Recurrence Rates of Cutaneous Squamous Cell Carcinoma of the Head and Neck After Mohs Micrographic Surgery vs. Standard Excision

A Retrospective Cohort Study

C.B. van Lee; B.M. Roorda; M. Wakkee; Q. Voorham; A.L. Mooyaart; H.C. de Vijlder; T. Nijsten; R.R. van den Bos


The British Journal of Dermatology. 2019;181(2):338-343. 

In This Article

Abstract and Introduction


Background: Recurrent cutaneous squamous cell carcinoma (cSCC) has been associated with an increased risk of local functional and aesthetic comorbidity, metastasis and mortality.

Objectives: To compare the risk of recurrence between Mohs micrographic surgery (MMS) and standard excision for cSCC of the head and neck.

Methods: This was a retrospective cohort study of all patients with a cSCC treated with MMS or standard excision at the departments of dermatology of a secondary or tertiary care hospital in the Netherlands between 2003 and 2012. To detect all recurrences, patients were linked to the Dutch pathology registry. To compare the risk of recurrence between MMS and standard excision, hazard ratios (HRs) were used adjusted for clinical tumour size > 2 cm and deep tumour invasion.

Results: A total of 579 patients with 672 cSCCs were included: 380 cSCCs were treated with MMS and 292 with standard excision. The risk of recurrence was 8% (22 of 292) after standard excision during a median follow-up of 5·7 years [interquartile range (IQR) 3·5–7·8], which was higher than the 3% (12 of 380) after MMS during a median follow-up of 4·9 years (IQR 2·3–6·0). The cumulative incidence of recurrence was higher for standard excision than for MMS during the entire follow-up period of 8·6 years. Carcinomas treated with MMS were at a three times lower risk of recurrence than those treated with standard excision when adjusted for tumour size and deep tumour invasion (adjusted HR 0·31, 95% confidence interval 0·12–0·66).

Conclusions: MMS might be superior to standard excision for cSCCs of the head and neck because of a lower rate of recurrence.


Cutaneous squamous cell carcinoma (cSCC) represent 20% of all skin cancers. SCC is the second most common skin cancer after basal cell carcinoma. At least one in 15 white people will develop a cSCC before the age of 85 and the incidence is still rising.[1–4] These cSCCs rarely metastasize (4%) and the disease-specific death rate is low (2%).[2,5] However, because of the frequent localization in the head and neck, treatment can lead to major functional and aesthetic comorbidity.

In the Netherlands, cSCC is commonly treated with standard excision. In the Dutch cSCC guideline, Mohs micrographic surgery (MMS) is noted as an alternative for standard excision for stage ≥ II, especially when standard excision would lead to substantial functional or aesthetic comorbidity.[6] In America it is generally accepted that MMS is indicated in high-risk cSCC and the American 'appropriate use criteria for MMS' state that it is also appropriate to use MMS for stage I cSCC.[7]

MMS is superior to standard excision for facial aggressive or recurrent basal cell carcinomas, because of the low recurrence rate and maximum preservation of healthy tissue.[8–10] Studies on cSCC recurrence rates after surgery are sparse and it therefore remains unclear if MMS is better than standard excision for cSCC. This large retrospective cohort study was conducted to determine if the risk of cSCC recurrence is lower after MMS than standard excision.