NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines

Melanoma and non-melanoma (basal and squamous cell carcinoma) skin cancer (NMSC) are now the most common types of cancer in the white populations and the incidence of skin cancer has reached epidemic proportions According to recent population-based studies from Australia the incidence rate is over 2% for basal cell carcinoma in males and 1% for squamous cell carcinoma, and there are over 50 new cases of melanoma per 100 000

The epidemiology of skin cancer.

Ductal carcinoma in situ (DCIS) of the breast represents a heterogeneous group of neoplastic lesions in the breast ducts. The goal for management of DCIS is to prevent the development of invasive breast cancer. This manuscript focuses on the NCCN Guidelines Panel recommendations for the workup, primary treatment, risk reduction strategies, and surveillance specific to DCIS.

https://www.unitypoint.org/desmoines/filesimages/Cancer%20Education/Oncology%20Nursing%20Conference/2015/2014%20NCCN%20Clin%20Pract%20Guidelines%20Male%20Sex%20Dysf.pdf

Clinical practice guidelines in oncology

Squamous cell carcinoma.

https://www.spg.pt/wp-content/uploads/2015/11/2015-CCR-hereditario.pdf

ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes.

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.

https://www.jaad.org/article/0190-9622(92)70178-I/pdf

Surgical margins for excision of primary cutaneous squamous cell carcinoma.

• Four hundred consecutive surgical wounds on the nose were studied for wound management. The most commonly used flap was the bilobed double transposition flap that is especially useful for reconstruction of defects on the lower third of the nose. While the standard design often results in tissue protrusions or pincushioning, improvements in the design are outlined herein to achieve the best results for defects on the nose. (Arch Dermatol.1989;125:957-959)

The Bilobed Flap for Nasal Reconstruction

Background: Optimal treatment of primary Merkel cell carcinoma (MCC) is unknown. High local recurrence rates after excision alone compel some physicians to advocate postoperative radiation therapy to improve local control. Objective: We wondered whether marginal recurrence and survival rates differed between patients with primary MCC treated with Mohs surgery alone and those treated with Mohs surgery and adjuvant postoperative radiation. Methods: A collaborative retrospective study was performed; the study group consisted of 45 patients with stage I MCC who were histologically and clinically free of disease after Mohs excision. Twenty patients subsequently received elective postoperative radiation to the primary site, and 25 patients had no adjuvant radiation therapy. Results: One marginal recurrence (4%) and 3 in-transit metastases were observed in the Mohs surgery alone group, whereas none were observed in the Mohs surgery and radiation group. The proportion of patients with these events was not significantly different between treatment groups. Overall survival, relapse-free survival, and disease-free survival were not significantly different between treatment groups. Conclusion: Adjuvant radiation appears unessential to secure local control of primary MCC lesions completely excised with Mohs micrographic surgery. Adjuvant radiation is recommended for patients unable to have complete excision or if complete histologic margin control is unavailable and should be considered for patients with large or recurrent tumors. (J Am Acad Dermatol 2002;47:885-92.)

https://www.jaad.org/article/S0190-9622(02)00318-3/pdf

Local control of primary Merkel cell carcinoma: Review of 45 cases treated with Mohs micrographic surgery with and without adjuvant radiation

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 $1243 versus $1167 for excision with permanent section margin control, $1400 for excision in the office with frozen section margin control, and $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. (J Am Acad Dermatol 1998;39:698-703.)

Mohs micrographic surgery: A cost analysis

Background Extramammary Paget's disease (EMPD) is an uncommon tumor that has a high rate of recurrence after conventional surgical treatments. Objective Our purpose was to establish the efficacy of Mohs micrographic surgery (MMS) in the treatment of EMPD, and to make treatment recommendations with regard to surgical margins. We also attempted to summarize the published recurrence rates of EMPD after standard surgical management. Methods In a retrospective chart review, pertinent demographic data, tumor data, treatment characteristics, and follow-up data were tabulated. A search of the literature for recurrence rates after MMS and non-MMS surgical treatment modalities was performed. Results The recurrence rate after treatment with MMS was 16% for primary EMPD and 50% for recurrent EMPD. The 5-year tumor-free rates (Kaplan-Meier analysis) were 80% for primary tumors and 56% for recurrent tumors. Using MMS, the salvage rate (and, hence, overall cure rate) was 100%. Margins of 5 cm were required to clear 97% of the tumors. The recurrence rate after non-MMS (from the literature) is 33% to 60%. Conclusion MMS is effective, and superior to standard surgical management in the treatment of EMPD. We recommend a 5-cm margin of normal skin if MMS cannot be offered.

John A. Zitelli

Papers

Surgical margins for excision of primary cutaneous squamous cell carcinoma.

The Bilobed Flap for Nasal Reconstruction

Local control of primary Merkel cell carcinoma: Review of 45 cases treated with Mohs micrographic surgery with and without adjuvant radiation

Mohs micrographic surgery: A cost analysis

Extramammary Paget's Disease: Surgical Treatment With Mohs Micrographic Surgery