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Total Margin-Controlled Excision is Superior to Standard Excision for Keratinocyte Carcinoma on the Nose: A Veterans Affairs Nested Cohort Study

  • Head and Neck Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

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.

Methods

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.

Results

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).

Conclusions

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.

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Acknowledgments

The authors thank Mark O’Leary, Daniel Marcus, and Ramy Ibrahim of Mass General Brigham Finance, as well as Christine Ciacca and Claire Sabino of the Boston VA Health Care System for their expert assistance with cost calculations and billing data.

Funding

No funding was received for this study.

Author information

Author notes

  1. Paul R. Massey and Sameer Gupta contributed equally to this work and are co-first authors.

Authors and Affiliations

  1. Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Paul R. Massey MD, MPH, Emily S. Ruiz MD, MPH, Chrysalyne D. Schmults MD, MSCE & Abigail Waldman MD

  2. Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Sameer Gupta MD, MPhil

  3. Department of Dermatology, Tufts Medical Center, Boston, MA, USA

    Brooke E. Rothstein MD

  4. Department of Dermatology, Veterans Affairs, Boston Healthcare System, Boston, MA, USA

    Nellie Konnikov MD, Emily S. Ruiz MD, MPH & Abigail Waldman MD

  5. Dermatopathology Section, Department of Pathology and Laboratory Medicine, Veterans Affairs, Boston Healthcare System, Boston, MA, USA

    Meera Mahalingam MD, PhD, FRCPath

Authors
  1. Paul R. Massey MD, MPH
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Contributions

Abigail Waldman and Paul Massey designed the study; Paul Massey, Sameer Gupta, and Brooke Rothstein collected the data; Paul Massey and Sameer Gupta performed the analysis; Paul Massey and Sameer Gupta wrote the manuscript. Nellie Konnikov, Meera Mahalingam, Emily Ruiz, and Chrysalyne Schmults provided generous insight into the design and analysis.

Corresponding author

Correspondence to Abigail Waldman MD.

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Disclousure

Chrysalyne Schmults has been a steering committee member for Castle Biosciences; a steering committee member and consultant for Regeneron Pharmaceuticals; and a consultant for Sanofi. She has also received research funding from Castle Biosciences, Regeneron Pharmaceuticals, Novartis, Genentech, and Merck, and is a chair for the NCCN. Emily S. Ruiz has been a consultant for Sanofi, Pellepharm Inc, and Jounce and is also on the advisory board for Leo Pharma and Checkpoint Therapeutics. Paul R. Massey, Sameer Gupta, Brooke E. Rothstein, Nellie Konnikov, Meera Mahalingam, and Abigail Waldman have no conflicts of interest to declare.

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Massey, P.R., Gupta, S., Rothstein, B.E. et al. Total Margin-Controlled Excision is Superior to Standard Excision for Keratinocyte Carcinoma on the Nose: A Veterans Affairs Nested Cohort Study. Ann Surg Oncol 28, 3656–3663 (2021). https://doi.org/10.1245/s10434-021-09604-9

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