American Association of Plastic Surgeons

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Clinical and Financial Implications of Positive Margins after Non-melanoma Skin Cancer Resection: A Longitudinal Evaluation
Bharat Ranganath, MD1, Robert Teixeira, MD1, Tyag Patel, BS1, Ramon Garza, MD2, Robert X. Murphy, Jr., MD1.
1Lehigh Valley Health Network, Allentown, PA, USA, 2PRMA, San Antonia, TX, USA.

Background:
Modern healthcare promotes "appropriateness of care" and reducing waste. Excision of non-melanoma skin cancers (NMSC) with frozen section occasionally results with final pathology documenting positive margins. Our goal was to determine the rate of residual tumor in re-excised NMSC & follow patients with positive margins who deferred re-excision and evaluate the fiscal implications.
 
Methods:
An IRB-approved retrospective review was conducted of all patient charts with NMSC excision over 15-years. Of 1054 charts, 272 met inclusion criteria. Patients who underwent initial NMSC excision with frozen section negative margins and then found to have positive margins were divided into: (1) re-excision (n=161) or (2) no re-excision (n=111). Variables included demographics, previous skin cancer, tumor location, cancer subtype, excision measurements, time between excisions/recurrence and financial data.
 
Results:
Mean follow-up was 60 months. 83 of 161 patients (52%) excision had no evidence of residual cancer upon re-excision. Patients with a previous history of basal cell carcinoma and larger re-excisions were more likely to have a positive margin after re-excision (p= 0.02 and 0.04, respectively). Only 7 of 111 patients (6.3%) who were observed had "recurrence" with the average time of recurrence being 60 months. Average reimbursement to the facility was $2,619 and for the provider was $365, for a total of $2,984.
 
Conclusion:
Less than half of those with positive margins of NMSC had residual tumor at re-excision while only 6.3% of patients who declined resection after positive margins developed recurrence. Given the prevalence of NMSC, re-excision of "positive" margins can be costly.


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