscalp) or periosteum (scalp) cleared all of the tumors. DFSP tumors that measured less than 2 cm were completely cleared with a 1.5 cm surgical margin. None of our patients had a recurrence of the tumor, and in 16 of 20 patients repairs were possible. CONCLUSION Our data support the use of Mohs surgery to excise DFSP with maximum conservation of tissue and a high cure rate.

New primary nonmelanoma skin cancer in patients with a history of squamous cell carcinoma of the skin: Implications and recommendations for follow-up

As the width of surgical margins declines, histologic evaluation of the margins is needed to assess the completeness of excision of a malignant melanoma. We studied 221 specimens in 59 patients and compared the interpretations of frozen and paraffin sections from the same block. Frozen sections had a sensitivity of 100% in detecting melanoma when present and a specificity of 90%.