7. Surgical treatment

From Clinical Guidelines Wiki


Introduction

Most basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCCs) are managed by surgical treatment options, most commonly by simple surgical procedures. However, nonsurgical modalities are an alternative for selected, clinically favourable lesions.

Compared with non-surgical modalities, well-performed surgery has the advantage of providing a complete specimen for both histologic confirmation of the diagnosis and the adequacy of excision, and is associated with a high rate of local control. Complete excision can be expected to cure the majority of tumours.

However, surgery can cause unnecessary morbidity because of technique, or when alternative treatments may have achieved a better aesthetic outcome. Likewise, nonsurgical modalities can cause unnecessary morbidity when surgery should have been the preferred option. Treating practitioners should work within their capabilities or refer.

Some cSCCs behave aggressively, resulting in extensive tissue destruction, regional spread, or both. High-risk cSCC is biologically distinct and needs special management.[1] Longstanding BCCs can also be highly destructive. Surgery, encompassing a range of techniques, remains the primary treatment modality for many of these lesions. Some may necessitate extensive resections. Radiotherapy and biologic treatments also play a role.

The challenge is to adequately manage all tumours and select the most effective modality, while giving the patient the most aesthetic and functional outcome appropriate to their expected longevity. Clinicians treating patients with KC must be familiar with all modalities available, even though they may not be able to offer all of these themselves.

The advantages, disadvantages and the material risk of each treatment must be explained to the patient. ‘Material risk’ is defined as a risk that a reasonable person in the patient’s circumstances would be likely to attach significance to if warned of it, or that the medical practitioner is aware (or should reasonably be aware) that the particular patient would be likely to attach significance to if warned.[2] The most appropriate treatment should be offered that balances optimal long-term tumour control with aesthetic and functional outcome, and is acceptable to both patient and clinician.[3][4]

See also: Cryotherapy and electrodessication and curettage; Topical treatments and photodynamic therapy; Radiotherapy; Pathology.

Tumour recognition and biopsy

Tumour recognition and appropriate management are skills developed through experience as well as training. Before any treatment is undertaken that may cause morbidity, the lesion should be definitively recognised either clinically or histologically.

Clinical recognition

Experienced clinicians are likely to recognise KCs and be correct most of the time (see: Clinical features of keratinocyte cancer). The use of dermatoscopy may improve the clinical recognition of KCs.[5] However, clinical recognition is not always reliable,[6] and cannot always predict the behaviour or aggressiveness of all tumours.[6]

If the diagnosis is in doubt, appropriate biopsy is prudent (see: Pathology). Biopsy is highly recommended if surgical treatment is likely to result in significant tissue removal or resection of unique structures such as nose, eyelid, lip or ear.

Histologic confirmation with biopsy

If there is any doubt concerning the clinical diagnosis or the lesion is in a cosmetically sensitive location, an appropriate biopsy should be performed (see: Pathology).

A tumour’s management should be based on the worst part of its histopathology. Some tumour types coexist. The biopsy should contain sufficient tissue to permit accurate histologic diagnosis. An insufficient biopsy may not represent all tumour types in a lesion with a mixed pattern of pathology.

Biopsy itself can cause morbidity.

Complete excision biopsy is the preferred technique because it permits the pathologist to examine the architecture and cytological appearances of the tumour, assessment of its extent, and an assessment of adequacy of excision.

If complete excision biopsy is not possible or appropriate, incision biopsy can be considered, taking into account the size and depth of the lesion under consideration (Biopsy considerations and the biopsy report). Incision biopsies include shave biopsy, curettage and punch biopsy.

Shave biopsy is appropriate for many lesions, especially if there is a possibility that the lesion is benign, in which case a minimal mark should be left.

Curettage usually obtains a representative amount of tumour to minimise the chance of missing mixed patterns. However, it may disrupt the architecture and so compromise the histological examination, and it may miss other (such as infiltrative) parts of the tumour.

Punch biopsy is the most commonly used method, but the biopsy specimen may be unrepresentative, especially in larger tumours. It is useful for small lesions and lesions with a subcutaneous component, and to sample the deeper infiltrative or fibrosing parts of a tumour.[7]

The biopsy should be repeated if the pathologist or proceduralist suspects that it is inadequate or unrepresentative.

If multiple biopsies are performed, it is essential to label all specimens and to ensure that the site can be identified unambiguously at a later date. Photographs, diagrams, and detailed descriptions are all useful and should be employed as appropriate.

Before the patient leaves the procedure room, the pathology specimens should be checked to confirm that a specimen is in each container and that they are labelled correctly with the patient’s name and address as well as the surgical site.


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References

  1. Nehal KS, Bichakjian CK. Update on Keratinocyte Carcinomas. N Engl J Med 2018 Jul 26;379(4):363-374 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/30044931.
  2. Lee MR, Paver R. Prophylactic antibiotics in dermatological surgery. Australas J Dermatol 2016 May;57(2):83-91 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25752777.
  3. Charles AJ Jr, Otley CC, Pond GR. Prognostic factors for life expectancy in nonagenarians with nonmelanoma skin cancer: implications for selecting surgical candidates. J Am Acad Dermatol 2002 Sep;47(3):419-22 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12196753.
  4. Yélamos, O., Braun, R. P., Liopyris, K., Wolner, Z. J., Kerl, K., Gerami, P., & Marghoob, A. A.. Usefulness of dermoscopy to improve the clinical and histopathologic diagnosis of skin cancers. J Am Acad Derm 2019 Feb 1;80(2), 365-377 Abstract available at https://doi.org/10.1016/j.jaad.2018.07.072.
  5. 6.0 6.1 Terushkin, V. , Braga, J. C., Dusza, S. W., Scope, A. , Busam, K. , Marghoob, A. A., Gill, M. and Halpern, A. C.. Agreement on the Clinical Diagnosis and Management of Cutaneous Squamous Neoplasms. Derm Surg 2010 Aug 4;36: 1514-1520 Abstract available at https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1524-4725.2010.01675.x.
  6. Russell EB, Carrington PR, Smoller BR. Basal cell carcinoma: a comparison of shave biopsy versus punch biopsy techniques in subtype diagnosis. J Am Acad Dermatol 1999 Jul;41(1):69-71 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10411414.


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