INTRODUCTION

Skin cancers (SCs) are among the most common human malignancies,[1] which for reasons such as progression, tissue destruction, and metastasis should be treated as soon as possible.[12]

Surgical excision is considered as the choice treatment of these cancers.[345] However, the outcome of this method strongly depends on complete removal of the tumor[6] and presence of clear and tumor-free histopathological margins.[7]

Incomplete excision of cancers can be correlated with complications such as recurrence, morbidity, and mortality.[5] Therefore, their re-treatment, preferably with surgery (surgical re-excision), is recommended.[3] This study aimed to evaluate re-excision rate in incompletely excised SCs and the presence of residual tumor in these re-excised samples.

MATERIALS AND METHODS

In this descriptive retrospective study, incompletely excised tumors from our previous study[8] were examined, and of them, a number of re-excised cases were determined. Then, based on histopathology reports and patients’ files, information such as the result of re-excision (with/without residual tumor), type of affected margin, age, sex, tumor location, and clinician specialty was collected.

RESULTS

Out of the 96 incompletely excised tumors, 19 cases (19.8%) were re-excised, of which residual tumors were observed again in 7 cases (36.8%). Clinicopathological characteristics of re-excised samples are presented in general and separately for each sample in Tables 1 and 2, respectively.

DISCUSSION

For incompletely excised SCs, re-excision of the lesion is preferably recommended to minimize the risk of recurrence,[4] which is considered the worst surgical complication.[2] Published data on re-excision of SCs are scarce and have been briefly supplied in a small number of studies. In this study, re-excision rate and presence of residual tumor in re-excised samples were investigated.

In the present study, 19.8% of the incompletely excised tumors underwent re-excision, which is almost similar to that reported by Codazzi et al.[9] (18.14%). Comparing different studies, the rate of re-excised tumors has been found to vary from 1.9% to 100%.[14,610,11] This difference between studies can be due to the following reasons:

• (I)

  Different biological behaviors of SCs, due to which in some tumors such as basal cell carcinoma (BCC), failure to completely remove the lesion does not necessarily correlate with recurrence. The reason for this can be the destruction of residual tumor by the cicatrization process[2] and the theory of disappearing tumor cells as part of the second stage of the wound-healing process (inflammatory phase). So not enough tumor cells are left to survive. Therefore, in some cases, close monitoring of the patient is recommended and reoperated in the case of recurrence. However, this procedure is dangerous for some other tumors, such as invasive squamous cell carcinoma (SCC) which can metastasize to regional lymph nodes and then to distant sites.[4]

• (II)

  Failure to perform reoperation in the same center under study and then referring it to another center either at the request of the patient or due to the uncertainty of the clinician about the availability of the necessary facilities for repair and reconstruction of tissue defects caused by re-excision.

• (III)

  Lack of knowledge, sufficient experience, and practical skills required for the proper management of patients in need of re-excision.

• (IV)

  Patient’s unwillingness for re-excision, which can be either due to inefficient follow-up systems and failure of the healthcare system in making the patient aware of a present problem or due to the patient’s unpleasant experience with previous surgery and/or high surgical treatment costs.

Meanwhile, performing re-excision is an individual’s choice, taking into account the patient’s age and general condition.

In histopathological report of re-excised tumors, 36.8% had a residual tumor, which is similar to the result of Patel et al.[10] (36%). This rate is relatively high in previous studies.[13,79] For example, Spyropoulou et al.[4] reported residual tumor in 100% of the cases.

In most studies, including ours, the presence of residual tumor may be due to not using Mohs micrographic surgery. In this technique, all removed margins are histopathologically examined to ensure the absence of tumor cells, whereas further incision is made only where the tumor remains until complete resection.[12] Non-application of this method in the present study with respect to the more invasive tendency of SCC to subclinical infiltration is probably the reason for the higher rate of residual tumor in this malignancy compared with BCC.

In addition, severe surgical outcomes such as significant cosmetic and functional defects or disfigured scars in the involved areas, especially in the visible areas, can also affect the outcome of surgical re-excision.

According to our findings, the residual tumor rate was 66.66% in the cheek, 50% in the limbs, and 27.27% in the nose. In the study of Griffiths et al.,[7] the residual tumor rate was found to be 40% in the cheek, 36% in the nose, and 32% in limbs, whereas Spyropoulou et al.[4] found it to be 83.3% in the cheek, 52.94% in the nose, and 75% in the ears. Similar to Griffiths et al.[7] and Spyropoulou et al.,[4] the highest frequency of residual tumor was observed in the cheek (probably due to using narrower margins for cosmetic, functional, and/or preserving underlay facial nerve reasons), but unlike the latter study,[4] we found the residual tumor rate to be zero in re-excised cancers of ears (75% vs. 0.0%).

The most re-excised margins were both margins followed by lateral margin and deep margin of lesions alone, whereas in the study of Griffiths et al.[7] and Masud et al.,[3] it was found to be in the order of lateral margin, deep margin, and both margins, respectively.

In this study, in agreement with Masud et al.,[3] although in disagreement with Griffiths et al.,[7] the highest frequency of residual tumor was observed in the deep margin of re-excised tumors. In contrast, in the study of Pua et al.,[5] the margin of all re-excised cases was free of tumor cells.

CONCLUSION

Given the limitations of this descriptive study, further research with larger sample size and involving other study designs (e.g., prospective and analytical studies), focussing on finding the factors influencing the success of SCs re-excision, is suggested. Collecting and reporting of surgical results of re-excised tumors may help clinicians enhance the success rate of reoperations.