A retrospective 10-year review of cutaneous squamous cell carcinomas of the hand and adherence to British Association of Dermatologists guidelines

Dear Editor,

We read with interest the manuscript entitled “Surgical options for malignant skin tumors of the hand” by Yun et al. [1].

The guidelines for surgical excision of squamous cell carcinomas (SCCs) by the British Association of Dermatologists (BAD) [2] recommends that a minimum of 4 mm tumor border margin for SCCs less than 2 cm in diameter and low risk in nature. For tumors that are moderately, poorly or undifferentiated in nature, or larger than 2 cm in diameter, a 6 mm or greater tumor margin is recommended. The BAD guidelines are not specific to any anatomical area, and it is important to consider that wide and deep excisions on the hand could lead to significant functional impairment for patients. Cutaneous SCCs are relatively common on the hand and the initial management of such conditions has evolved from radical surgical excision to taking smaller margins [3]. A retrospective audit of 150 cases of cutaneous SCC of the hand was performed to assess adherence to BAD guidelines, and the resulting excision margins.

A retrospective review of 150 patients who underwent surgical excision of SCCs to the hand, distal to the wrist crease, over a 10-year period from 2009 to 2019 was selected from our database. The electronic notes were reviewed to identify patient demographics, peripheral and deep margins on histology and the tumor subtype. Our data was collated and analyzed with Microsoft Excel (Microsoft Corp., Redmond, WA, USA).

The average patient age was 65.9 years (range, 61–100 years). The cohort comprised of 90 males and 60 females. Histological examination of the tumor subtype revealed 63 high-risk tumors and 87 lowrisk tumors. Intended peripheral surgical excision margins were 2 mm in 19 cases (those undergoing excisional biopsies), 4 mm in 58 cases, 5 mm in 33 cases, 6 mm in 24 cases and 10 mm in 16 cases. Deep margin excision was to paratenon in 126 patients and fascia in 24 patients. Peripheral clearance of greater than 1 mm was achieved in all cases, and deep histological clearance in 88% of cases (18 out of 150 patients were found to have tumor at the deep margin of the specimen).

With increasing population longevity, and increasing use of immunosuppressive therapy after organ transplantation, squamous cell carcinoma of the hand is an increasingly prevalent problem. The management of such lesions must take into consideration oncological clearance, whilst aiming to optimize functional and aesthetic outcomes. Lesions that have uncertainty regarding diagnosis may best initially be managed with excisional biopsies, and our results showed high rates of complete SCC excision with 2 mm surgical margins. For clinical suspicious or biopsy proven SCCs to the hand, we recommend following the BAD guidelines [2] where small lesions less than 2 cm should be excised with a 4 mm margin and larger, high risk, lesions should be given at least a 6 mm margin. By adhering to these recommendations, our unit has achieved a 100% peripheral margin excision rate. Most SCCs to the hand lie on the dorsum where there is greatest sun exposure. The anatomy of this area can be challenging when it comes to achieving deep margin clearance, as taking a deep margin corresponding to the peripheral margins recommended may lead to excision of cutaneous nerves and extensor tendons, with obvious resulting functional deficits, and potentially painful neuromas.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

^*The two authors contributed equally to this work.

This study was presented as a poster presentation at the British Society for Surgery of the Hand Conference on November 1, 2019, in Dublin, Ireland.

• References

• 1 Yun MJ, Park JU, Kwon ST. Surgical options for malignant skin tumors of the hand. Arch Plast Surg 2013; 40: 238-43
• 2 Motley R, Kersey P, Lawrence C. et al. Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma. Br J Dermatol 2002; 146: 18-25
• 3 Moehrle M, Metzger S, Schippert W. et al. “Functional” surgery in subungual melanoma. Dermatol Surg 2003; 29: 366-74

Publication History

Received: 10 March 2020

Accepted: 02 April 2020

Article published online:
25 March 2022