Question 1 of 4
(demo test)
Product Demo for MohsQBank
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A renal transplant patient with a history of numerous squamous cell carcinomas (SCCs) presents to you with a growing lesion on the left forearm. It measures 1.5 cm and is quite tender. On histopathology there is a well-differentiated cutaneous (cSCC) measuring 1.8 mm in Breslow depth. No other characteristics of the tumor are commented on in the pathology report. Would micrographic dermatologic surgery (Mohs) be considered appropriate and generally accepted in this scenario based on the published Mohs appropriate use criteria (AUC)?
Diagnosis & Management of Keratinocyte and other Non-Melanoma Skin Cancers
Appropriate Use Criteria
U
A
In an immunosuppressed patient, any non-aggressive form of cutaneous squamous cell carcinoma (cSCC) greater than 1.0 cm in size meets criteria for Mohs surgery based on Mohs appropriate use criteria (AUC) regardless of location (Connolly et al. JAAD 2012). In this case, a score of 7/9 is generated based on the following criteria:
- Squamous cell carcinoma
- Area L
- Primary
- Without histologic aggressive features (outlined below)
- Immunocompromised
- 1.1-2 cm in size
Immunosuppression is based on the following:
- Patient with HIV
- Organ transplant
- Hematologic malignancy
- Pharmacologic immunosuppression
Area H = Central face, eyelids, eyebrows, nose, lips, chin, ears, periauricular, temple, genitalia, perineal, perianal, hands, feet, nails, ankles, nipples
Area M = Cheeks, forehead, scalp, neck, jawline, pretibial surface
Area L = Trunk and extremities (excludes pretibial, hands, feet, nails, ankles)
If the tumor in the above clinical vignette was less than 1.0 cm in diameter, then a score of 5-6/9 would be generated, which would require additional clinical/patient information and physician judgement for a final determination of the appropriateness of Mohs surgery.
It is important to note that any SCC with aggressive histologic features regardless of size, location or immunosuppression status meets Mohs AUC (at least a score of 7/9) for treatment with micrographic dermatologic surgery (Mohs).
Aggressive SCC features (eg, high-risk for recurrence) (Connolly et al. JAAD 2012):
- Sclerosing
- Basosquamous (excluding keratitis BCC)
- Small cell, single cell, or clear cell
- Poorly or undifferentiated (characterized by a high degree of nuclear polymorphism, high mitotic rate, or low degree of keratinization)
- Perineural/perivascualr,
- Spindle cell
- Pagetoid
- Infiltrating
- Keratoacanthoma (central facial type)
- Lymphoepithelial
- Sarcomatous
- Breslow depth of 2 mm or greater
- Clark level IV or greater
A good understanding and appreciation of Mohs AUC by surgeons who utilize micrographic dermatology surgery (Mohs) is incredibly useful. An application is available for Apple and Android users for Mohs AUC, and can be found here. This application can be very helpful to make sure each individual tumor is appropriate for Mohs surgery.
Micrographic dermatologic surgery is the gold standard for treatment of skin cancer. Its use needs to be appropriate. The American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and American Society for Mohs Surgery collaborated to publish appropriate use criteria for Mohs micrographic surgery (MMS) (Connolly et al. JAAD 2012). They make a recommendation on appropriate use criteria MMS in 270 clinical situations. A consensus was reached for all 270 clinical situations, with 200 (74.1%) deemed appropriate, 24 (8.9%) deemed uncertain, and 46 (17.0%) deemed inappropriate. Of note, the recommendations put forward for Mohs appropriate use criteria are supported by the NCCN Guidelines.
Appropriate Use Criteria for micrographic dermatologic surgery (Mohs):
Mask areas of the face (central face, eyelids, eyebrows, nose, lips, chin, ears, periauricular, temple, genitalia, perineal, perianal, hands, feet, nails, ankles, nipples)
Appropriate (score of 7-9)
- BCC
- Primary or Recurrent: Aggressive, Nodular, or Superficial
- SCC
- Primary or Recurrent: Aggressive, Nonaggressive, Verrucous, KA-type not central facial, SCC-in situ/Bowen's
- LM and MIS
- Primary or Recurrent: LM, MIS
Inappropriate
- SCC
- Primary or Recurrent: AK with focal SCC in situ
Cheeks, forehead, scalp, neck, jawline, pretibial surface
Appropriate
- BCC
- Primary or Recurrent: Aggressive, Nodular, Superficial in immunocompromised
- Primary: Superficial ≥ 0.6cm
- SCC
- Primary or Recurrent: Aggressive, Nonaggressive, KA-type not central facial, SCC in situ/Bowen's
- LM and MIS
- Primary or recurrent: LM; MIS
- BCC
- Primary: Superficial ≤ 0.5cm
Inappropriate
- SCC
- Primary or recurrent: AK with focal SCC in situ
Trunk and extremities (excludes pretibial, hands, feet, nails, ankles)
Appropriate
- BCC
- Recurrent: Aggressive, Nodular
- Primary: Aggressive ≥ 0.6cm, Nodular ≥ 2.0cm, Nodular in immunocompromised ≥ 1.1cm
- SCC
- Primary or recurrent: Aggressive
- Recurrent: KA-type, Nonaggressive
- Primary ≥ 2.0cm: Nonaggressive, SCC in situ/Bowen's
- Primary ≥ 1.1cm: Nonaggressive in immunocompromised, KA-type, SCC in situ/Bowen's in immunocompromised
- KA-type SCC in immunocompromised ≥ 0.6cm
- LM and MIS
- Recurrent: LM; MIS
Uncertain
- BCC
- Primary: Aggressive ≤ 0.5cm, Nodular 1.1-2.0cm, Nodular in immunocompromised 0.6-1.0cm, Superficial in immunocompromised ≥ 1.1cm
- SCC
- Recurrent: SCC in situ/Bowen's
- Primary 1.1-2.0cm: Nonaggressive, SCC in situ/Bowen's
- Primary ≤ 1.0cm: Nonaggressive in immunocompromised
- Primary 0.6-1.0cm: SCC in situ/Bowen's in immunocompromised
- Primary ≤ 0.5cm: KA-type in immunocompromised
- LM and MIS
- Primary: LM, MIS
Inappropriate
- BCC
- Recurrent: superficial
- Primary: Nodular ≤ 1.0cm, Nodular in immunocompromised ≤ 0.5cm, Superficial, Superficial in immunocompromised ≤ 1.0cm
- SCC
- Primary or recurrent: AK with focal SCC in situ
- Primary ≤ 1.0cm: Nonaggressive, KA, SCC in situ/Bowen's
- Primary ≤ 0.5cm: SCC in situ/Bowen's in immunocompromised
Clinical Pearl: National Societies, including the American Academy of Dermatology, American Society of Dermatologic Surgery, American College of Mohs Surgery, and NCCN Guidelines, have published data that guide appropriate selection of cutaneous malignancies for treatment with micrographic dermatologic surgery (Mohs). Immunosuppression status plays a big role in Mohs AUC for determination of appropriateness of Mohs surgery for treatment of squamous cell carcinoma.
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