Dermatologic surgery
Outcomes in intermediate-risk squamous cell carcinomas treated with Mohs micrographic surgery compared with wide local excision

https://doi.org/10.1016/j.jaad.2019.12.049Get rights and content

Background

Brigham and Women's Hospital stage T2a squamous cell carcinomas, demonstrating a single high-risk feature, have a low risk of metastasis and death but an increased risk of local recurrence. Little evidence exists for the best treatment modality and associated outcomes in T2a squamous cell carcinoma.

Objective

We aimed to compare outcomes for T2a squamous cell carcinoma treated by Mohs micrographic surgery compared with wide local excision with permanent sections.

Methods

Retrospective review of an institutional review board–approved single-institution registry of T2a squamous cell carcinoma.

Results

Three hundred sixty-six primary T2a tumors were identified, including 240 squamous cell carcinomas (65.6%) treated with Mohs micrographic surgery and 126 (34.4%) treated with wide local excision. A total of 32.5% of patients were immunosuppressed and mean oncologic follow-up was 2.8 years. Local recurrence was significantly more likely after wide local excision (4.0%) than after Mohs micrographic surgery (1.2%) (P = .03). Multiple logistic regression demonstrated immunocompromised state (odds ratio [OR] 5.1; 95% confidence interval [CI] 1.1-23.3; P = .03) and wide local excision (OR 4.8; 95% CI 1.1-21.6; P = .04) associated with local recurrence; and wide local excision (OR 7.8; 95% CI 2.4-25.4; P < .001), high-risk head and neck location (OR 8.3; 95% CI 1.8-38.7; P = .004), and poor histologic differentiation (OR 4.7; 95% CI 1.4-15.4; P = .03) associated with poor outcomes (overall recurrence or disease-specific death).

Conclusion

Mohs micrographic surgery provides improved outcomes in Brigham and Women's Hospital T2a squamous cell carcinoma.

Introduction

The majority of cutaneous squamous cell carcinomas are readily managed by various modalities, including electrodesiccation and curettage, wide local excision with routine permanent sections, and Mohs micrographic surgery, with low recurrence rates and minimal potential for poor outcomes. Much attention recently has been given to the management of high-risk tumors, especially in the setting of immunosuppression.1, 2, 3 However, variable definitions and staging systems have been applied to stratify tumor risk across studies.

Although the homogeneity (outcome similarity within stages) and monotonicity (outcome worsening with increasing stage) have been improved in the Brigham and Women's Hospital alternate staging system4 and in the updated eighth edition of the American Joint Committee on Cancer staging system compared with previous editions, poor outcomes continue to occur in low-stage tumors.5 Furthermore, staging systems rely on end points occurring with a relatively low frequency in daily practice, including nodal disease or recurrence, distant metastasis, and disease-specific death. In addition to metastasis, locoregional disease recurrence may also be important in contributing to squamous cell carcinoma morbidity, especially in advanced local recurrences in anatomically sensitive areas such as the head and neck. Comparative treatment data between conventional wide local excision and Mohs micrographic surgery are lacking. This knowledge gap is of significant clinical interest, especially in intermediate-risk tumors, which may most strongly benefit from Mohs micrographic surgery. Brigham and Women's Hospital stage T2a squamous cell carcinomas are tumors with a single feature deemed at high risk of a poor outcome (≥ 2 cm, poor differentiation, perineural invasion of nerves of ≥ 0.10-mm caliber, or invasion beyond fat). Although less frequently life threatening than their more aggressive counterparts (T2b and T3), the relative frequency with which T2a tumors are encountered in clinical practice is higher than that of more advanced stages (26%-41.3% of study cohorts).3,6 This higher frequency, combined with a higher local recurrence (5%-9%) than that of T1 squamous cell carcinomas (0.6%-2%), warrants dedicated study of the T2a tumor stage.4,6 Previous studies of T2a tumor behavior in mixed-treatment cohorts including wide local excision, Mohs micrographic surgery, and electrodessication and curettage demonstrate higher recurrence rates compared with that for T1 tumors.4, 5, 6 A recent study showed that Mohs micrographic surgery monotherapy is a highly efficacious treatment for squamous cell carcinoma,3 underscoring a possible role of surgical treatment modality in squamous cell carcinoma prognosis and outcomes. We aimed to study outcomes for intermediate-risk Brigham and Women's Hospital T2a squamous cell carcinomas treated by Mohs micrographic surgery compared with those treated by wide local excision with routine permanent sections.

Section snippets

Methods

An institutional review board–approved single-institution registry of patients receiving a diagnosis of invasive squamous cell carcinoma between January 1, 2010, and December 31, 2012, was used. Patients receiving a diagnosis of squamous cell carcinoma in situ, receiving adjuvant therapy (including postoperative radiation) after primary tumor treatment, or having incomplete medical records detailing diagnosis or treatment were excluded. All patients were otherwise included irrespective of

Results

A total of 366 primary T2a squamous cell carcinoma tumors were identified, including 240 tumors (65.6%) treated with Mohs micrographic surgery and 126 (34.4%) treated with wide local excision. The average patient age at diagnosis was 71.9 years. Most patients were men (68.6%) and 32.5% (N = 119) of the cohort was immunosuppressed. The mean follow-up time was 2.8 years (95% confidence interval [CI] 2.5-3.1 years; range 0.0-13.3 years). Characteristics of the entire T2a squamous cell carcinoma

Discussion

We present a comparative retrospective review of wide local excision versus Mohs micrographic surgery treatment arms for intermediate risk (Brigham and Women's Hospital stage T2a) squamous cell carcinoma. The benefit of Mohs micrographic surgery, even in higher-risk squamous cell carcinoma, has previously been reported.3,11 The Brigham and Women's Hospital staging system was chosen for our study because it was thought to be more inclusive than the American Joint Committee on Cancer eighth

Limitations

This study is limited by its retrospective nature and single tertiary care medical center setting. The 2 historical treatment arms were well matched in key variables. Where discrepancies existed, the Mohs micrographic surgery treatment arm had less favorable conditions, including a higher rate of immunosuppression and central facial high-risk head and neck anatomic location. Nevertheless, undocumented high-risk variables may have confounded treatment outcomes. Tumors lacking initial histologic

Conclusion

Treatment modality, tumor size, and tumor recurrence status are associated with increased local recurrence. Wide local excision has 3.3 times the risk of local recurrence compared with Mohs micrographic surgery for primary squamous cell carcinoma and 4.8 times the risk of local recurrence for recurrent squamous cell carcinoma. Mohs micrographic surgery provides superior long-term outcomes for patients with T2a squamous cell carcinoma and has a definitive role in the management of T2a tumors.

References (22)

  • J. Lanz et al.

    Aggressive squamous cell carcinoma in organ transplant recipients

    JAMA Dermatol

    (2019)
  • Cited by (24)

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      Mean MMS stages were 1.44, as previously published.17 Mean tumor size for T2a tumors was 2.6 cm (SD, 1.3).21 Closure probabilities were based on a previous study comparing MMS to WLE.22

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      MMS and SE are the mainstay of treatment for cSCC. No randomized control trials (RCT) have been conducted; therefore, treatment recommendations are frequently based on results of retrospective studies and availability.10,11,22,26 In addition to a lower cure rate, the most important downside of SE is to deal with incomplete excisions.

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      SCCs with a single high-risk feature have a low risk for metastasis and death but an increased risk of local recurrence. A recent study comparing outcomes for these intermediate-risk tumors, BWH T2a, found that MMS provided improved outcomes when compared to WLE with permanent sections.99 Treatment of SCC with MMS has shown superior cure rates than WLE, and local recurrences occur less frequently when SCC is treated by MMS, demonstrating to be a highly effective modality in the treatment of these tumors.5,98

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    Funding sources: None.

    Conflicts of interest: None disclosed.

    This study was IRB approved.

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