Surgery for Bowen Disease: Clinicopathological Factors Associated With Incomplete Excision

Julia Fougelberg; Hampus Ek; Magdalena Claeson; John Paoli

doi:10.5826/dpc.1102a46

Surgery for Bowen Disease: Clinicopathological Factors Associated With Incomplete Excision

Authors

Julia Fougelberg Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 2. Region Västra Götaland, Sahlgrenska University Hospital, Department of Dermatology and Venereology, Gothenburg, Sweden https://orcid.org/0000-0003-3433-5557
Hampus Ek Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Magdalena Claeson Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg & Region Västra Götaland, Sahlgrenska University Hospital, Department of Dermatology and Venereology, Gothenburg, Sweden; Department of Population Health, QIMR Berghofer Medical Research Institute & Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Australia
John Paoli Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 2. Region Västra Götaland, Sahlgrenska University Hospital, Department of Dermatology and Venereology, Gothenburg, Sweden https://orcid.org/0000-0003-1326-8535

Keywords:

Bowen disease, dermatological surgery, surgical margins, nonmelanoma skin cancer

Abstract

Background: One common treatment for Bowen’s disease (BD) is surgical excision, but there is no international consensus on the appropriate surgical margins.

Objectives: This study examined what factors affect the rate of incomplete excision of BD.

Methods: Clinicopathological data potentially linked to surgical outcome (complete or incomplete excision) were retrospectively collected from medical and histopathological records on all surgically excised BD lesions diagnosed at Sahlgrenska University Hospital in Gothenburg, Sweden during 2014-2015. Data were analyzed with two definitions of incomplete excision: less strict (ie, BD present at the surgical margin) and strict (ie, dysplasia present at the surgical margin).

Results: In total, 463 BD lesions among 408 patients were included. With the less strict definition, 3 factors were associated with significantly higher rates of incomplete excision: surgical margins <3 mm, a less experienced surgeon, and use of punch biopsy excision. The same factors plus a tumor location on the head and neck area or upper extremities were associated with significantly higher rates of incomplete excision using the strict definition. After adjustment for confounders, less experience was independently associated with incomplete excision using the less strict definition, whereas less experience and location on the head and neck area or upper extremities were independently associated with incomplete excision using the strict definition. Surgeon specialty was not associated with incomplete excision regardless of the definition.

Conclusions: When removing BD surgically, an elliptical excision with surgical margins ≥3 mm carried out by an experienced surgeon should be recommended. Surgical margins may need to be adjusted depending on body site.

References

The Swedish Cancer Registry of the National Board of Health and Welfare [Cancer incidence in Sweden 2019] 2020. Accessed March 3, 2021. http://www.socialstyrelsen.se

Peterka ES, Lynch FW, Goltz RW. An association between Bowen's disease and internal cancer. Arch Dermatol. 1961;84:623-629. DOI: 10.1001/archderm.1961.01580160087015.

Kao GF. Carcinoma arising in Bowen's disease. Arch Dermatol. 1986;122(10):1124-1126. PMID: 3767398.

Cox NH, Eedy DJ, Morton CA. Guidelines for management of Bowen's disease: 2006 update. Br J Dermatol. 2007;156(1):11-21. DOI: 10.1111/j.1365-2133.2006.07610.x.

Morton CA, Birnie AJ, Eedy DJ. British Association of Dermatologists' guidelines for the management of squamous cell carcinoma in situ (Bowen's disease) 2014. Br J Dermatol. 2014;170(2):245-260. DOI: 10.1111/bjd.12766.

Shimizu I, Cruz A, Chang KH, Dufresne RG. Treatment of squamous cell carcinoma in situ: a review. Dermatol Surg. 2011;37(10):1394-411. DOI: 10.1111/j.1524-4725.2011.02088.x.

Bath-Hextall FJ, Matin RN, Wilkinson D, Leonardi-Bee J. Interventions for cutaneous Bowen's disease. Cochrane Database Syst Rev. 2013(6):Cd007281. DOI: 10.1002/14651858.CD007281.pub2.

Eriksson T, Tinghog G. Societal cost of skin cancer in Sweden in 2011. Acta Derm Venereol. 2015;95(3):347-348. DOI: 10.2340/00015555-1938.

Bassas P, Hilari H, Bodet D, Serra M, Kennedy FE, García-Patos V. Evaluation of surgical margins in Basal cell carcinoma by surgical specialty. Actas Dermosifiliogr. 2013;104(2):133-140. DOI: 10.1016/j.ad.2012.06.001.

Westers-Attema A, van den Heijkant F, Lohman BG, et al. Bowen's disease: A six-year retrospective study of treatment with emphasis on resection margins. Acta Derm Venereol. 2014;94(4):431-435. DOI: 10.2340/00015555-1771.

Delaney EK, Duckworth L, Thompson WD, Lee AJ, Murchie P. Excising squamous cell carcinomas: comparing the performance of GPs, hospital skin specialists and other hospital specialists. Fam Pract. 2012;29(5):541-546. DOI: 10.1093/fampra/cms007.

European Dermatology Forum. Guideline on the diagnosis and treatment of invasive squamous cell carcinoma of the skin. 2018. Accessed October 26, 2020. https://www.edf.one/home/Guidelines/Guidelines.html.

Swedish Society of Dermatological Surgery and Oncology (SDKO). [SDKO Guidelines for management of squamous cell carcinoma and basal cell carcinoma]. 2016. Accessed October 26, 2020. https://ssdv.se/images/pdf/SDKOs_Riktlinjer_for_SCC__BCC_2016.pdf.

National Comprehensive Cancer Network. Clinical practice guidelines in oncology. Basal cell and squamous cell skin cancers. 2020. Accessed October 26, 2020. http://www.nccn.org/professionals.

Bonerandi JJ, Beauvillain C, Caquant L, et al. Guidelines for the diagnosis and treatment of cutaneous squamous cell carcinoma and precursor lesions. J Eur Acad Dermatol Venereol. 2011;25 Suppl 5:1-51. DOI: 10.1111/j.1468-3083.2011.04296.x.

Bogdanov-Berezovsky A, Cohen AD, Glesinger R, Cagnano E, Rosenberg L. Risk factors for incomplete excision of squamous cell carcinomas. J Dermatolog Treat. 2005;16(5-6):341-344. DOI: 10.1080/09546630500424649.

Mirshams M, Razzaghi M, Noormohammadpour P, Naraghi Z, Kamyab K, Sabouri Rad S. Incidence of incomplete excision in surgically treated cutaneous squamous cell carcinoma and identification of the related risk factors. Acta Med Iran. 2011;49(12):806-809. PMID: 22174169.

Pua VS, Huilgol S, Hill D. Evaluation of the treatment of non-melanoma skin cancers by surgical excision. Australas J Dermatol. 2009;50(3):171-175. DOI: 10.1111/j.1440-0960.2009.00531.x.

Stewart TJ, Saunders A. Risk factors for positive margins after wide local excision of cutaneous squamous cell carcinoma. J Dermatolog Treat. 2018;29(7):706-708. DOI: 10.1080/09546634.2018.1441493.

Trakatelli M, Bylaite-Bucinskiene M, Correia O, et al. Clinical assessment of skin phototypes: watch your words! Eur J Dermatol. 2017;27(6):615-619. DOI: 10.1684/ejd.2017.3129.

Paoli J, Ternesten Bratel A, Lowhagen GB, Stenquist B, Forslund O, Wennberg AM. Penile intraepithelial neoplasia: results of photodynamic therapy. Acta Derm Venereol. 2006;86(5):418-421. DOI: 10.2340/00015555-0130.

Goulding JM, Levine S, Blizard RA, Deroide F, Swale VJ. Dermatological surgery: a comparison of activity and outcomes in primary and secondary care. Br J Dermatol. 2009;161(1):110-114. DOI: 10.1111/j.1365-2133.2009.09228.x.

Murchie P, Delaney EK, Thompson WD, Lee AJ. Excising basal cell carcinomas: comparing the performance of general practitioners, hospital skin specialists and other hospital specialists. Clin Exp Dermatol. 2008;33(5):565-571. DOI: 10.1111/j.1365-2230.2008.02710.x.

Salmon P, Mortimer N, Rademaker M, Adams L, Stanway A, Hill S. Surgical excision of skin cancer: the importance of training. Br J Dermatol. 2010;162(1):117-122. DOI: 10.1111/j.1365-2133.2009.09548.x.