Journal of Clinical and Aesthetic Dermatology

APR 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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41 JCAD journal of clinical and aesthetic dermatology April 2017 • Volume 10 • Number 4 aggressive behavior and have a lower risk of metastasis. Recurrence is common in lesions at least 4mm thick that extend to the deep dermis. 3 National Comprehensive Cancer Network. The NCCN guidelines categorize margin selection of cSCC as low- and high-risk and recommendations are substantiated based on the findings of Brodland and Zitelli who conducted a study involving 141 cases of primary invasive cSCC lesions treated by MMS. 15 For well-defined, low-risk tumors, it was found that 4mm peripheral margins resulted in a complete excision rate of 95 percent. Their recommendation stands as 4 to 6mm peripheral margins for low-risk lesions using SE. High-risk lesions are described as those that are ill-defined, affecting the genitalia, mucosal surfaces, face, and/or neck. For high-risk lesions greater than 6mm in high-risk locations, greater than 10mm in moderate risk locations, or those penetrating to the level of subcutaneous fat on biopsy, the NCCN advises SE with greater than 6mm peripheral margins. 20,21 Upon review of the guidelines, deep margin recommendations do not appear to be available; however, the NCCN does highlight their prognostic value in diagnosis and staging. 15 European Dermatology Forum. The latest EDF guidelines for the management of cSCC were established by a collaboration of the EDF, the European Association of Dermato-Oncology, and the European Organization of Research and Treatment of Cancer. For low- risk, well-defined cSCC less than 2cm in diameter, the EDF recommends SE using 5mm peripheral margins. Higher risk lesions include those at least 2cm in diameter with history of chronic ulceration, presence of high histological thickness greater than or equal to 6mm, subcutaneous invasion, and/or perineural invasion. High-risk locations are described as those affecting the ear, lip, scalp, or eyelid. 16,17 For such lesions, SE with 6 to 10mm peripheral margins is recommended. MMS is an alternative surgical therapy in appropriate candidates. The deep margin should extend to the hypodermis, avoiding the aponeuroses, perichondrium, and periosteum if unaffected by tumor extension. 16 British Association of Dermatology. Per the BAD, low- risk, clinically well-defined cSCC lesions less than 2cm in diameter require SE with peripheral margins of 4mm. 16,18 Lesions greater than 2cm should undergo SE with at least 6mm peripheral margins, including those that are moderately, poorly, or undifferentiated in character, those extending to the level of subcutaneous tissue, and those affecting high-risk areas, such as the ear, lip, eyelid, or scalp. 14,19–21 MMS is an alternative surgical approach in appropriate candidates. 18 Cancer Council Australia and Australian Cancer Network. According to the CCA/ACN guidelines, for well-differentiated cSCC lesions less than 2cm in diameter, the recommendation is SE with 4mm peripheral margins. Lesions at least 2cm in diameter require SE using up to 10mm peripheral margins. Deep margins should extend through normal adipose tissue to ensure complete removal. 1 2 Swedish guidelines. For low-risk cSCC, the Swedish guidelines recommend SE using at least 4mm peripheral margins. High-risk cSCC features include, but are not limited to, poor differentiation, location involving the ear and/or scalp, and immunosuppression in the host. Such high-risk lesions are recommended to be excised using SE with a peripheral margin of at least 6mm. Alternatively, high-risk lesions can be excised via MMS in appropriate candidates (Table 3). 13 Dermatofibrosarcoma protuberans. Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive, slow-growing sarcoma known for its highly irregular tumor shape, eccentric projections, and high recurrence rate. 22,23 The most recent data estimates an incidence of 4.1 per million person-years, most commonly in African- American female patients. 23 Greater than 90 percent of DFSP lesions have a fusion gene product, which promotes persistent production of collagen. 24–26 Due to its more aggressive nature, treatment margin selection is crucial. Studies have shown recurrence rates of 7.3 percent following WLE. 26 Areas prone to recurrence include the extremities, head, and neck, likely secondary to difficulty achieving wide margins in these areas. 26,27 National Comprehensive Cancer r E v i E W

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