Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Ann Surg Oncol. 2021 Jul;28(7):3656-3663. doi: 10.1245/s10434-021-09604-9. Epub 2021 Mar 19.
Keratinocyte carcinoma (KC), including basal and squamous cell carcinoma, is the most common human malignancy. Limited real-world data have compared surgical outcome or cost between total margin-controlled excision (TMCE) and standard excision (SE), the two most common treatments for invasive KC. We compared reconstruction, margin status, and cost between TMCE and SE for KC on the nose at a Veterans Affairs (VA) healthcare system.
Randomly selected primary KCs on the nose ≤3 cm that were confined to soft tissue, without nerve or lymphovascular invasion, and treated with SE or TMCE between 2000 and 2010, were assessed. Utilization of flap or graft reconstruction and margin status following all surgical attempts were recorded. Costs were based on Current Procedural Terminology codes standardized to 2019 Medicare payments.
Overall, 148 cases were included in each treatment group. Baseline characteristics were similar between groups, although SE tumor median diameter was 1 mm larger. SE was associated with increased utilization of flap or graft reconstruction (odds ratio 2.05, 95% confidence interval 1.16-3.59, p = 0.01). Positive margins were present in 24% of SEs initially and remained positive after the final recorded excision in 9% of cases. No positive final margins were noted in TMCE cases. SE cost per tumor was significantly higher than TMCE ($429.03 ± 143.55; p = 0.003).
Surgical management of KC with SE is associated with increased reconstruction complexity, a significant risk of positive margins, and higher cost compared with TMCE. The 23% risk of positive margins supports National Comprehensive Cancer Network guidelines for the treatment of high-risk KC with TMCE, unless delayed reconstruction is employed.
角化细胞癌（KC）包括基底细胞癌和鳞状细胞癌，是最常见的人类恶性肿瘤。有限的真实世界数据比较了全边缘控制切除术（TMCE）和标准切除术（SE）两种最常见的侵袭性 KC 治疗方法的手术结果或成本。我们比较了退伍军人事务部（VA）医疗系统中鼻部 TMCE 和 SE 治疗 KC 的重建、边缘状态和成本。
评估了 2000 年至 2010 年间接受 SE 或 TMCE 治疗的鼻内最大直径≤3cm、局限于软组织、无神经或淋巴血管侵犯的原发性 KC 患者。记录了所有手术尝试后的皮瓣或移植物重建的利用情况和边缘状态。成本基于按 2019 年医疗保险支付标准标准化的当前程序术语（CPT）代码。
总体而言，每组各纳入 148 例病例。两组患者的基线特征相似，尽管 SE 肿瘤的平均直径大 1mm。SE 与皮瓣或移植物重建利用率增加相关（比值比 2.05，95%置信区间 1.16-3.59，p=0.01）。SE 最初有 24%的病例存在阳性边缘，在最后一次记录的切除后仍有 9%的病例存在阳性边缘。TMCE 病例中未发现阳性最终边缘。SE 每例肿瘤的成本明显高于 TMCE（$429.03±143.55；p=0.003）。
与 TMCE 相比，SE 治疗 KC 与重建复杂性增加、显著的阳性边缘风险和更高的成本相关。23%的阳性边缘风险支持国家综合癌症网络（NCCN）指南，建议对高危 KC 采用 TMCE 治疗，除非需要延迟重建。
