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Original Investigation |

Suggested Excisional Margins for Cutaneous Malignant Lesions Based on Mohs Micrographic Surgery

Amy E. Schell, MD1; Mark A. Russell, MD2; Stephen S. Park, MD3
[+] Author Affiliations
1School of Medicine, University of Virginia, Charlottesville
2Department of Dermatology, University of Virginia, Charlottesville
3Department of Otolaryngology–Head and Neck Surgery, University of Virginia, Charlottesville
JAMA Facial Plast Surg. 2013;15(5):337-343. doi:10.1001/jamafacial.2013.1011.
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Published online

Importance  Surgical excision of skin cancer is a common treatment, yet the proper surgical margin remains unclear. This study reviews data on lesions and their margins as defined by Mohs micrographic surgery.

Objective  To review margins as defined by Mohs micrographic surgery.

Design  Retrospective review of data from patients with skin cancer.

Setting  Academic medical center.

Participants  All patients with nonmelanoma skin cancer.

Main Outcome and Measure  Size and final defect size were compared to calculate the margins needed. All lesions were categorized based on histologic characteristics.

Results  A total of 495 lesions were reviewed. All tumors and defects had precise measurements. The mean margins for low-risk basal cell carcinomas, high-risk basal cell carcinomas, low-risk squamous cell carcinomas, and high-risk squamous cell carcinomas were 2.4 mm, 3.7 mm, 2.6 mm, and 5.3 mm, respectively. Statistical differences in surgical margins were found between all low- and high-risk cancer types. Established high-risk zones (H-zone) for basal cell carcinoma and squamous cell carcinoma were not associated with larger margins. Margins required to excise completely 95% of all the low-risk basal cell carcinomas, high-risk basal cell carcinomas, low-risk squamous cell carcinomas, and high-risk squamous cell carcinomas, were 4.75 mm, 8 mm, 5 mm, and 13.25 mm, respectively.

Conclusions and Relevance  Differences are noted between low- and high-risk cutaneous lesions. When primary excision instead of Mohs micrographic surgery is the only option, the aforementioned margins may be considered guidelines. The relevance of this study is to guide future management and margins for primary excision.

Level of Evidence  3.

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Figures

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Figure 1.
Squamous Cell Carcinoma (SCCA) High-Risk Zone

High-risk areas for SCCA are highlighted in blue.

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Figure 2.
Surgical Margin Estimation Based on Lesion and Defect Measurements

Lesions and defects were measured with length and width reported. They were averaged. The surgical margin, m, is half of the difference between lesion and defect diameters. Surgical margin, m, was then calculated as half of the difference between lesion and defect diameters.

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Figure 3.
High-Risk Squamous Cell Carcinoma

Before (A) and after (B) removal with Mohs micrographic surgery. This lesion was deemed to be high risk owing to its recurrent nature. Previous undermining was performed in left cheek.

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Figure 4.
Poorly Differentiated Squamous Cell Carcinoma (SCCA)

Poorly differentiated SCCA tumor cells (thin arrows) are arranged haphazardly throughout the dermis and no longer produce keratin. Note the nerve fiber encircled by SCCA tumor cells (thick arrow). A normal hair follicle is indicated by the open arrow (hematoxylin-eosin, original magnification ×10).

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Figure 5.
Low-Risk Basal Cell Carcinoma (BCCA)

Before (A) and after (B) removal with Mohs micrographic surgery (MMS). Low-risk BCCA (small size, nodular histologic subtype, nonrecurrent) of the left temple before and after removal with MMS.

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Figure 6.
Nodular Basal Cell Carcinoma (BCCA)

Nodular subtype consisting of a relatively uniform, cohesive group of cancer cells. Note the peripheral palisading (thin arrow) and stromal retraction (thick arrow); both features are commonly seen with nodular BCCA (hematoxylin-eosin, original magnification ×10).

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Figure 7.
High-Risk Basal Cell Carcinoma (BCCA) of the Right Ala

Before (A) and after (B) removal with Mohs micrographic surgery. High-risk BCCA owing to infiltrative pathologic findings.

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Figure 8.
Infiltrative Basal Cell Carcinoma

Tumor islands (thin arrows) are irregularly spaced and extend deeply into the dermis (thick arrow). An area of solar elastosis is encircled; this is indicative of dermal tissue abnormality owing to sun exposure (hematoxylin-eosin, original magnification ×10).

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Figure 9.
Superficial Basal Cell Carcinoma (BCCA)

Note the superficial, yet unpredictably spaced, islands of tumor cells (thin arrows) that are characteristic for this BCCA subtype. This does not always result in an obvious sharp clinical margin (hematoxylin-eosin, original magnification ×10).

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