1. In a retrospective review of 55 patients with subungal squamous cell carcinoma (SUSCC) without bone infiltration, wide surgical excision (WSE) followed by full-thickness skin graft reconstruction was associated with low rates of diseases recurrence.
2. WSE is also associated with low rates of post-operative complications and high patient satisfaction.
Evidence Rating Level: 3 (Average)
Study Rundown: SUSCC is the most common malignancy of the nail. Its clinical manifestations are often nonspecific, but it can present as erythronychia, onycholysis, hyperkeratosis, or a viral wart. Although invasive disease that infiltrates the bone requires amputation, presently, there is no established treatment protocol for in situ disease. Mohs micrographic surgery (MMS) has demonstrated effectiveness, but is time-consuming, challenging, and requires the expertise of both surgeons and pathologists. In contrast, WSE of the nail followed by full-thickness skin graft reconstruction has been shown to be a more efficient and a viable alternative with low recurrence. The objective of this study was to evaluate the effectiveness of WSE with full-thickness skin graft reconstruction through extended follow-up.
This study retrospectively evaluated the treatment of 55 patients with non-invasive SUSCC using WSE with full-thickness graft reconstruction through retrospective medical record review and questionnaires. At the conclusion of the study, WSE demonstrated high cure rate, few immediate post-operative complications, low risk of major complications, lower recurrence rate than MMS, and high patient satisfaction with minimal impairment of quality of life. Thus, WSE may serve as the optimal therapeutic modality for SUSCC without bone invasion. This study is strengthened by the collection of outcome data from both medical records and patient/physician questionnaires, its larger study population, and longer follow-up compared to similar studies. This study is limited by its retrospective protocol, lack of control group for comparison, use of a single center and single surgeon, and misclassification bias as a result of data collection from questionnaires. Larger, multi-center, prospective, randomized controlled trials, which directly compare MMS to WSE may improve study conclusions.
In-Depth [retrospective cohort]: This study retrospectively evaluated the use of WSE with full-thickness skin graft reconstruction for biopsy-proven SUSCC with no radiographic evidence of bone invasion in 55 patients at a single institution in France. Clinical outcomes were assessed by retrospective medical record review and questionnaires sent to patients and practitioners that assessed functional complications, quality of life, postoperative complications, and recurrences. Median follow-up was 6.6 years and recurrence rate was 4%. Immediate postoperative complications included severe pain (15%), delayed wound healing (9%), and graft infection (2%). Delayed postoperative complications included sensory disorders of the nail unit (92.7%), epidermal inclusion cysts (18%), and nail spicules (14%). Functional disabilities included difficulty in gripping objects (49%) and loss of motion of the interphalangeal joint (20%). Fifty patients (98%) reported no effect or mild effect on quality of life and 47 (92%) were very satisfied with surgical outcomes.
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