2024 Top Story in Dermatology: Dermatologic Surgery — Sometimes, Less Is More

Dermatologists have become famous for devising incredible surgical treatment approaches for a wide variety of benign and malignant conditions utilizing excisional methods, lasers, Mohs surgery with traditional staining and immunostains along with a variety of repairs, cosmetic surgeries, hair transplants, and vein surgeries and even medical approaches to tumors (such as using sirolimus for the management of angiofibromas of tuberous sclerosis). There are fewer and fewer conditions that we are unable to treat! However, treatment is not always warranted. Certainly, there are cosmetic procedures that patients may choose to forgo after careful consideration of benefits, risks, and costs. Of course, cancers always require treatment, right?

This article¹ suggests that squamous cell carcinoma in situ (SCCis) has only a 4% chance of recurrence when biopsy sites heal without evidence of a persistent tumor. Dermatologists are fully capable of educating patients about the features of recurrent SCCis and can monitor patients in the office at prudent intervals — perhaps every 6 months for a couple of years. Of note, there were no nodal metastases, distant metastases, or disease-specific deaths among the 411 patients included in the study.

Why does this happen? Perhaps these intraepidermal foci of keratinocyte atypia have been completely removed in the tangential specimen. Alternatively, local inflammation following the surgical procedure may eliminate small foci of atypia. There are caveats, of course! Lesions on the lips or ears, cases involving superficial biopsies with tumors transected at the base, and lesions in patients with underlying immunocompromising conditions should generally be treated because they have a greater chance of recurrence. In addition, these findings would not reflect expectations for a shave procedure of a lesion with clinical evidence of recurrent SCCis following a previous procedure.

There are other important implications. Patients with small (perhaps less than 1.5 cm) fixed erythematous and slightly scaled patches that call to mind superficial basal cell carcinoma or SCCis should have the entire lesion shave excised with a small margin of normal tissue to maximize the potential that initial healing will occur without evidence of a persistent tumor. It will also make the dermatopathologist happy to have the opportunity to examine as much of the target lesion as possible.

To further reduce the risk of recurrence, light electrodesiccation could be used following a shave procedure to achieve hemostasis and knock out a few adjacent atypical cells. The potential for scarring must be considered when electrodesiccation is used.

This study also has implications for dermatopathologists as they decide whether to provide an assessment of margins in shave specimens. I routinely write, "The tumor appears to be completely in the sections of this shave specimen that were examined. Clinical follow-up is required." My submitting dermatologists know that all margins are not examined in tangential specimens processed in the traditional manner. Knowing whether the tumor was transected at the base would be one more factor in making the clinical decision regarding whether additional treatment is required if the lesion heals without clinical signs of a persistent tumor.

In summary: sometimes, less is more! Careful monitoring of SCCis removed by shave technique without evidence of lesion persistence may be just what the doctor orders and may save the properly educated patient an extra procedure, time, and money.