Elsevier

Current Surgery

Volume 62, Issue 5, September–October 2005, Pages 518-526
Current Surgery

Original report
Surgical Margins in the Treatment of Nonmelanoma Skin Cancer and Mohs Micrographic Surgery

https://doi.org/10.1016/j.cursur.2005.01.003Get rights and content

Traditional surgical treatment of nonmelanoma skin cancer includes excision with subsequent evaluation of surgical margins, either via frozen sections intraoperatively or after excision and closure. Accurate communication between surgeon and pathologist regarding the meaning of surgical margins should be confirmed. Recurrences of tumor growth may in part be attributed to asymmetrical tumor growth patterns with extension of tumor in an unanticipated direction. Mohs micrographic surgery is an outpatient procedure that maximizes surgical margin evaluation while minimizing the amount of tissue that must be excised. This article will discuss the concept of surgical margins in excisions of nonmelanoma skin cancer and the role of Mohs micrographic surgery.

Introduction

Skin cancer (melanoma and nonmelanoma) is the most common type of cancer.1 Nonmelanoma skin cancer is composed of numerous types of malignant skin tumors; however, approximately 95% consist of basal cell and squamous cell carcinoma.2, 3 Other less common types of nonmelanoma skin cancer include Merkel cell carcinoma, dermatofibrosarcoma protuberans, atypical fibroxanthoma, angiosarcoma, and other adnexal/glandular carcinomas.2 Previous reports estimated over 600,000 new cases of nonmelanoma skin cancers are diagnosed and treated annually in the United States alone.1 More recent studies report numbers approaching 1.3 million cases annually, which reflect the increasing prevalence.4 The annual Medicare expenditure for nonmelanoma skin cancer is estimated at $562 million or 4.5% of all cancer expenditures, which makes this the fifth most costly cancer.5, 6

Although advances in molecular genetics have localized mutations for numerous nonmelanoma skin cancers, the cause remains both multifactorial and complex.7 In addition, environmental (ultraviolet radiation) and lifestyle factors, as well as an aging population, certainly play a key part.3, 7 Mutations in tumor suppressor genes and oncogenes have been identified to play a role in some nonmelanoma skin cancers.

Section snippets

Nonmelanoma skin cancer

Basal cell and squamous cell carcinoma are the most common types of cancer.2 These two types of skin cancer can both cause significant local destruction. Basal cell carcinoma is rarely metastatic, with a reported incidence of 0.0028% to 0.55%.8, 9, 10 Although variable, the risk of metastasis for squamous cell carcinoma is greater and estimated to approximate 5%, with a range of 0.5% to 6%, and some reports ranging up to 16%.11, 12, 13 Squamous cell carcinoma of the lip carries a greater risk

Surgical margins

The concept of surgical margins is central in the surgical treatment of cutaneous neoplasms. Confusion regarding this concept results in a lack of consistency in the histologic interpretation of surgical margins.29, 30, 31, 32 This problem stresses the importance of communication between surgeon and pathologist.29, 30, 31, 32 Multiple methods exist for grossing histologic specimens; it is therefore important for the surgeon to be aware of these methods and their implications.

The term “margin”

Mohs micrographic surgery

The Mohs micrographic surgery technique has been extensively reported (FIGURE 7, FIGURE 8).1, 35, 36, 37 Briefly, after the initial biopsy report of cancer is confirmed, Mohs micrographic surgery may be performed. Excision is performed under local anesthesia with narrow margins (typically 1 to 4 mm) depending on anatomic site and tumor type. Unlike standard excision, the excision is performed at a 45° angle to allow for histopathologic examination of the lateral tumor edges (Fig. 3). After

Summary

An understanding of surgical margins is a critical component of oncologic surgery. Appropriate communication between surgeon and pathologist allows the surgeon to better understand the resultant report. Routine histologic margin evaluation of tissue specimens is not always sufficient as the entire surgical margin is not evaluated. Mohs micrographic surgery allows evaluation of the entire surgical margin with sparing of noninvolved tissue. This technique may be used by surgeons for a multitude

Acknowledgement

We would like to acknowledge Brian C. Brockway, M.S. of the Department of Medical Photography and Illustration at the Veteran’s Affairs Medical Center in Augusta, Georgia for illustrations.

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