Detection of High-Risk Histologic Features and Tumor Upstaging of Nonmelanoma Skin Cancers on Debulk Analysis: A Quantitative Systematic Review

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Histologic analysis of tumor debulks from Mohs micrographic surgery (MMS) or wide local excision may lead to the detection of adverse features missed on initial biopsy.


Determine the incidence of (1) high-risk features on debulk analysis compared with initial biopsy and (2) upstaging of tumors on debulk analysis according to the American Joint Committee of Cancer-7th Edition (AJCC-7) and the Brigham and Women's Alternative (BWH) staging criteria.


A comprehensive search strategy using PubMed/MEDLINE, Web of Science, and EMBASE was conducted to identify articles published from 1960 to present that detail histology of initial biopsy and debulked tumor.


Fourteen studies, encompassing 2,565 cases of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) were included in the data extraction process. BCCs (30.9%) were reclassified from a low-risk histologic subtype to a high-risk subtype on debulk analysis (p < .001). Cases with perineural invasion (89.4%) were detected on debulk analysis. SCC tumors (9.1% and 11.1%) were upstaged according to the AJCC-7 and BWH Alternative criteria, respectively. Ninety percent of high-risk BWH T2b SCCs were inaccurately staged lower on initial biopsy.


Tumor debulk analysis in MMS may aid in the identification of additional high-risk features, thereby improving staging accuracy, treatment decisions and patient outcomes.

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