British Association of Dermatologists’ national audit on nonmelanoma skin cancer excision, 2014

Revisiting basal cell carcinoma clinical margins: Leveraging natural language processing and multivariate analysis with updated Royal College of Pathologists histological reporting standards

INTRODUCTION

Data supporting the current British Association of Dermatologists guidelines for the management of basal cell carcinoma (BCC) are based on historic studies and do not consider the updated Royal College of Pathologists (RCPath) histological reporting standards. The aim of this study was to use natural language processing (NLP)-derived data and undertake a multivariate analysis with updated RCPath standards, providing a contemporary update on the excision margins required to achieve histological clearance in BCC.

METHODS

A validated NLP information extraction model was used to perform a rapid multi-centre, pan-specialty, consecutive retrospective analysis of BCCs, managed with surgical excision using a pre-determined clinical margin, over a 17-year period (2004-2021) at Swansea Bay University Health Board. Logistic regression assessed the relationship between the peripheral and deep margins and histological clearance.

RESULTS

We ran our NLP algorithm on 34,955 BCCs. Out of the 1447 BCCs that met the inclusion criteria, the peripheral margin clearance was not influenced by the BCC risk level (p = 0.670). A clinical peripheral margin of 6 mm achieved a 95% histological clearance rate (95% confidence interval [CI], 0.93-0.98). Tumour thickness inversely affected deep-margin histological clearance (OR 0.720, 95% CI, 0.525-0.991, p < 0.05). Depth level 2 had a 97% probability of achieving deep-margin histological clearance across all tumour thicknesses.

CONCLUSION

Updated RCPath reporting standards minimally impact the peripheral margin histological clearance in BCC. Larger clinical peripheral margins than those indicated by current guidelines may be necessary to achieve excision rates of ≥95%. These findings emphasise the need for continuous reassessment of clinical standards to enhance patient care.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Surgical Treatment of Nonmelanoma Skin Cancer in Older Adult Veterans

BACKGROUND

Older adult patients are frequently referred to surgical services for the treatment of nonmelanoma skin cancer (NMSC). The appropriateness of offering surgery to patients with serious comorbidities and a limited life expectancy has been questioned in the literature. The purpose of this study was to determine the morbidity and 5-year mortality for patients with NMSC referred to the plastic surgery service.

METHODS

A retrospective chart review was performed from July 1, 2011, to June 30, 2015, of all plastic surgery service consults for the treatment of NMSC. We collected the following data: age and life-limiting comorbidities at the time of referral, treatment, complications, and 5-year mortality. A χ² analysis was used to determine the statistical significance (P < .05) between the individual risk factors and 5-year mortality. The relative risk of 5-year mortality was calculated combining advanced age with individual comorbidities.

RESULTS

The plastic surgery service completed 800 consults for NMSC over a 4-year period. Five-year mortality was 28.6%. Median age of patients deceased at 5 years was 78 years at the time of the consult submission. The surgical complication rate was 5%. Aged ≥ 80 years, coronary artery disease, congestive heart failure, cerebral vascular disease, peripheral vascular disease, dementia, chronic kidney disease, chronic obstructive pulmonary disease, and diabetes mellitus were found individually to be statistically significant predictors of 5-year mortality. Combining aged ≥ 80 years, coronary artery disease, congestive heart failure, or dementia increased the 5-year mortality to a relative risk > 3.

CONCLUSIONS

Surgical excision of NMSC in older adult patients is indicated in most situations. A frank discussion with the patient and caregiver is suggested. Surgical treatment of NMSC in older adult patients has a low morbidity but needs to be balanced against a patient's quality of life when they present with life-limiting comorbidities.

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta‐analysis*

BACKGROUND

Keratinocyte or nonmelanoma skin cancer (NMSC) is the commonest malignancy worldwide. The usual treatment is surgical excision. Current guidelines underestimate incomplete excision rates.

OBJECTIVES

We aimed to determine the risk of incomplete excision of NMSCs through a systematic review and meta-analysis of primary clinical studies.

METHODS

A PRISMA-compliant systematic review and meta-analysis was performed using methodology proposed by Cochrane (PROSPERO CRD42019157936). A comprehensive search strategy was applied to MEDLINE, Embase, Scopus, CINAHL, EMCare, Cochrane Library and the grey literature (January 2000-27 November 2019). All studies were included except those on Mohs micrographic surgery, frozen section or biopsies. Abstract screening and data extraction were performed in duplicate. Risk of bias was assessed using a tool for prevalence/incidence studies. The primary outcome was the proportion of incomplete surgical excisions. A random-effects model for pooling of binomial data was used. Differences between proportions were assessed by subgroup meta-analysis and meta-regression, which were presented as risk ratios (RRs).

RESULTS

Searching identified 3477 records, with 110 studies included, comprising 53 796 patients with 106 832 basal cell carcinomas (BCCs) and 21 569 squamous cell carcinomas (SCCs). The proportion of incomplete excisions for BCC was 11·0% [95% confidence interval (CI) 9·7-12·4] and for SCC 9·4% (95% CI 7·6-11·4). Proportions of incomplete excisions by specialty were: dermatology, BCCs 6·2% and SCCs 4·7%; plastic surgery, BCCs 9·4% and SCCs 8·2%; general practitioners, BCCs 20·4% and SCCs 18·9%. The risk of incomplete excision for general practitioners was four times that of dermatologists for both BCCs (RR 3·9, 95% CI 2·0-7·3) and SCCs (RR 4·8, 95% CI 1·0-22·8). Studies were heterogeneous (I²  = 98%) and at high risk of bias.

CONCLUSIONS

The proportion of incomplete excisions is higher than previously reported. Excisions performed by specialists may lower the risk of incomplete excision.

Global incidence of incomplete surgical excision in adult patients with non-melanoma skin cancer: study protocol for a systematic review and meta-analysis of observational studies

BACKGROUND

Non-melanoma skin cancer, which includes basal cell carcinoma and cutaneous squamous cell carcinoma, is the commonest malignancy worldwide. The mainstay of treatment is surgical excision. Despite this being an exceptionally common procedure, it is not known what the accepted standard is for incomplete excision. Multiple single-centre, regional and national studies have previously reported their incidence of incomplete excision in isolation. Furthermore, is it not known what effect potential risk factors such as the operating group, location of lesions, type of reconstruction, histological components or use of loupe magnification have on the incidence of incomplete excisions. The objective of this study will be to systematically evaluate observational data that present incidence of incomplete surgical excision amongst adult patients with non-melanoma skin cancer worldwide.

METHODS

We designed and registered a study protocol for a systematic review and meta-analysis of descriptive epidemiology data. A comprehensive literature search will be conducted (from January 2000 onwards) in MEDLINE, EMBASE, Scopus, CINAHL, EMCare and Cochrane Library. Grey literature will be identified through searching Open Grey, dissertation databases (e.g. Open Access Theses and Dissertations) and clinical trial registers (e.g. WHO ICTRP). Observational studies (cohort, cross-sectional, case series and clinical audits) reporting the incidence of incomplete surgical excision and conducted in adult patients with non-melanoma skin cancer will be included. The primary outcome will be the incidence of incomplete surgical excision (defined as residual tumour at either the peripheral or deep margin). Secondary outcomes will be risk factors that may affect incomplete excision (e.g. operating group, location of lesions, types of reconstruction, histological components). Data will not be extracted if the study uses other surgical techniques such as Mohs micrographic surgery, intra-operative frozen section, incision, shave or punch biopsies. Two investigators will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion. No limitations will be imposed on publication status or language of publication. The study methodological quality (or bias) will be appraised using an appropriate tool. If feasible, we will conduct a random effect meta-analysis of observational data. Incidence estimates will be stratified according to cancer type (e.g. basal cell carcinoma vs squamous cell carcinoma) and operating group (e.g. dermatology, plastic surgery and general practice). Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g. methodological quality, sample size).

DISCUSSION

This systematic review will summarise the best available evidence and definitively establish the incidence of incomplete surgical excision in non-melanoma skin cancer. It will determine if there is variation observed amongst different operating groups and provide some evidence for potential other factors causing this difference. This knowledge will provide a standard for future audits and will contribute to improving the treatment of non-melanoma skin cancer treatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019157936.

Who Should Carry Out Skin Cancer Excisions? A Systematic Review

Background:

The incidence of melanoma and nonmelanoma skin cancers is increasing in the United Kingdom. Surgical excision carries the highest cure rates for all skin cancers and is the first-line treatment for melanomas and high-risk nonmelanoma cancers. This is most commonly performed by general practitioners (GPs), dermatologists, and plastic surgeons.

Objective:

The aim of this study was to identify which health-care professionals achieve the best outcomes following surgical excision of skin cancer lesions.

Materials and Methods:

A comprehensive search of the Cochrane Library and PubMed databases was conducted. PRISMA guidelines were adhered to throughout.

Results:

Six studies were identified and reviewed. Dermatologists were most likely to excise lesions adequately, and GPs were the least likely. Dermatologists displayed the greatest diagnostic accuracy, and excisions led by them had the highest overall and disease-free survival rates. Plastic surgeons were most likely to excise complex lesions on difficult-to-treat areas.

Conclusion:

Dermatologists can excise many skin lesions adequately, but plastic surgeons should continue to take an active role in complex or anatomically challenging lesions. There is a need for more validated training for GPs in the management of skin cancers. Further studies incorporating a randomized control protocol are needed to definitely assess who is best placed to surgically excise these lesions.

Identifying the factors that influence surgeon's compliance with excisional margins of non-melanoma skin cancer

The rising incidence of Non Melanoma Skin Cancers (NMSC) leads to a high number of surgical procedures worldwide. The strict compliance with international guidelines with regard to excisional margins may help decrease the number of re-excision procedures and reduce the risk of NMSC recurrence. The aim of this study was to investigate the prevalence of excisional margins as recommended by the European Academy of Dermatology and Venereology (EADV) and the European Dermatology Forum (EDF) guidelines, and the factors (demographic or clinical) that influence surgeons' compliance with these guidelines.This was a prevalence study looking at surgical excisions of NMSCs performed over a period of 2 years (2011-2012). A sample size of 1669 patients was considered. Definition of excisional margins recommended by the international guidelines (EADV and EDF) were used as point of reference for the analysis. Tumor and histologic specimen size were calculated ex vivo by 5 different pathologists. The size of skin specimens was measured with a major axis and a minor axis. The same was done for the tumor present on the skin specimens. The differences between the major and minor axes of surgical specimen and tumor were calculated. These differences were subsequently divided by two, hypothesizing that the lesion had the same distance from the margins of the surgical specimen. The differences obtained were named "Delta", the formulas applied being the following:Delta major = (major axis specimen-major axis tumor)/2; Delta minor = (minor axis specimen-minor axis tumor)/2.Results show a significant statistical difference, associated with factors such as: age of the patient, anatomical localization of the tumor, histological diagnosis, and surgeons' experience.The identification of these factors sheds light on clinicians' practice and decision-making regarding excisional margins. Hopefully a higher level of adherence to the guidelines can be achieved in the future.

Review of outcomes of 500 consecutive cases of non-melanoma skin cancer of the head and neck managed in an oral and maxillofacial surgical unit in a District General Hospital

We provide a non-melanoma skin cancer (NMSC) service for skin cancers of the head and neck in the south-west of England. We hypothesised that certain anatomical sites such as the nose and eyelid would have a higher incidence of close or involved margins than others, and that the choice of repair might influence the excised margins. We therefore retrospectively analysed the data of 500 consecutive NMSC that were operated on in the oral and maxillofacial surgery unit of Taunton and Somerset NHS Trust. The database reports were crosschecked against the Trust's own pathology reporting system to ensure that they were accurate. Data collected included clinical and personal details of patients, anatomical sites, type of reconstruction, histopathological diagnosis, excision margins, and complications. Of the 500 patients reviewed 362 (72%) were basal cell carcinomas (BCC) and 138 (28%) squamous cell carcinomas (SCC). The outcomes of 243 patients treated by primary closure, 134 treated by reconstruction with local flaps, and 123 treated by skin grafts, were reviewed with particular attention paid to the anatomical site and excision margins. There was an overall incomplete excision rate of 10.8% (n=54) and 29 patients developed complications (5.8%). We confirmed that rates of close or incomplete margins are more likely in certain anatomical sites such as the nose, forehead, and ear. The rate of involved margins was unaffected by choice of surgical technique.