Surgical Case Study: When You Have to Go Against the Standard of Care

Have you ever had to go against the recommended standard of care due to the circumstances of your patient?  I am sure your answer is “yes”.  Take a look at this case study and remember the takeaway points as you continue to give the best dermatologic care for your patients.

If you look at the above left picture, this is a case study where a patient was referred to me for an excision to his left posterior shoulder for a - Well Differentiated SCC (Site A).

Due to size (>2cm), I would have preferred Mohs for this patient based on standard guidelines.  However, despite my recommendation, this elderly frail patient insisted he was not able to wait a full day if Mohs was performed due to the medical current challenges he was facing. His daughter, who is the primary caretaker, also mentioned how they have transportation issues.

Looking at our surgical options, we discussed the possibility of positive margins if an excision was performed, and they were willing to take that risk. 

In the left picture, you can see adjacent to 'Site A', there was another suspicious lesion lateral to it that was new and never biopsied (Site B).  I recommended performing an excisional biopsy, along with 'Site A', in hopes that if it were another skin cancer we would be able to clear it as well.  The suspicious lesion was present within the lateral dog ear of 'Site A', so it made practical sense to excise both lesions at the same time.

With that, I performed the excisions for the patient.  

The surgical margins I used for 'Site A' was 5mm, wider than the standard 4mm excisional margins for a "less aggressive" SCC, due to its large size. 

For 'Site B', I used more conservative margins to minimize the size and total length of the incision.  

Results?...

Site A: Residual SCC, Deep Margins Focally Positive.  

Site B: Actinic Keratosis, Excoriated and Inflamed, Margins Clear.

In retrospect, should I have deferred the excision and pushed harder for Mohs for 'Site A' due to size? 

Should I have excised at a deeper subcuticular plane to guarantee a higher clearance rate?

The answer to both of these questions are most likely...YES!

But what gives me peace of mind, as a provider, is knowing that I thoroughly discussed the treatment options and risks to the patient and caretaker. I listened to them understanding their needs...and we all came up with a collaborative decision together.

Also, although I knew it was going to take more time to excise the second lesion (Site B), that extra time and attention given to the patient was worth it.  We came up with the most practical option for his situation by treating both lesions that same day.

The discussions we had, prior to the final decision, made that follow-up phone call much easier when I had to inform him and his daughter about the bad news…

'Site A' had positive deep margins and 'Site B' was precancerous. Both needed to be further treated by the Mohs surgeon. In the middle picture, these were the markings when the patient returned back for Mohs.  In the right picture, what the surgical site looked like after the Mohs surgeon reexcised the cancer.  Thankfully, after the first Mohs layer, margins were clear and patient was then repaired.

Cases like these are our best teaching moments, and I hope you will remember what the takeaway points are in this case study...

• Listen to your patients and use your best clinical judgement based on who...your...patient...is. Sometimes we may have to go against the typical standard of care, but that is acceptable...as long as both parties, the provider and the patient, both are understanding of the risk. Each patient has his/her own circumstances, medical conditions, social factors, and lifestyle we have to consider. 
• There will be, also, surprises and unexpected occurrences that will throw off your schedules because you are now having to address other areas of concern.  Despite how inundated we are, we are our patients’ advocate.  The quality of care we provide as dermatology NPs/PAs should always take precedence and why our role is so critical in the dermatology community.

I really hope this case study reaffirmed all that you already know. It is just always reassuring to learn how others approach certain cases.  Please share any comments by replying to this post.  I am looking forward to sharing more pearls of practice with you and learning from you as well. 

P.S. If you liked this article and want to build your confidence in your surgical skills, I created an advanced suturing course tailored specifically for dermatology NPs/PAs. It’s the course I wish I had when I first started!  My mission is to help shortcut your learning curve in hopes to help empower our community.  Click HERE to learn more!

Serving with GRATITUDE,

Theresa Talens DNP, FNP-C

P.U.L.S.E. Dermatology & Procedures, Inc.