Retrospective audit of patients referred for further treatment following Mohs surgery for non‐melanoma skin cancer

• Published in: Australasian journal of dermatology Vol. 59; no. 4; pp. 302 - 308
• Main Authors: Wee, Edmund, Goh, Michelle S, Estall, Vanessa, Tiong, Albert, Webb, Angela, Mitchell, Catherine, Murray, William, Tran, Phillip, McCormack, Christopher J, Henderson, Michael, Hiscutt, Emma L
• Format: Journal Article
• Language: English
• Published: Australia Wiley Subscription Services, Inc 01.11.2018
• Subjects: Adult; Aged; Aged, 80 and over; Basal cell carcinoma; Carcinoma, Basal Cell - pathology; Carcinoma, Basal Cell - radiotherapy; Carcinoma, Basal Cell - surgery; Carcinoma, Squamous Cell - pathology; Carcinoma, Squamous Cell - radiotherapy; Carcinoma, Squamous Cell - surgery; Chronic lymphocytic leukemia; Discordance; Documentation; Female; Head and neck; Head and Neck Neoplasms - surgery; Humans; laboratory discrepancy; Leukemia; Male; Management; Margins of Excision; Medical Audit; Melanoma; Middle Aged; Mohs micrographic surgery; Mohs Surgery; Neoplasm Recurrence, Local - therapy; Neoplasm, Residual; non‐melanoma skin cancer; Paraffin; Pathology; Patients; Photography; Quality assurance; Radiation therapy; Radiotherapy, Adjuvant; Referral and Consultation; Reoperation; Retreatment; Retrospective Studies; Skin cancer; Skin Neoplasms - pathology; Skin Neoplasms - radiotherapy; Skin Neoplasms - surgery; Squamous cell carcinoma; Surgery; Treatment Outcome; Mohs micrographic surgery; basal cell carcinoma; non-melanoma skin cancer; laboratory discrepancy; squamous cell carcinoma
• DOI: 10.1111/ajd.12779
• ISSN: 0004-8380

Background/Objectives To describe the characteristics, subsequent management and outcomes of patients referred for further management following Mohs micrographic surgery (MMS) for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Methods Retrospective analysis of patients referred to a quaternary cancer centre from 2000 to 2015. Results In total, 83 lesions in 82 patients were referred for further management; 52 (62%) were SCC and 80 (96%) were located in the head and neck. Reasons for referral included high‐risk disease for consideration for adjuvant radiotherapy (37/83, 45%), inadequate resection (28/83, 34%) or recurrence following previous MMS (15/83, 17%). Fewer than 40% of the 69 referrals received from MMS surgeons included photos or an operative report and diagram. There was discordance in pathology opinion in 11 (13%) of cases. Histopathology from MMS was reviewed in eight cases and there was discordance with the in‐hospital pathology opinion in six of these. In‐hospital re‐excision was performed in 19 cases and in five of these the pathology report on the paraffin‐sectioned re‐excised tissue was discordant with prior MMS assessment. Significantly, two cases were associated with a misinterpretation of lymphocytic infiltrate as residual disease in patients with chronic lymphocytic leukaemia (CLL). Conclusion This study highlights some of the challenges and limitations of MMS. Early referral for multidisciplinary management is recommended when MMS resection margins are inadequate or uncertain, especially for high‐risk SCC. We recommend that referrals be accompanied by histological material, as well as a detailed report with operative photos and diagrams. CLL can pose an intraoperative diagnostic challenge. Discrepancies in the interpretation of MMS slides present an opportunity for improvement, and our findings support the role of ongoing quality assurance programs.