Customize your JAMA Network experience by selecting one or more topics from the list below.
Sasor SE, Nosrati NN, Katona T, et al. Predicting the Presence of Nonmelanoma Skin Cancers After Biopsy: A Method to Reduce Unnecessary Surgical Procedures. JAMA Surg. 2016;151(3):289–290. doi:10.1001/jamasurg.2015.3243
Nonmelanoma skin cancer (NMSC) is the most common type of skin cancer in the United States.1 The incidence of NMSC has nearly doubled in the past 20 years, creating a significant financial burden on health care systems.1 The current recommended surgical treatment of NMSC is complete reexcision of the biopsy scar with a several-millimeter margin. Studies2-4 have shown spontaneous clearance rates of 24% to 72% after biopsy and have tried to identify associated characteristics. Previous data from our institution suggest that the clinical appearance of a scar was associated with no cancer after surgical excision.5 The purpose of this study was to determine whether clearance of NMSC in excisional specimens can be predicted based on the appearance of a lesion after biopsy and on the demographic characteristics of the patient.
After institutional review board approval was obtained from Indiana University, a database was created of patients presenting to the Richard L. Roudebush VA Medical Center for treatment of NMSC over a 10-month period. Consent was not indicated for a retrospective deidentified data set. All patients had shave biopsy–proven basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) with positive margins. Collected variables included age, type and location of cancer, size of lesion, personal history of skin cancer, history of tobacco use, length of time from biopsy to excision, and final pathology. Attending and resident physicians independently evaluated the postbiopsy lesion for the suspected clinical presence of residual carcinoma after biopsy. Cancer clearance was defined as no residual carcinoma present in the excisional specimen at final pathology. Statistical analysis was performed using the t test, and significance was set at P < .05.
A total of 150 patients with a total of 183 cases of NMSC were identified during the study period. Of the 183 cases of NMSC, 110 (60.1%) were cases of BCC, and 73 (39.9%) were cases of SCC. Residual BCC was present in the excision specimens of 76 of 110 cases of BCC (69.1%), and residual SCC was present in the excision specimens of 31 of 73 cases of SCC (42.5%). When subdividing cases into head/neck and trunk/limb regions, we found that residual BCC was present in 59 of 89 cases of BCC of the head/neck (66.3%) and 17 of 21 cases of BCC of the trunk/limb (81.0%) and that residual SCC was present in 18 of 44 cases of SCC of the head/neck (40.9%) and 13 of 29 cases of SCC of the trunk/limb (44.8%).
Age and tobacco use were not clearly associated with the presence of residual NMSC in excision specimens. Patients with a personal history of skin cancer were less likely to have residual cancer present in subsequent excision specimens. There was a trend toward clearance of NMSC with longer wait times between biopsy and excision (Table 1). The resident surgeon correctly predicted residual cancer in 47 of the 76 cases of residual BCC (61.8%) and in 21 of 31 cases of residual SCC (67.7%). The attending surgeon correctly predicted residual cancer in 45 of the 76 cases of residual BCC (59.2%) and in 22 of 31 cases of residual SCC (71.0%). Overall, residents estimated that 55.5% of cases of BCC and 56.1% of cases of SCC would have residual cancer present in the excision specimens, whereas attending surgeons estimated 43.6% and 49.3%, respectively. The sensitivity, specificity, and positive and negative predictive values for identification of residual cancer by resident and attending surgeons are shown in Table 2.
Previous studies have shown high spontaneous clearance rates regarding NMSC after biopsy.2-4 The ability to predict cancer clearance based on lesion and patient characteristics would enable patients to avoid unnecessary surgical procedures and would allow health care resources to be used more efficiently. Residual cancer existed in the majority of cases of NMSC in our study. The cases of SCC showed higher rates of spontaneous clearance (42 of 73 cases [57.5%]) than did the cases of BCC (34 of 110 cases [30.9%]). No patient-specific risk factors were identified. There was a trend toward clearance of lesions with longer wait times between biopsy and excision, which suggests that close clinical surveillance may be appropriate for some low-risk lesions. Surgeons had difficulty predicting the persistence of cancer based on the appearance of the biopsy scar alone, regardless of experience. Future studies are needed to determine additional patient and lesion characteristics that contribute to clearance of NMSC after biopsy.
Corresponding Author: Sunil S. Tholpady, MD, PhD, Division of Plastic Surgery, Department of Surgery, Indiana University, 705 Riley Hospital Dr, RI 2514, Indianapolis, IN 46202 (firstname.lastname@example.org).
Published Online: October 28, 2015. doi:10.1001/jamasurg.2015.3243.
Author Contributions: Drs Tholpady and Sasor had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Sasor, Nosrati, Katona, Wooden, Cohen, Tholpady.
Acquisition, analysis, or interpretation of data: Sasor, Nosrati, Wooden, Munshi, Tholpady.
Drafting of the manuscript: Sasor, Nosrati, Wooden, Tholpady.
Critical revision of the manuscript for important intellectual content: Sasor, Nosrati, Katona, Cohen, Munshi, Tholpady.
Statistical analysis: Sasor, Nosrati, Tholpady.
Administrative, technical, or material support: Sasor, Nosrati, Wooden, Munshi, Tholpady.
Study supervision: Wooden, Cohen, Munshi, Tholpady.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This paper was presented at the 39th Annual Meeting of the Association of VA Surgeons; May 4, 2015; Miami Beach, Florida.
Create a personal account or sign in to: