CLOSE MARGIN EXCISION OUTCOMES IN (NON … Inclusion / Exclusion and Long Term Clinical Management...
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INTRODUCTION Background Non-Melanoma Skin Cancer (NMSC, ICD10 C44) is the most common malignancy in white populations 1 , with at least 100,000 cases in the UK each year 2 , 8,000 in Scotland 3 . It is usually categorized by histological type as Basal Cell Carcinoma (BCC), Squamous Cell Carcinoma (SCC), or others. NMSC Management is predominantly surgical, and recurrence rates approximate 3% for SCC and 5% for completely excised BCCs 4 . Even in cases of incomplete BCC excision, only 39% recur 5 . Estimated mortality rates are less than 1%, almost entirely in cases of SCC 2,4 . Followup of these patients is heterogeneous 6,7 . Our own clinical practice has been that when histology confirms a completely excised SCC, the patients are reviewed for a period of 2 years. In BCCs we have to date (with certain provisos) discharged any cases with excision margins of 1mm or more. Aim To reduce unnecessary follow-up after NMSC excisions, by identifying those patients likely to require further surgery. METHODS Patient Selection : Pathology database records were used to identify all NMSC excisions (n=1,223) conducted within our department between Jan 1991 and Dec 2007. Data Collection : Pathology report data was was obtained, including diagnosis, site, size, BCC morphology, SCC differentiation, and excision margins. Cases of close excision (complete excisions, but with less than 1mm clearance laterally or deep) with follow-up for at least 18 months were selected for casenote review. Additional data collected included post operative followup, further management and later pathology findings. Ethics : Institutional Caldicott Guardian approval was obtained for the study. Statistical Methods : Data was summarized, and Kaplan Meier Survival Analysis was used to determine the number needed to follow up for 2 years to detect one recurrence. RESULTS Study Flow / Demographics Case Inclusion / Exclusion and Long Term Clinical Management are illustrated in the flow chart opposite. Patient demographics and lesion characteristics for all cases and for the close excision subgroup are illustrated in Boxes 1 and 2 respectively. Follow Up Analysis Kaplan Meier Survival analysis determined that it would be necessary to follow up 34 patients for 2 years to detect one recurrence in the close margin subgroup. DISCUSSION Inverness has a large, rural catchment area, with a relatively static population. At the same time, there are virtually no other centers within 3 hours of traveling that a patient could attend. For these reasons, we believe our data is an accurate reflection of the long term outcome of these cases. All patients should be empowered to self monitor, and written advice / illustrations would seem important. Patients, their carers and primary care doctors should be aware of the availability of further review. We suspect our findings are transferable to other settings (and countries), but have no specific data to support this. Variations in pathological processing and reporting are perhaps more likely than geographic variations in lesion behavior 8 . CONCLUSION We conclude that neither long term follow up nor further excision is indicated when pathology demonstrates close margins (<1mm), but there are certain exceptions that must be made: 1.The incidence of SCC is less than BCC, so our data for this group is more limited. There is also a higher risk with potential for regional and distal spread. We do not feel we can make any overall recommendation with regard to their followup, although our findings suggest that their risk of recurrence is also low. 2.Certain BCC groups have higher risks of recurrence and should be followed up indefinitely. In our own practice, this has included patients with Gorlinʼs Syndrome, those receiving immunosuppressive therapy, and an occasional patient with widespread sun induced damage and recurrent lesions. CLOSE MARGIN EXCISION OUTCOMES IN (NON-MELANOMA) HEAD AND NECK SKIN CANCER M.L. BARNES, S.K. ROSS, A.J. BARNES, L.G. MCCLYMONT. RAIGMORE HOSPITAL, INVERNESS, SCOTLAND. CONTACT: MR. MARTYN L. BARNES. EMAIL: [email protected] ABSTRACT Objectives 1.Determine clinical and histological outcomes for patients following close margin excisions of head and neck skin cancer. 2.Guide decisions regarding further intervention and follow-up. Methods Retrospective review of Otolaryngology department skin excisions from 1991 to 2008. Pathology reports and casenotes were reviewed to identify lesions excised with less than 1mm margins and determine their further management and outcome. Kaplan- Meier survival analysis was used to obtain the number needed to follow-up for 2 years (NNFU) to detect a recurrence. Results Of 1223 skin cancers, 1207 histology reports were obtained - 24% were squamous cell carcinomas, 76% were basal cell carcinomas. 1060 had histological (lateral and deep) margin assessments. Of these, 72.4% were complete, 16.1% close (<1mm) and 11.5% incomplete. 112 closely excised lesions were identified and 107 casenotes were obtained. 2 underwent ʻimmediateʼ further excision, both demonstrating no residual tumor. Of the remaining 105 subjects, 8 developed clinically suspected recurrence, but 5 were disproved histologically. During follow-up, 10 subjects had a new lesion diagnosed (9 malignant). 12 patients had new lesions diagnosed beyond followup; 6 were malignant. 104 (97%) of the original closely excised lesions did not require further excision within the studyʼs 4.1 years of observation (mean) following the initial procedure (range 1.5 - 12.1). The NNFU following close margin excisions was 34 (95% CI 16 to infinity). Conclusions In similar cases, close surgical margins will rarely indicate a need for further surgery or follow-up. Good quality patient advice leaflets and self monitoring is advised. Abbreviations BCC - Basal Cell Carcinoma NMSC - Non Melanoma Skin Cancer NNFU - Number Needed to Follow Up SCC - Squamous Cell Carcinoma Complete (64%) Close (14%) Incomplete (10%) Uncertain (8%) Biopsy Only (4%) 54 93 122 171 300 SCCs, n=292 BCCs, n=915 Differentiation Morphology Nose Pinna Cheek Forehead Temple Scalp Post-Auricular Neck Peri-Orbital Lip Mandible Unspecified 322 232 164 124 80 59 46 45 33 20 11 71 Box 1 - Subject Demographics and Lesion Characteristics all Excisions (n=1,207) 22 81 106 46 37 Early Well Moderately Poorly Not Reported 99 426 84 306 Infiltrative Nodular Superficial Not Reported 76% 24% 80 40 60 100 Age Distribution by Gender / years Women n=376 Men n=831 Lesion Size Distribution / mm Illustrates Quartiles of Largest Dimension Median Quartiles 0 90 30 60 Median Lesion Actual Size Box 2 - Subject Demographics and Lesion Characteristics Close Margin Excisions with 18 Month Follow Up (n=107) Nose Pinna Cheek Forehead Temple Scalp Post-Auricular Neck Peri-Orbital Lip Mandible Unspecified 48 12 10 8 7 4 4 6 10 1 0 2 SCCs, n=17 BCCs, n=90 Differentiation Morphology 1 8 5 3 Early Well Moderately Poorly Not Reported 13 38 8 31 Infiltrative Nodular Superficial Not Reported 84% 16% Lesion Size Distribution / mm Illustrates Quartiles of Largest Dimension Median Quartiles 0 90 30 60 Median Lesion Actual Size Men n=40 Women n=67 80 40 60 100 Age Distribution by Gender / years 1,264 NMSC Coded Pathology Specimens 17 Miscoded (Mucosal / Node Disease) 10 External Auditory Canal 14 Non Head & Neck 16 Pathology Reports Not Available 59 Without 18 Months Follow Up. 5 Unobtainable Notes. 2 Immediate Further Excisions - No Persistent Maligancy. 10 Discharged - None were referred back. 29 Reviewed for a single wound check - at 1 to 8 wks. 1 Returned (Referred from Primary Care) 20 months later. Recurrent BCC confirmed. 56 Further Followed Up - 48% to 1 Year, 11% to 2 Years. Clinical recurrence was suspected in 7 subjects. On further excision, 2 recurrent BCCs and 1 SCC were confirmed. The remainder were keloid, other benign or non-specific changes. 10 Discharged to Peripheral Hospital Follow Up. 1 Developed a clinical recurrence after 2.5 yrs. Pathology was benign. References 1. Trakatelli, M., et al., Epidemiology of nonmelanoma skin cancer (NMSC) in Europe: accurate and comparable data are needed for effective public health monitoring and interventions. Br J Dermatol, 2007. 156 Suppl 3: p. 1-7. 2. Toms, J.R., Cancer incidence, survival and mortality in the UK and EU, in CancerStats Monograph. 2004, Cancer Research UK: London. 3. Jensen, S., Cancer Incidence 2005. 2008, ISD Scotland: Edinburgh. 4. Mortality Statistics: Cause. England and Wales 2005, Office for National Statistics: London. 5. Improving Outcomes for People with Skin Tumours including Melanoma, in Cancer Service Guidance, National Institute for Health & Clinical Excellence: London. 6. Marghoob, A., et al., Risk of another basal cell carcinoma developing after treatment of a basal cell carcinoma. J Am Acad Dermatol, 1993. 28(1): p. 22-8. 7. Park, A.J., M. Strick, and J.D. Watson, Basal cell carcinomas: do they need to be followed up? J R Coll Surg Edinb, 1994. 39(2): p. 109-11. 8. Abide, J.M., F. Nahai, and R.G. Bennett, The meaning of surgical margins. Plast Reconstr Surg, 1984. 73(3): p. 492-7. Definitions Close Margin Excision - Complete Histological Excision, with lateral and / or deep margins of less than 1mm.
Transcript of CLOSE MARGIN EXCISION OUTCOMES IN (NON … Inclusion / Exclusion and Long Term Clinical Management...
INTRODUCTION
BackgroundNon-Melanoma Skin Cancer (NMSC, ICD10 C44) is the most common malignancy in white populations1, with at least 100,000 cases in the UK each year2, 8,000 in Scotland3. It is usually categorized by histological type as Basal Cell Carcinoma (BCC), Squamous Cell Carcinoma (SCC), or others.
NMSC Management is predominantly surgical, and recurrence rates approximate 3% for SCC and 5% for completely excised BCCs4. Even in cases of incomplete BCC excision, only 39% recur5. Estimated mortality rates are less than 1%, almost entirely in cases of SCC2,4.
Followup of these patients is heterogeneous6,7. Our own clinical practice has been that when histology confirms a completely excised SCC, the patients are reviewed for a period of 2 years. In BCCs we have to date (with certain provisos) discharged any cases with excision margins of 1mm or more.
AimTo reduce unnecessary follow-up after NMSC excisions, by identifying those patients likely to require further surgery.
METHODS
Patient Selection : Pathology database records were used to identify all NMSC excisions (n=1,223) conducted within our department between Jan 1991 and Dec 2007.
Data Collection : Pathology report data was was obtained, including diagnosis, site, size, BCC morphology, SCC differentiation, and excision margins. Cases of close excision (complete excisions, but with less than 1mm clearance laterally or deep) with follow-up for at least 18 months were selected for casenote review. Additional data collected included post operative followup, further management and later pathology findings.
Ethics : Institutional Caldicott Guardian approval was obtained for the study.
Statistical Methods : Data was summarized, and Kaplan Meier Survival Analysis was used to determine the number needed to follow up for 2 years to detect one recurrence.
RESULTS
Study Flow / DemographicsCase Inclusion / Exclusion and Long Term Clinical Management are illustrated in the flow chart opposite. Patient demographics and lesion characteristics for all cases and for the close excision subgroup are illustrated in Boxes 1 and 2 respectively.
Follow Up AnalysisKaplan Meier Survival analysis determined that it would be necessary to follow up 34 patients for 2 years to detect one recurrence in the close margin subgroup.
DISCUSSION
Inverness has a large, rural catchment area, with a relatively static population. At the same time, there are virtually no other centers within 3 hours of traveling that a patient could attend. For these reasons, we believe our data is an accurate reflection of the long term outcome of these cases.All patients should be empowered to self monitor, and written advice / illustrations would seem important. Patients, their carers and primary care doctors should be aware of the availability of further review.We suspect our findings are transferable to other settings (and countries), but have no specific data to support this. Variations in pathological processing and reporting are perhaps more likely than geographic variations in lesion behavior8.
CONCLUSION
We conclude that neither long term follow up nor further excision is indicated when pathology demonstrates close margins (<1mm), but there are certain exceptions that must be made:
1.The incidence of SCC is less than BCC, so our data for this group is more limited. There is also a higher risk with potential for regional and distal spread. We do not feel we can make any overall recommendation with regard to their followup, although our findings suggest that their risk of recurrence is also low.
2.Certain BCC groups have higher risks of recurrence and should be followed up indefinitely. In our own practice, this has included patients with Gorlinʼs Syndrome, those receiving immunosuppressive therapy, and an occasional patient with widespread sun induced damage and recurrent lesions.
CLOSE MARGIN EXCISION OUTCOMES IN (NON-MELANOMA) HEAD AND NECK SKIN CANCER
M.L. BARNES, S.K. ROSS, A.J. BARNES, L.G. MCCLYMONT.RAIGMORE HOSPITAL, INVERNESS, SCOTLAND.
CONTACT: MR. MARTYN L. BARNES. EMAIL: [email protected]
ABSTRACTObjectives1.Determine clinical and histological outcomes for patients following close margin excisions of head and neck skin cancer.2.Guide decisions regarding further intervention and follow-up.MethodsRetrospective review of Otolaryngology department skin excisions from 1991 to 2008. Pathology reports and casenotes were reviewed to identify lesions excised with less than 1mm margins and determine their further management and outcome. Kaplan-Meier survival analysis was used to obtain the number needed to follow-up for 2 years (NNFU) to detect a recurrence.ResultsOf 1223 skin cancers, 1207 histology reports were obtained - 24% were squamous cell carcinomas, 76% were basal cell carcinomas. 1060 had histological (lateral and deep) margin assessments. Of these, 72.4% were complete, 16.1% close (<1mm) and 11.5% incomplete. 112 closely excised lesions were identified and 107 casenotes were obtained. 2 underwent ʻimmediateʼ further excision, both demonstrating no residual tumor. Of the remaining 105 subjects, 8 developed clinically suspected recurrence, but 5 were disproved histologically. During follow-up, 10 subjects had a new lesion diagnosed (9 malignant). 12 patients had new lesions diagnosed beyond followup; 6 were malignant.104 (97%) of the original closely excised lesions did not require further excision within the studyʼs 4.1 years of observation (mean) following the initial procedure (range 1.5 - 12.1). The NNFU following close margin excisions was 34 (95% CI 16 to infinity).ConclusionsIn similar cases, close surgical margins will rarely indicate a need for further surgery or follow-up. Good quality patient advice leaflets and self monitoring is advised.
AbbreviationsBCC - Basal Cell CarcinomaNMSC - Non Melanoma Skin CancerNNFU - Number Needed to Follow UpSCC - Squamous Cell Carcinoma
Complete (64%)
Close (14%)
Incomplete (10%)
Uncertain (8%)
Biopsy Only (4%) 54
93
122
171
300
Not For POSTER
Vascular Invasion 4 / 124
Perineural Infiltration 3 / 113
Lymphatic Infiltration 2 / 65
BCC 915
SCC 292
Early 22 Infiltrative 99 Complete (64%) 300 0.6354598177
Well 81 Nodular 426 Close (14%) 171 0.1416735708
Moderately 106 Superficial 84 Incomplete (10%) 122 0.1010770505
Poorly 46 Not Reported 306 Uncertain (8%) 93 0.0770505385
Not Reported 37 Biopsy Only (4%) 54 0.0447390224
SCCs, n=292 BCCs, n=915
Differentiation MorphologySize - Greatest Dimension / mm Mean 25.1
SD 13.5
Min 2.0
25% 15.0
Median 22.0
75% 30.0
Max 90.0
X 2X
Size - Area / cm2 Mean 3.6
Assuming Rough Ellipse SD 4.1
Area = PI * A * B Min 0.0 0.082 0.163
25% 1.3 0.753 1.506
Ratio 4 to 3 Median 2.4 1.010 2.020
Area = PI * 3/4X^2 75% 4.3 1.355 2.710
X = ROOT (Area/(0.75*PI)) Max 38.5 4.041 8.083
X is the largest Dimension for the illustration (Radius so double!)X is the largest Dimension for the illustration (Radius so double!)X is the largest Dimension for the illustration (Radius so double!)X is the largest Dimension for the illustration (Radius so double!)
Area Plots Abandoned! - Just Median Illustration UsedArea Plots Abandoned! - Just Median Illustration UsedArea Plots Abandoned! - Just Median Illustration Used
Picture of
Face
with Illustrated
Zones
Nose
Pinna
Cheek
Forehead
Temple
Scalp
Post-Auricular
Neck
Peri-Orbital
Lip
Mandible
Unspecified
322
232
164
124
80
59
46
45
33
20
11
71
Box 1 - Subject Demographics and Lesion Characteristics
all Excisions (n=1,207)
22
81
106
46
37
Early
Well
Moderately
Poorly
Not Reported
99
426
84
306
Infiltrative
Nodular
Superficial
Not Reported
76%24%
8040 60 100
Age Distribution by Gender / years
Women
n=376
Men
n=831
Figure Will Be Over SizeFigure Will Be Over Size
Box Width
Original Size 26.11
On Poster 36.13
Actual Size Illustrations Need to be Undersize by same ratioActual Size Illustrations Need to be Undersize by same ratioActual Size Illustrations Need to be Undersize by same ratioActual Size Illustrations Need to be Undersize by same ratio
i.e. 0.7226681428 x Actual Size
= 1.4453362856 for Box 1
= 2.4932050927 for Box 2
Lesion Size Distribution / mm
Illustrates Quartiles of Largest Dimension
Median
Quartiles
0 9030 60
Median Lesion
Actual Size
Complete (64%)
Close (14%)
Incomplete (10%)
Uncertain (8%)
Biopsy Only (4%)
Not For POSTER
Box 2 - Subject Demographics and Lesion Characteristics
Close Margin Excisions with 18 Month Follow Up (n=107)
Nose
Pinna
Cheek
Forehead
Temple
Scalp
Post-Auricular
Neck
Peri-Orbital
Lip
Mandible
Unspecified
48
12
10
8
7
4
4
6
10
1
0
2
Vascular Invasion 1 / 4
Perineural Infiltration 0 / 3
Lymphatic Infiltration 0 / 2
BCC 94
SCC 18
Early 1 Infiltrative 13
Well 8 Nodular 38
Moderately 5 Superficial 8
Poorly 3 Not Reported 31
Not Reported 0
SCCs, n=17 BCCs, n=90
Differentiation MorphologySize - Greatest Dimension / mm Mean 23.0
SD 10.9
Min 6.0
25% 15.0
Median 20.0
75% 30.0
Max 60.0
X 2X
Size - Area / cm2 Mean 3.1
Assuming Rough Ellipse SD 3.3
Area = PI * A * B Min 0.3 0.365 0.730
25% 1.2 0.704 1.407
Ratio 4 to 3 Median 7.0 1.724 3.447
Area = PI * 3/4X^2 75% 4.0 1.296 2.592
X = ROOT (Area/(0.75*PI)) Max 21.2 3.000 6.000
X is the largest Dimension (Radius so double!)X is the largest Dimension (Radius so double!)
Area Plots Abandoned! - Just Median Illustration UsedArea Plots Abandoned! - Just Median Illustration UsedArea Plots Abandoned! - Just Median Illustration Used
SURGICAL PROCEDURE TYPE -
NOTE NK for 5 unobtainable
casenotes
1
8
5
3
Early
Well
Moderately
Poorly
Not Reported
13
38
8
31
Infiltrative
Nodular
Superficial
Not Reported
84%16%
Lesion Size Distribution / mm
Illustrates Quartiles of Largest Dimension
Median
Quartiles
0 9030 60
Median Lesion
Actual Size
Men
n=40
Women
n=67
8040 60 100
Age Distribution by Gender / years
1,264 NMSC Coded Pathology Specimens 17 Miscoded (Mucosal / Node Disease)10 External Auditory Canal
14 Non Head & Neck16 Pathology Reports Not Available
59 Without 18 Months Follow Up.
5 Unobtainable Notes.
2 Immediate Further Excisions - No Persistent Maligancy.
10 Discharged - None were referred back.
29 Reviewed for a single wound check - at 1 to 8 wks.1 Returned (Referred from Primary Care) 20 months later.
Recurrent BCC confirmed.
56 Further Followed Up - 48% to 1 Year, 11% to 2 Years. Clinical recurrence was suspected in 7 subjects.
On further excision, 2 recurrent BCCs and 1 SCC were confirmed. The remainder were keloid, other benign or non-specific changes.
10 Discharged to Peripheral Hospital Follow Up.1 Developed a clinical recurrence after 2.5 yrs.
Pathology was benign.
References1. Trakatelli, M., et al., Epidemiology of nonmelanoma skin cancer (NMSC) in Europe: accurate and comparable data
are needed for effective public health monitoring and interventions. Br J Dermatol, 2007. 156 Suppl 3: p. 1-7.2. Toms, J.R., Cancer incidence, survival and mortality in the UK and EU, in CancerStats Monograph. 2004, Cancer
Research UK: London.3. Jensen, S., Cancer Incidence 2005. 2008, ISD Scotland: Edinburgh.4. Mortality Statistics: Cause. England and Wales 2005, Office for National Statistics: London.5. Improving Outcomes for People with Skin Tumours including Melanoma, in Cancer Service Guidance, National
Institute for Health & Clinical Excellence: London.6. Marghoob, A., et al., Risk of another basal cell carcinoma developing after treatment of a basal cell carcinoma. J
Am Acad Dermatol, 1993. 28(1): p. 22-8.7. Park, A.J., M. Strick, and J.D. Watson, Basal cell carcinomas: do they need to be followed up? J R Coll Surg
Edinb, 1994. 39(2): p. 109-11.8. Abide, J.M., F. Nahai, and R.G. Bennett, The meaning of surgical margins. Plast Reconstr Surg, 1984. 73(3): p.
492-7.DefinitionsClose Margin Excision - Complete Histological Excision, with lateral and / or deep margins of less than 1mm.
