A Team Approach to Nonmelanotic Skin Cancer Procedures

For many decades, the treatment of choice for nonmetastatic but locally invasive nonmelanotic basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) has been complete surgical excision that ensures minimal tissue waste, yet retains adequate tumor-free resection margins. From early on, the primary challenge has been assessing the appropriateness of those margins at the time of the initial surgical procedure, rather than having to recall the patient later for an additional surgery to excise involved margins.

In 1953, Steven Mohs, MD, envisioned the use of a vital dye to distinguish benign from malignant skin tissue at the time of surgery.^1-3 At that point intraoperative consultation with a pathologist and the process of examining frozen sections (FS) for diagnosis were not standards of care in oncologic surgery. This process allowed Mohs, with limited success, to excise tumors with negative margins. Mohs repeatedly revised and improved his procedure, including the utilization of intraoperative FS to examine the entire specimen margin, a process that is at the core of the Mohs micrographic surgery.^1-3

Currently, the Mohs procedure is one of the most popular approaches to definitive skin cancer surgery, especially in the head and neck region where tissue preservation can be critical. It is usually performed as an outpatient or clinic procedure by a specially trained dermatologist who acts both as a surgeon and a pathologist, excising the lesion and processing it for FS diagnosis.^4-6 In a hospital setting, other practitioners (surgeons and pathologists) often use the standard approach of limited sampling of resection margins for FS by serially sectioning a specimen that had already been inked or marked for the appropriate margins and freeze-sectioning representative portions of those margins. Reports published by experienced operators using these different approaches indicate variable cancer recurrence rates of 1% to 6%.^7-9

At the VA it is a priority to deliver the same quality health care at a much lower price. In this setting it is prudent to periodically reexamine alternative approaches to patient care delivery that utilize existing resources or excess capacity to achieve comparable, if not superior, outcomes to the usually more costly private sector outsourcing contractual arrangements.

With that goal in mind, a few years ago Robley Rex VAMC (RRVAMC) embarked on a new team approach for resectable nonmelanotic skin cancer cases. The team consisted of a plastic surgeon and a pathologist with the appropriate technical and nursing support (histotechnicians, surgical nurse practitioners, and/or nurse anesthsesists) staff. None of the team members were exclusively dedicated to the procedure but were afforded adequate time and material resources to handle all such cases. In this report, the authors describe their experience and the impact of their approach on the affected patients.

Methods

At RRVAMC, primary care providers were encouraged to refer patients suspected of nonmelanotic skin cancer directly to a hospital-based plastic surgeon, who schedules them for a FS-controlled surgical excision of the suspected lesion. The plastic surgeon also plans to cover the resulting wound, if too large for primary closure, with a micrograft during the same procedure. The procedure is usually performed under local anesthesia. A general surgeon or surgical fellow with basic training in plastic surgery may substitute for the plastic surgeon. When not performing this procedure, the surgeon carries on other routine surgical duties.

A dedicated FS room was set up next to an operating room (OR), which was designated for this specialized skin cancer surgery, among other surgeries. The pathologist could walk into the OR anytime to assess the lesion, its location, and the surgeon’s plan of resection, and both physicians could discuss the best strategy for the initial resection or any subsequent margin reexcision. Both could also discuss whether a permanent section would be more appropriate under the conditions.

A small window separated the FS room from the OR, allowing two-way communication and the delivery of specimens. If the specimen was more complex in terms of margin definition, the pathologist could personally take the specimen after its excision directly from the surgeon who could offer further explanation of the special attributes of the specimen. The specimen was usually placed on a topographic drawing of the body region with one or more permanent marks that denoted specific landmarks for orientation.

Once the specimen was in the FS room, the pathologist proceeded with standard gross description followed by color inking of the margins and sampling, according to the following rules:

1. Small specimen (< 0.5 cm): Embed as is; FSs may be cut parallel to epidermal surface and examined until no more tumor is seen.
2. Medium specimen (0.5-3.0 cm): Serially cross-section and embed all in ≥ 1 blocks; ≥ 6 FSs (cuts) examined from each block.
3. Large specimen (> 3.0 cm): Peripheral margins shaved; few central sections taken through deep margin.