Marginal Excision of Squamous Cell Carcinomas of the Hand

Abstract

Squamous cell carcinoma is the most common malignant tumor of the hand. Most hand surgery texts recommend wide excision with 1- to 2-cm margins. During a 10-year period, 32 patients with 35 lesions were treated with marginal surgical excision for squamous cell carcinoma of the hand. Greater potential morbidity and functional loss associated with wide excision was avoided in these patients. No recurrences were found at a mean follow-up of 31 months. One case of possible metastasis was identified. Three (8%) tumors required further treatment due to positive surgical margins. Marginal excision of squamous cell carcinoma of the hand is associated with a low rate of recurrence and metastasis. In addition, the potential for improved cosmesis and diminished morbidity when compared to older more radical surgical methods supports marginal excision for squamous cell carcinoma of the hand as a viable treatment technique.

Squamous cell carcinoma is the most common malignant tumor of the hand, accounting for 58% to 90% of all hand malignancies. Of all squamous cell carcinoma, 11% to 16% are located on the hand or upper extremity.¹ Many risk factors have been identified, the most important of which is ultraviolet radiation exposure from the sun. Other important risk factors are immunocompromise, irradiated skin, human papillomavirus infection, chemical exposures, chronic wounds, previous burn injury, and certain genetic diseases such as xeroderma pigmentosum. Men are afflicted twice as often as women with a peak incidence in the sixth decade of life.¹

---

advertisement

---

Haws et al² reported a 0.1% to 3% rate of metastasis for squamous cell carcinoma of sun-exposed skin. However, squamous cell carcinoma of the hand is associated with a higher risk of metastasis compared to squamous cell carcinoma of the skin in other regions of the body, having been reported to metastasize in 5.5% to 28% of cases.^1,3

In 1981, Rayner⁴ described the “danger zone” of the hand to include the dorsal skin of the proximal phalanges, interdigital clefts, and the first webspace. He noted that tumors in this region of the hand were associated with an increased incidence of local recurrence and metastasis when compared to other regions of the hand. The 5-year survival rate for metastatic squamous cell carcinoma is 20% to 40%.² Effective diagnosis and treatment for squamous cell carcinoma of the hand and upper extremity prior to metastasis is therefore paramount in impacting long term outcomes. Surgical excision of squamous cell carcinoma is a useful tool in the treatment of squamous cell carcinoma of the hand, but has the potential to impose significant functional and cosmetic morbidity postoperatively. Recurrence rates after surgical excision have been reported and vary from 3% to 22%.^3,5,6

Uncertainty exists with regard to proper margins for excision. To date, no prospective, randomized trial has compared margins of resection. Most hand surgery texts recommend wide excision with 1- to 2-cm margins.^2,7 Wide excision, as opposed to marginal excision has been recommended due to the concern for undetectable tumor extension within surgical margins at the time of surgery requiring multiple operations to obtain complete tumor resection. High rates of recurrence and metastasis experienced by some surgeons also have influenced the recommendation for wide surgical excision. Clearly, wide excision with the recommended surgical margins can lead to functional morbidity, undesirable cosmetic appearance and potential need for amputation.

Dermatologists have used Mohs surgical technique for treatment of cutaneous squamous and basal cell carcinomas. This technique uses serial excision of thin horizontal layers of the lesion with minimal excision of surrounding normal tissue. Appropriate margins are determined by the type of tumor and location. This technique allows for histological evaluation of the tumor margin to confirm clear margins while preventing significant surgical injury to the surrounding tissues.^8,9

Margins of 4 to 6 mm with Mohs have been successful in treating tumors of the skin.¹⁰ Wagner and Cottel¹¹ performed Mohs surgery on 53 cases of squamous cell carcinoma and basal cell carcinoma of the hand and reported no recurrences at 66.9 and 14.3 years of cumulative follow-up, respectively. Rowe et al¹² reviewed all studies since 1940 on prognosis of treatment of squamous cell carcinoma of the skin and lip and found Mohs surgery to be superior in minimizing recurrence rates compared to other techniques including cryotherapy, curettage and electrodessication, surgical excision, and radiation therapy.

With the development of Mohs surgery in dermatology and its success in treatment of squamous cell carcinomas of the hand using minimal margins with high cure rates and low recurrence rates, the senior author (S.F.V.) has been offering marginal excision as an option in the surgical management of squamous cell carcinoma of the hand to patients for a number of years.

This retrospective study of 32 patients with 35 squamous cell carcinomas of the hand evaluated the results of marginal surgical excision at the authors’ institution pertaining to the rate of recurrence and metastasis as well as the incidence of positive margins requiring further intervention.

Materials and Methods

Thirty-two patients with 35 lesions treated surgically for squamous cell carcinoma of the hand with marginal surgical excision at the authors’ institution from 1993 to 2003 were included in this study. Approval was received from the institutional review board. All patients were referred by dermatologists or primary care physicians for surgical treatment of suspected or biopsy confirmed squamous cell carcinoma of the hand.

A metastatic work-up was not performed by our clinic; however, no palpable lymph nodes were discerned in this group of patients on physical examination. All patients underwent marginal tumor excision with primary closure or skin grafting of the wound. A 2- to 4-mm normal margin of tissue was excised with the tumor based on gross appearance by intraoperative evaluation with loupe magnification.

Wound management included primary closure or skin grafting. All specimens were sent for histological evaluation to detect presence of tumor and assess biopsy margins. If margins were positive for residual tumor, then further intervention was subsequently performed. All patients had postoperative short-term follow-up with the hand surgeon. Long-term follow-up was coordinated with the patient’s dermatologist or primary care physician.

Patient medical records were reviewed and the following information was gathered: patient age, sex, relevant medical history, preoperative diagnosis, postoperative diagnosis, date of procedure, location and size of the lesion, length of follow-up, and outcome.

Results

There were 32 patients with 34 squamous cell carcinomas of the hand and 1 keratoacanthoma. Mean patient age was 69 years (range, 44-93 years). The average age for women was 72 years and for men, 68 years. There were 22 (69%) men and 10 (31%) women. Four patients had kidney transplants, and 1 patient had a heart transplant, thus, 16% of the patients in this study were on chronic immunosuppressive therapy. The average size of the lesions was 2.2 cm² (range, 0.18-10.5 cm²).

Preoperative diagnoses included 24 invasive squamous cell carcinomas, 2 Bowen’s disease (squamoos cell carcinoma in situ), two Bowen’s cannot rule out invasive squamous cell carcinoma, 3 squamous cell carcinoma keratoacanthoma types, one actinic keratosis cannot rule out invasive squamous cell carcinoma, and 1 keratoacanthoma. Two patients had suspected squamous cell carcinoma without a preoperative biopsy to confirm the diagnosis. The actinic keratosis was determined to be invasive squamous cell carcinoma by permanent pathology. The keratoacanthoma was found not to be malignant.

Eleven (31% of squamous cell carcinomas) lesions that were found to be malignant preoperatively based on preoperative biopsy had no evidence of malignancy on postoperative pathology. The preoperative diagnoses for the 11 lesions included 7 invasive squamous cell carcinomas, 2 squamous cell carcinoma keratoacanthoma types, and 2 Bowen’s cannot rule out invasion. Twenty-nine of the squamous cell carcinomas were primary and 5 (15%) were recurrent. Two patients had multiple hand lesions removed. One patient had 2 lesions and one had 3 lesions. The defects for 20 lesions were closed primarily at surgery. Twelve required split thickness skin grafting while 3 underwent full thickness skin grafting. Evaluation of specimens by surgical pathology revealed positive margins in three (9%) tumors treated with marginal excision. One patient required ray resection of the nondominant index finger after repeat marginal excision resulted in persistent positive surgical margins. Another patient had a positive margin on the proximal border of the specimen after undergoing marginal excision and split thickness skin grafting for a squamous cell carcinoma on the dorsum of his left hand. This was effectively treated with Mohs surgery and primary closure. A third patient underwent marginal excision for a recurrent squamous cell carcinoma located at the right index finger nailbed. This lesion had previously been treated with radiation therapy. A positive margin was detected after marginal excision and was managed with 5FU. None of these patients had further evidence of remaining tumor at the latest follow-up. Mean follow-up time for all patients was 31 months (range, 2-103 months) with no recurrences (Table). One patient was found to have metastatic desmoplastic squamous cell carcinoma in his vertebrae. This patient died from metastatic adenocarcinoma and had a history of multiple head and neck squamous cell carcinomas for which he had undergone extensive treatment before and after surgical excision of his hand squamous cell carcinoma. Surgical margins were negative at the time of marginal excision of his hand lesion. It would be difficult to attribute the metastatic disease of the spine to the squamous cell carcinoma of the hand in this patient.

Discussion

The recurrence rate for patients who underwent marginal excision of squamous cell carcinoma of the hand in this study is 0%. This recurrence rate is comparable or better than results that have previously been published in other studies.^3,5,6,11,12 Other studies have shown higher recurrence rates even with wide surgical margins, such as Schiavon et al³ with 22%. The rate of metastasis is 2.9% (1 of 34 squamous cell carcinomas) if the vertebral metastasis as described above is attributed to the squamous cell carcinoma of the hand.

Wagner and Cottel¹¹ have reported a lower incidence of metastasis with Mohs surgery; however, this procedure is associated with limited availability. Two patients required further surgical intervention due to positive margins after initial marginal excision. A third patient was effectively managed with 5FU without need for further surgical intervention. None of these 3 patients had evidence of persistent or recurrent tumor at their latest follow-up. All patients who underwent marginal excision were satisfied with the cosmetic result, and, excluding the ray resection, all patients maintained hand function consistent with their preoperative functional status. Also of note is the fact that 16% of patients in this study were organ transplant recipients and were therefore on chronic immunosuppressive therapy.

Most other reports have not commented on the number of patients with medical conditions resulting in immunocompromise. Bean et al⁵ reported 1 of 70 patients who was immunocompromised. Skin cancer is a significant problem for those on chronic immunosuppressive therapy. Glover et al¹³ found 21.9% of patients on chronic immunosuppression developed nonmelanoma skin cancer. In a group of transplant recipients greater than 9 years out from transplant surgery, 40% developed nonmelanoma skin cancer.

Another important point for consideration is that, as discussed earlier, histological assessment of surgical specimens revealed no evidence of remaining tumor in 11 lesions following marginal excision. Each of these lesions was confirmed as malignant based upon preoperative intralesional biopsy performed by a dermatologist. Therefore, in these patients, the initial biopsy performed by the dermatologist was apparently adequate or initiated subsequent immunological events associated with wound healing which may have destroyed residual skin cancer prior to definitive surgical management.¹⁴ In these circumstances following positive biopsy, further treatment is indicated due to an increased risk of recurrence without further definitive treatment.¹⁵ Subsequent marginal excision in these patients may have avoided greater potential morbidity and functional loss, which would have been likely with a more aggressive surgical treatment.

Marginal excision of squamous cell carcinoma of the hand in this series is associated with a low rate of tumor recurrence and metastasis. The potential for improved cosmesis and diminished morbidity when compared to more commonly described and radical surgical methods supports marginal excision for squamous cell carcinoma of the hand as a viable treatment technique. All patients should be evaluated postoperatively for findings that may be consistent with tumor recurrence or new primary tumors. However, it appears that marginal excision of squamous cell carcinoma of the hand in a high-risk population of patients with significant sun exposure is successful and can be presented to patients as an alternative form of treatment for this condition.

References

1. Fink JA, Akelman E. Nonmelanotic malignant skin tumors of the hand. Hand Clin. 1995; 11:255-264.
2. Haws MJ, Neumeister MW, Kenneaster DG, Russell RC. Management of nonmelanoma skin tumors of the hand. Clin Plast Surg. 1997; 24:779-795.
3. Schiavon M, Mazzoleni F, Chiarelli A, Matano P. Squamous cell carcinoma of the hand: fifty-five case reports. J Hand Surg. 1988; 13:401-404.
4. Rayner CR. The results of treatment of two hundred and seventy-three carcinomas of the hand. Hand. 1981; 13:183-186.
5. Bean DJ, Rees RS, O’Leary JP, Lynch JB. Carcinoma of the hand: a 20-year experience. South Med J. 1984; 77:998-1000.
6. Chakrabarti I, Watson JD, Dorrance H. Skin tumours of the hand. A 10-year review. J Hand Surg [Br]. 1993; 18:484-486.
7. Fleegler EJ. Skin Tumors. In: Green DP, Hotchkiss RN, Pedersen WC, eds. Green’s Operative Hand Surgery. 4th ed. Philadelphia, PA: Churchill Livingstone; 1999:2191-2193.
8. Finley EM, Ratz JL. Mohs Micrographic Surgery. In: Ratz JL, Geronemus RG, et al, eds. Textbook of Dermatologic Surgery. Philadelphia, PA: Lippincott-Raven; 1998:417-437.
9. Steinman HK. Mohs Surgical Techniques. In: Gross KG, Steinman HK, Rapini RP, eds. Mohs Surgery: Fundamentals and Techniques. St. Louis, MO: Mosby; 1999:49-66.
10. Brodland DG, Zitelli JA. Surgical margins for excision of primary cutaneous squamous cell carcinoma. J Am Acad Dermatol. 1992; 27:241-248.
11. Wagner RF, Cottel WI. Treatment of squamous and basal cell carcinomas of the hand with mohs micrographic surgery: Analysis of 53 consecutive patients. Skin Cancer. 1989; 4:73-77.
12. Rowe DE, Carroll RJ, Day CL Jr. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. Implications for treatment modality selection. J Am Acad Dermatol. 1992; 26:976-990.
13. Glover MT, Niranjan N, Kwan JT, Leigh IM. Non-melanoma skin cancer in renal transplant recipients: the extent of the problem and a strategy for management. Br J Plast Surg. 1994; 47:86-89.
14. Swetter SM, Boldrick JC, Pierre P, Wong P, Egbert BM. Effects of biopsy-induced wound healing on residual basal cell and squamos cell carcinomas: rate of tumor regression in excisional specimens. J Cutan Pathol. 2003; 30(2):139-146.
15. Holmkvist KA, Rogers GS, Dahl PR. Incidence of residual basal cell carcinoma in patients who appear tumor free after biopsy. J Am Acad Dermatol. 1999; 41:600-605.

Authors

Drs Joyner and Viegas and Mr Wilson are from the Department of Orthopedic Surgery, and Dr Wagner is from the Department of Dermatology, University of Texas Medical Branch, Galveston, Texas.

Drs Joyner and Viegas and Mr Wilson have no relevant financial relationships to disclose.

Correspondence should be addressed to: Steven F. Viegas, MD, Dept of Orthopedic Surgery, University of Texas Medical Branch, Galveston, TX 77555-0165.