Wee Edmund, Goh Michelle S, Estall Vanessa, Tiong Albert, Webb Angela, Mitchell Catherine, Murray William, Tran Phillip, McCormack Christopher J, Henderson Michael, Hiscutt Emma L
Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
Australas J Dermatol. 2018 Nov;59(4):302-308. doi: 10.1111/ajd.12779. Epub 2018 Jan 18.
BACKGROUND/OBJECTIVES: To describe the characteristics, subsequent management and outcomes of patients referred for further management following Mohs micrographic surgery (MMS) for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).
Retrospective analysis of patients referred to a quaternary cancer centre from 2000 to 2015.
In total, 83 lesions in 82 patients were referred for further management; 52 (62%) were SCC and 80 (96%) were located in the head and neck. Reasons for referral included high-risk disease for consideration for adjuvant radiotherapy (37/83, 45%), inadequate resection (28/83, 34%) or recurrence following previous MMS (15/83, 17%). Fewer than 40% of the 69 referrals received from MMS surgeons included photos or an operative report and diagram. There was discordance in pathology opinion in 11 (13%) of cases. Histopathology from MMS was reviewed in eight cases and there was discordance with the in-hospital pathology opinion in six of these. In-hospital re-excision was performed in 19 cases and in five of these the pathology report on the paraffin-sectioned re-excised tissue was discordant with prior MMS assessment. Significantly, two cases were associated with a misinterpretation of lymphocytic infiltrate as residual disease in patients with chronic lymphocytic leukaemia (CLL).
This study highlights some of the challenges and limitations of MMS. Early referral for multidisciplinary management is recommended when MMS resection margins are inadequate or uncertain, especially for high-risk SCC. We recommend that referrals be accompanied by histological material, as well as a detailed report with operative photos and diagrams. CLL can pose an intraoperative diagnostic challenge. Discrepancies in the interpretation of MMS slides present an opportunity for improvement, and our findings support the role of ongoing quality assurance programs.
背景/目的：描述接受莫氏显微外科手术（MMS）治疗基底细胞癌（BCC）和鳞状细胞癌（SCC）后被转诊接受进一步治疗的患者的特征、后续管理及治疗结果。
对2000年至2015年转诊至一家四级癌症中心的患者进行回顾性分析。
共有82例患者的83处病灶被转诊接受进一步治疗；其中52处（62%）为SCC，80处（96%）位于头颈部。转诊原因包括考虑辅助放疗的高危疾病（37/83，45%）、切除不充分（28/83，34%）或既往MMS术后复发（15/83，17%）。从MMS外科医生处收到的69例转诊病例中，不到40%包含照片、手术报告或示意图。11例（13%）病例存在病理意见不一致的情况。对8例病例的MMS组织病理学进行了复查，其中6例与院内病理意见不一致。19例进行了院内再次切除，其中5例石蜡切片再切除组织的病理报告与先前MMS评估不一致。值得注意的是，2例慢性淋巴细胞白血病（CLL）患者的淋巴细胞浸润被误判为残留疾病。
本研究凸显了MMS的一些挑战和局限性。当MMS切除切缘不充分或不确定时，尤其是高危SCC，建议尽早转诊进行多学科管理。我们建议转诊时应附带组织学材料以及带有手术照片和示意图的详细报告。CLL可带来术中诊断挑战。MMS切片解读的差异提供了改进的机会，我们的研究结果支持持续质量保证计划的作用。
