From the Vanguard Aesthetic Plastic Surgery, Fort Lauderdale, FL.
Division of Plastic Surgery, Department of Surgery, Lehigh Valley Health Network, Allentown, PA.
Ann Plast Surg. 2021 Jul 1;87(1):80-84. doi: 10.1097/SAP.0000000000002566.
Management of positive margins after nonmelanoma skin cancer (NMSC) excision is debated in the literature. The purpose of this study is to determine the rate of residual tumor in reexcised NMSC specimens after previous excision with positive margins, to determine the rate of recurrence in patients who had positive margins but did not undergo reexcision, and to define the financial burden of negative reexcisions.
An Institutional Review Board-approved retrospective review was conducted on all patients with NMSC excision over a 15-year period. Patients who met inclusion criteria and underwent initial NMSC excision with negative frozen section margins, but had positive permanent section margins were divided into 2 groups: those who underwent reexcision for clearance of tumor (n = 161) or those who did not undergo further reexcision (n = 105). Variables collected include demographics, previous skin cancer, tumor location, cancer subtype, excision measurements, and time between first and second excisions. For those patients who did not undergo reexcision, charts were examined for recurrence.
Two hundred sixty-six patients met inclusion criteria with mean follow-up of 60 months. Eighty-three (52%) of 161 patients with positive margins on initial excision had no evidence of residual cancer upon reexcision. Residual tumor on permanent section was confirmed in 48% of patients. Patients with a previous history of basal cell carcinoma were more likely to have a true-positive margin after reexcision (P = 0.02). Larger reexcisions were more likely to harbor residual cancer (5.9 cm2, P = 0.04). Patients with positive margins that did not undergo reexcision, only 7 of 105 patients (6.6%) had recurrence. No mortalities were reported from NMSC recurrence. US $247,672 was spent in reexcision for negative margins in 98 patients for an average cost of US $2984 per case.
Forty-eight percent of NMSC patients with positive margins had residual tumor upon reexcision. There were 6.6% of the patients who did not undergo resection after positive margins developed recurrence of disease at 5 years. Patients requiring larger reexcisions or those with a prior history of BCC were more likely to have residual cancer upon reexcision. This study suggests that observation is an appropriate option of care for certain patients with residual NMSC on permanent pathology.
非黑素瘤皮肤癌 (NMSC) 切除术后阳性切缘的处理在文献中有争议。本研究旨在确定先前切除有阳性切缘的 NMSC 标本中残留肿瘤的发生率，确定未行再次切除的阳性切缘患者的复发率，并确定阴性再次切除的经济负担。
对 15 年来所有接受 NMSC 切除术的患者进行了机构审查委员会批准的回顾性研究。符合纳入标准且初次 NMSC 切除时冷冻切片切缘阴性但石蜡切片切缘阳性的患者分为两组：行肿瘤清除术的再次切除术组（n=161）和未行进一步再次切除术组（n=105）。收集的变量包括人口统计学、既往皮肤癌、肿瘤位置、癌症亚型、切除测量值以及首次和第二次切除之间的时间。对于未行再次切除术的患者，检查其病历以确定复发情况。
266 例患者符合纳入标准，平均随访 60 个月。161 例初次切除时阳性切缘的患者中有 83 例（52%）在再次切除时无残留肿瘤证据。48%的患者在石蜡切片上证实有残留肿瘤。有基底细胞癌既往史的患者再次切除时更有可能出现真正的阳性切缘（P=0.02）。较大的再次切除更容易有残留肿瘤（5.9cm2，P=0.04）。未行再次切除术的阳性切缘患者中，仅 105 例患者中有 7 例（6.6%）复发。无因 NMSC 复发导致的死亡病例。98 例阴性切缘再次切除的患者中花费了 247672 美元，平均每个病例 2984 美元。
48%的 NMSC 阳性切缘患者再次切除时有残留肿瘤。有阳性切缘的患者中有 6.6%在 5 年内出现疾病复发而未行切除。需要更大范围切除或有基底细胞癌既往史的患者再次切除时更有可能有残留肿瘤。本研究表明，对于某些永久性病理存在残留 NMSC 的患者，观察是一种合适的治疗选择。
