Uncertainty in the perioperative management of high-risk cutaneous squamous cell carcinoma among Mohs surgeons

Objective: To evaluate whether Mohs surgeons' management of high-risk cutaneous squamous cell carcinoma (HRCSCC) is uniform regarding radiologic nodal staging (RNS) and adjuvant radiation therapy (ART). Design: A survey study of randomly selected, fellowship-trained Mohs surgeons. Setting: An academic medical center. Participants: American College of Mohs Surgery members who responded to an e-mail invitation completed either a survey regarding management of HRCSCC (n=117) or SCC with perineural invasion (PNI) (n=118). Participants totaled approximately 25% of the American College of Mohs Surgery membership. Main Outcome Measures: (1) Percentage of patients with HRCSCC referred for RNS, sentinel lymph node biopsy (SLNB), or ART over the preceding 12 months; (2) top factors leading surgeons to consider RNS, SLNB, or ART; and (3) acceptance of ART for clinical scenarios of various degrees of PNI. Results: Most respondents cited PNI and in-transit metastasis as top factors leading to consideration of RNS, SLNB, or ART. Otherwise, there was no consensus regarding use of, or indications for, RNS, SLNB, or ART. Conclusions: The lack of consistency between experts indicates that there is equipoise regarding indications for RNS and ART in HRCSCC. There is also wide variation in RNS and ART practices among Mohs surgeons who are specifically trained to manage HRCSCC. Clinical trials should therefore be conducted in these areas as there is no clear standard of care.