From the Guidelines
The recommended treatment for a partially removed squamous cell carcinoma on the leg found by punch biopsy is complete surgical excision with appropriate margins, typically involving a procedure called wide local excision with a margin of 4-6 mm of healthy tissue around the tumor. This approach is based on the guidelines for the management of primary cutaneous squamous cell carcinoma, which emphasize the importance of complete excision to prevent recurrence and potential metastasis 1.
Key Considerations
- The size and location of the tumor, as well as its histological characteristics, should guide the decision on the width of the surgical margin, with larger or higher-risk tumors requiring wider margins 1.
- Mohs micrographic surgery is a valuable option for high-risk tumors or those in sensitive areas, as it offers high cure rates while minimizing the loss of healthy tissue 1.
- The choice between wide local excision and Mohs micrographic surgery should be based on the specific clinical scenario, including the tumor's characteristics, the patient's overall health, and the availability of expertise.
Treatment Approach
- Complete surgical excision is the primary treatment for partially removed squamous cell carcinoma, with the goal of removing the remaining cancer along with a margin of healthy tissue.
- Radiation therapy may be considered as an alternative for patients who cannot undergo surgery or as an adjuvant treatment for high-risk tumors.
- Post-treatment follow-up is crucial, with regular check-ups every 3-6 months for the first 2 years, then annually, to monitor for recurrence or the development of new skin cancers.
Evidence-Based Decision
The recommendation for complete surgical excision with appropriate margins is supported by multiprofessional guidelines for the management of primary cutaneous squamous cell carcinoma, which highlight the importance of complete tumor removal to achieve the best outcomes in terms of morbidity, mortality, and quality of life 1.
From the Research
Treatment Options for Partially Removed Squamous Cell Carcinoma
- The treatment for cutaneous squamous cell carcinoma (cSCC) typically involves surgery, with radiation therapy (RT) used selectively as definitive treatment for low-risk tumors or as adjuvant/salvage treatment for high-risk tumors 2.
- For partially removed cSCC, the treatment approach may depend on various factors, including the size and location of the tumor, as well as the patient's overall health and preferences.
Risk Factors for Positive Margins
- Studies have identified several risk factors for positive margins after wide local excision (WLE) of cSCC, including older age, lesion location on the head and neck, previous treatment, increased lesion diameter, invasive subtype, and increased tumor thickness 3.
- These risk factors can help guide treatment decisions and inform the choice of primary management for cSCC.
Guidelines for Excision
- National guidelines for operative radial margins predict 95% oncological clearance with a margin of 4 mm for low-risk and 6 mm for high-risk tumors 4.
- However, the incomplete excision rate remains higher than expected, with most incomplete excisions occurring at the deep margin rather than the radial margin.
Role of Radiation Therapy
- Radiation therapy (RT) can be used as a definitive treatment for patients with cSCC who are not surgical candidates, or as a postoperative treatment after an adequate resection 5.
- The American Society for Radiation Oncology recommends RT as primary treatment for patients with BCC and cSCC who are not surgical candidates, and conditionally recommends RT in situations where adequate resection can lead to a less than satisfactory cosmetic or functional outcome.
Comparison of Treatment Modalities
- A study comparing outcomes for T2a squamous cell carcinoma treated with Mohs micrographic surgery versus wide local excision found that Mohs micrographic surgery provided improved outcomes, with lower rates of local recurrence and poor outcomes 6.
- The choice of treatment modality may depend on various factors, including the size and location of the tumor, as well as the patient's overall health and preferences.