Squamous cell carcinoma of the skin surgery: Difference between revisions

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{{Squamous cell carcinoma}}
{{Squamous cell carcinoma}}
{{CMG}}; '''Associate Editor(s)-in-Chief:''' [[User:Aditya Govindavarjhulla|Aditya Govindavarjhulla, M.B.B.S.]] [mailto:agovi@wikidoc.org], [[User:Raviteja Reddy Guddeti|Raviteja Guddeti, M.B.B.S.]] [mailto:ravitheja.g@gmail.com]
{{CMG}}; {{AE}} [[User:Aditya Govindavarjhulla|Aditya Govindavarjhulla, M.B.B.S.]] [mailto:agovi@wikidoc.org], [[User:Raviteja Reddy Guddeti|Raviteja Guddeti, M.B.B.S.]] [mailto:ravitheja.g@gmail.com] {{RAK}}


== Overview ==
== Overview ==
Surgery is the most widely used management of choice for high risk [[Squamous cell carcinomas]] (SCC). Two types of Surgical methods exist which are Surgical excision and Moh's micrographic surgery.
Surgery is the mainstay of therapy for squamous cell carcinoma of the skin.


== Surgery ==
== Surgery ==
* Squamous cell carcinoma are most commonly treated with surgery or radiation therapy
* Surgery is the mainstay of therapy for squamous cell carcinoma of the skin:<ref name="pmid26219687">{{cite journal| author=Stratigos A, Garbe C, Lebbe C, Malvehy J, del Marmol V, Pehamberger H et al.| title=Diagnosis and treatment of invasive squamous cell carcinoma of the skin: European consensus-based interdisciplinary guideline. | journal=Eur J Cancer | year= 2015 | volume= 51 | issue= 14 | pages= 1989-2007 | pmid=26219687 | doi=10.1016/j.ejca.2015.06.110 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26219687  }}</ref>
* However, consideration of function, cosmetic outcome, and patient preference may cause RT to be chosen as primary treatment to achieve optimal overall results. The algorithms list all of the therapies currently used to treat localized NMSC, including surgical techniques (i.e., curettage and electrodesiccation, excision with postoperative margin assessment [POMA], Mohs surgery or excision with “complete circumferential peripheral and deep-margin assessment” [CCPDMA]), RT, and superficial therapies.<ref name="pmid26219687">{{cite journal| author=Stratigos A, Garbe C, Lebbe C, Malvehy J, del Marmol V, Pehamberger H et al.| title=Diagnosis and treatment of invasive squamous cell carcinoma of the skin: European consensus-based interdisciplinary guideline. | journal=Eur J Cancer | year= 2015 | volume= 51 | issue= 14 | pages= 1989-2007 | pmid=26219687 | doi=10.1016/j.ejca.2015.06.110 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26219687  }}</ref>
** '''Standard excision with wide margins'''
* urettage and Electrodesiccation
*** Not the preferred method for surgical removal of high-risk squamous cell carcinoma of the skin<ref name="pmid27882625">{{cite journal| author=Skulsky SL, O'Sullivan B, McArdle O, Leader M, Roche M, Conlon PJ et al.| title=Review of high-risk features of cutaneous squamous cell carcinoma and discrepancies between the American Joint Committee on Cancer and NCCN Clinical Practice Guidelines In Oncology. | journal=Head Neck | year= 2017 | volume= 39 | issue= 3 | pages= 578-594 | pmid=27882625 | doi=10.1002/hed.24580 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27882625  }}</ref>
* Excision With Postoperative Margin Assessment
*** It is the first-line treatment for low risk squamous cell carcinoma of the skin.
* Regional Lymph Node Dissection
*** The standard excision for low risk squamous cell carcinoma should include a margin of at least 4 to 6 mm.
For patients with squamous cell carcinoma, regional nodal involvement significantly increases the risk of recurrence and mortality.116 If there are positive findings on either FNA or open biopsy of a lymph node, the preferred treatment is regional lymph node dissection following the corresponding pathway for the head and neck region (see page 845) or the trunk and extremity region (see page 846). Radiation alone is an alternative when surgery is not initially feasible; however, after radiation, patients should be reevaluated for neck dissection candidacy
*** While for high risk squamous cell carcinoma lesions, the European Dermatology Forum, the European Association of Dermato-Oncology, and the European Organization for Research and Treatment of Cancer suggest a margin of 10 mm.<ref name="pmid262196872">{{cite journal| author=Stratigos A, Garbe C, Lebbe C, Malvehy J, del Marmol V, Pehamberger H et al.| title=Diagnosis and treatment of invasive squamous cell carcinoma of the skin: European consensus-based interdisciplinary guideline. | journal=Eur J Cancer | year= 2015 | volume= 51 | issue= 14 | pages= 1989-2007 | pmid=26219687 | doi=10.1016/j.ejca.2015.06.110 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26219687  }}</ref>
* [[Surgical excision]] is the most widely used treatment of choice in high risk SCCs. It is well tolerated, extremely effective and completeness of the procedure can be confirmed by assessing the margins of the lesion histologically. Deeply invasive and metastatic lesion require more wide excision and exploration of the adjacent nodes. Cure rates with method approach 92% and 77% for primary and recurrent SCCs at the end of 5 years. Well defined, small (< 2 cm) lesions without any high risks the margin of the normal tissue around the tumor mass that is required during excision is 4mm. For larger, high risk lesions the margin has to be wide to make sure no residual lesion is left over after excision.
*** Surgeon must utilize a primary or delayed closure to allow for further excision with CCPDMA if margins are positive.
* [[Moh's micrographic surgery]] is particularly effective for  high-risk localized cutaneous SCCs and SCCs located in cosmetically sensitive or critical areas because of its high cure rate and ability to spare normal tissue. 5 year cure rates for primary and recurrent tumors are 97% and 90% - 94% respectively. It is performed in the out patient setting and is well tolerated.<ref>{{cite journal |author=Drake LA, Dinehart SM, Goltz RW, ''et al.'' |title=Guidelines of care for Mohs micrographic surgery. American Academy of Dermatology |journal=J. Am. Acad. Dermatol. |volume=33 |issue=2 Pt 1 |pages=271–8 |year=1995 |month=August |pmid=7622656 |doi= |url=}}</ref> The procedure is performed in stages and the lesion is excised at an oblique angel along with a small rim of normal tissue. Histological assessment is then done and if the margins of the specimen test positive for tumor cells the locations are noted on Mohs map and a repeat procedure is done in the involved area itself and this process is repeated until the margins are clear of any tumor cells. This procedure is some what prolonged and take 2-4 hrs to complete. While [[Mohs surgery]] is frequently utilized and often considered the treatment of choice for squamous cell carcinoma of the skin, physicians have utilized the method for the treatment of squamous cell carcinoma of the mouth, throat, and neck.<ref>Gross, K.G., et al. Mohs Surgery, Fundamentals and Techniques. 1999, Mosby.</ref>
*** In case of incomplete excision, a repeat standard excision is needed or Moh's micrographic surgery should be performed.
** '''Moh's micrographic surgery'''
*** is particularly effective for  high-risk localized cutaneous SCCs and SCCs located in cosmetically sensitive or critical areas because of its high cure rate and ability to spare normal tissue.  
*** 5 year cure rates for primary and recurrent tumors are 97% and 90% - 94% respectively. It is performed in the out patient setting and is well tolerated.<ref>{{cite journal |author=Drake LA, Dinehart SM, Goltz RW, ''et al.'' |title=Guidelines of care for Mohs micrographic surgery. American Academy of Dermatology |journal=J. Am. Acad. Dermatol. |volume=33 |issue=2 Pt 1 |pages=271–8 |year=1995 |month=August |pmid=7622656 |doi= |url=}}</ref>  
*** The procedure is performed in stages and the lesion is excised at an oblique angel along with a small rim of normal tissue. Histological assessment is then done and if the margins of the specimen test positive for tumor cells the locations are noted on Mohs map and a repeat procedure is done in the involved area itself and this process is repeated until the margins are clear of any tumor cells.  
*** This procedure is some what prolonged and take 2-4 hrs to complete. While [[Mohs surgery]] is frequently utilized and often considered the treatment of choice for squamous cell carcinoma of the skin, physicians have utilized the method for the treatment of squamous cell carcinoma of the mouth, throat, and neck.<ref>Gross, K.G., et al. Mohs Surgery, Fundamentals and Techniques. 1999, Mosby.</ref>
** Surgical excision with complete circumferential peripheral and deep margin assessment (CCPDMA)
*** An alternative to Mohs surgery
*** Involves the examination of the entire margin of the tissue specimen by a pathologist
*** Histopathologic examination may be performed intraoperatively with frozen sections or with permanent sections and delayed wound closure
*** Typically performed for advanced tumors that are best approached under general anesthesia due to large tumor size or great depth
** '''Curettage and Electrodesiccation'''
* [[Electrosurgery|'''Electrosurgery''']]
**Used for small lesions, well defined and located in non-critical areas of the body
**Cost-effective
**Gives favorable cosmetic results
**Low complication rate
**The procedure is performed by alternatively curetting away tumor and then electrodessicating the ulcer base with inclusion of a rim of normal surrounding skin.
**Cure rates of nearly 96% can be achieved with this treatment provide the lesion is small and well defined.
**This treatment should be avoided on the mid-face region.
**It is contraindicated in recurrent, large, poorly defined, and other high risk SCCs.


==References==
==References==

Latest revision as of 13:55, 14 June 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2], Raviteja Guddeti, M.B.B.S. [3] Roukoz A. Karam, M.D.[4]

Overview

Surgery is the mainstay of therapy for squamous cell carcinoma of the skin.

Surgery

  • Surgery is the mainstay of therapy for squamous cell carcinoma of the skin:[1]
    • Standard excision with wide margins
      • Not the preferred method for surgical removal of high-risk squamous cell carcinoma of the skin[2]
      • It is the first-line treatment for low risk squamous cell carcinoma of the skin.
      • The standard excision for low risk squamous cell carcinoma should include a margin of at least 4 to 6 mm.
      • While for high risk squamous cell carcinoma lesions, the European Dermatology Forum, the European Association of Dermato-Oncology, and the European Organization for Research and Treatment of Cancer suggest a margin of 10 mm.[3]
      • Surgeon must utilize a primary or delayed closure to allow for further excision with CCPDMA if margins are positive.
      • In case of incomplete excision, a repeat standard excision is needed or Moh's micrographic surgery should be performed.
    • Moh's micrographic surgery
      • is particularly effective for high-risk localized cutaneous SCCs and SCCs located in cosmetically sensitive or critical areas because of its high cure rate and ability to spare normal tissue.
      • 5 year cure rates for primary and recurrent tumors are 97% and 90% - 94% respectively. It is performed in the out patient setting and is well tolerated.[4]
      • The procedure is performed in stages and the lesion is excised at an oblique angel along with a small rim of normal tissue. Histological assessment is then done and if the margins of the specimen test positive for tumor cells the locations are noted on Mohs map and a repeat procedure is done in the involved area itself and this process is repeated until the margins are clear of any tumor cells.
      • This procedure is some what prolonged and take 2-4 hrs to complete. While Mohs surgery is frequently utilized and often considered the treatment of choice for squamous cell carcinoma of the skin, physicians have utilized the method for the treatment of squamous cell carcinoma of the mouth, throat, and neck.[5]
    • Surgical excision with complete circumferential peripheral and deep margin assessment (CCPDMA)
      • An alternative to Mohs surgery
      • Involves the examination of the entire margin of the tissue specimen by a pathologist
      • Histopathologic examination may be performed intraoperatively with frozen sections or with permanent sections and delayed wound closure
      • Typically performed for advanced tumors that are best approached under general anesthesia due to large tumor size or great depth
    • Curettage and Electrodesiccation
  • Electrosurgery
    • Used for small lesions, well defined and located in non-critical areas of the body
    • Cost-effective
    • Gives favorable cosmetic results
    • Low complication rate
    • The procedure is performed by alternatively curetting away tumor and then electrodessicating the ulcer base with inclusion of a rim of normal surrounding skin.
    • Cure rates of nearly 96% can be achieved with this treatment provide the lesion is small and well defined.
    • This treatment should be avoided on the mid-face region.
    • It is contraindicated in recurrent, large, poorly defined, and other high risk SCCs.

References

  1. ↑ Stratigos A, Garbe C, Lebbe C, Malvehy J, del Marmol V, Pehamberger H; et al. (2015). "Diagnosis and treatment of invasive squamous cell carcinoma of the skin: European consensus-based interdisciplinary guideline". Eur J Cancer. 51 (14): 1989–2007. doi:10.1016/j.ejca.2015.06.110. PMID 26219687.
  2. ↑ Skulsky SL, O'Sullivan B, McArdle O, Leader M, Roche M, Conlon PJ; et al. (2017). "Review of high-risk features of cutaneous squamous cell carcinoma and discrepancies between the American Joint Committee on Cancer and NCCN Clinical Practice Guidelines In Oncology". Head Neck. 39 (3): 578–594. doi:10.1002/hed.24580. PMID 27882625.
  3. ↑ Stratigos A, Garbe C, Lebbe C, Malvehy J, del Marmol V, Pehamberger H; et al. (2015). "Diagnosis and treatment of invasive squamous cell carcinoma of the skin: European consensus-based interdisciplinary guideline". Eur J Cancer. 51 (14): 1989–2007. doi:10.1016/j.ejca.2015.06.110. PMID 26219687.
  4. ↑ Drake LA, Dinehart SM, Goltz RW; et al. (1995). "Guidelines of care for Mohs micrographic surgery. American Academy of Dermatology". J. Am. Acad. Dermatol. 33 (2 Pt 1): 271–8. PMID 7622656. Unknown parameter |month= ignored (help)
  5. ↑ Gross, K.G., et al. Mohs Surgery, Fundamentals and Techniques. 1999, Mosby.


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