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Delays in Mohs surgery may adversely affect outcomes for poorly-differentiated SCCs


Delays in Mohs surgery may adversely affect outcomes for poorly-differentiated squamous cell carcinomas.

Clinical Pearls

  • A 2-year single-center retrospective original study assessing non-melanoma skin cancer (NMSCs) growth rates and tumor factors.

  • For Squamous cell carcinomas (cSCC), increased tumor growth was associated with more aggressive histologic subtypes (p=.001), number of Mohs stages, and prior treatment (p=.002)

  • Authors estimated delays longer than 11 months may increase morbidity for cSCCs, especially those with with more aggressive histological subtype.


Discussion:

This single-center retrospective original study sought to determine how delays in Mohs micrographic surgery (MMS) for one surgeon between 2016-2018 correlated with tumor growth of non-melanoma skin cancers, primarily basal cell carcinomas (BCC) and cutaneous squamous cell carcinomas (cSCC). Only definitively diagnosed BCCs and cSCCs with known lesion sizes were included. Delays were measured in number of days between initial biopsy and MMS and change in tumor size was measured as difference in lesion size at biopsy versus size of postoperative MMS defect. Additional patient (e.g., age, prior treatment) and tumor characteristics (e.g., histologic subtype, anatomic location, size larger than ≥2.0cm) were used for multivariate analysis.


Among 1101 NMSCs from 889 patients, there was a median surgical delay of 48 days and a mean change in lesions diameter of 0.9 cm. cSCCs had a greater change in mean lesion size than BCC (median 0.9 cm vs 0.7 cm, p<.001) but the former required fewer MMS stages (mean 1.28 vs 1.38, p=.015).


Among the 299 cSCCs, independent predictors for change in lesion diameter included histologic subtype (p=.001), with more aggressive histologic subtypes having a greater effect on change in tumor size (p=.001) and number of Mohs stages, and prior treatment (p=.002). Among 802 BCCs, independent predictors included age (p=.001), male gender (p=.001), histologic subtype (p=.001), prior treatment (p=.001), and anatomic location (location L > M, p=.001).


Limitations of the study include limited generalizability given data was sourced from a single-site and single surgeon and extrapolation of time beyond ~48 days. Furthermore, retrospective nature of data limits causality between delay and tumor size.


Authors ultimately concluded a relationship was evident between surgical delay and tumor growth up to 0.2-0.3 cm/month for cSCCs, with increasing growth rates correlating with more aggressive histological subtype. Given delays in treatment were only exacerbated by COVID-19 practice regulations, authors note that delays exceeding 11 months may increase patient morbidity. These findings are particularly salient in the context of system wide delays as a result of the initial and on-going logistic and social limitations associated with COVID-19.[1] Dermatologists on an individual scale may find this information useful when in patient management to give priority to patients who a) may have already had an extended period of time between biopsy and planned surgery and b) who were diagnosed with poorly-differentiated and/or high-risk squamous cell carcinoma at initial biopsy.



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