{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T17:45:00Z","timestamp":1789148700803,"version":"build-2803163510"},"reference-count":30,"publisher":"Harborside Press, LLC","issue":"12","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:p>\n                    <jats:bold>Background:<\/jats:bold>\n                    Among the 1.5 million cases of cutaneous squamous cell carcinoma (cSCC) diagnosed annually in the United States, a subset of aggressive tumors recur or metastasize. Treatment options include total margin-controlled surgery, such as Mohs micrographic surgery or other forms of peripheral and deep en face margin assessment (MMS\/PDEMA), and standard excision with postoperative vertical section margin assessment (SEVMA). NCCN Guidelines recommend MMS\/PDEMA for the management of cSCC classified as very high risk based on NCCN risk stratification criteria. This study aims to validate the recommendation of MMS\/PDEMA as the preferred surgical approach for NCCN very high-risk cSCCs, using data from a multicenter, multinational cohort.\n                    <jats:bold>Methods:<\/jats:bold>\n                    A multicenter cohort study was conducted across 12 sites, including 10 in the United States, 1 in Spain, and 1 in Brazil, comprising 2,752 primary NCCN very high-risk cSCCs treated with MMS\/PDEMA or SEVMA. Propensity score\u2013weighted analysis was used to balance baseline characteristics. Outcomes included local recurrence (LR), nodal metastasis (NM), distant metastasis (DM), and disease-specific death (DSD).\n                    <jats:bold>Results:<\/jats:bold>\n                    After balancing baseline characteristics, SEVMA was associated with a 2-fold higher rate of poor outcomes, including recurrence, metastasis, and DSD, compared with MMS\/PDEMA. The 3-year cumulative incidence of poor outcomes was higher for SEVMA: LR (12.5% vs 5.9%), NM (11.6% vs 6.0%), DM (4.3% vs 1.9%), and DSD (6.2% vs 3.3%).\n                    <jats:bold>Conclusions:<\/jats:bold>\n                    This study supports the NCCN recommendation of MMS\/PDEMA for NCCN very high-risk cSCC, showing reduced recurrence, metastasis, and cSCC-specific mortality compared with SEVMA.\n                  <\/jats:p>","DOI":"10.6004\/jnccn.2025.7072","type":"journal-article","created":{"date-parts":[[2025,12,17]],"date-time":"2025-12-17T13:56:22Z","timestamp":1765979782000},"page":"531-537","source":"Crossref","is-referenced-by-count":1,"title":["Excision With Total Margin Control Versus Vertical Section Margin Assessment for NCCN Very High-Risk Cutaneous Squamous Cell Carcinoma"],"prefix":"10.6004","volume":"23","author":[{"given":"David M.","family":"Wang","sequence":"first","affiliation":[{"name":"Department of Dermatology, Brigham and Women\u2019s Hospital, Boston, MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nina A.","family":"Ran","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Brigham and Women\u2019s Hospital, Boston, MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily E.","family":"Granger","sequence":"additional","affiliation":[{"name":"Department of Medicine, Newton-Wellesley Hospital, Boston, MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shlomo","family":"Koyfman","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Allison","family":"Vidimos","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Cleveland Clinic, Cleveland, OH"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashley","family":"Wysong","sequence":"additional","affiliation":[{"name":"Department of Dermatology, University of Nebraska Medical Center, Omaha, NE"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David R.","family":"Carr","sequence":"additional","affiliation":[{"name":"Department of Dermatology, The Ohio State University Medical Center, Columbus, OH"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathryn T.","family":"Shahwan","sequence":"additional","affiliation":[{"name":"Department of Dermatology, The Ohio State University Medical Center, Columbus, OH"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelsey E.","family":"Hirotsu","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Stanford School of Medicine, Stanford, CA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John A.","family":"Carucci","sequence":"additional","affiliation":[{"name":"Department of Dermatology, New York University School of Medicine, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joi B.","family":"Carter","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Geisel School of Medicine at Dartmouth, Hanover, NH"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Javier","family":"Ca\u00f1ueto","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fabio M.","family":"Girardi","sequence":"additional","affiliation":[{"name":"Department of Head and Neck Surgery, Ana Nery Hospital, Santa Cruz do Sul, RS, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aaron R.","family":"Mangold","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Mayo Clinic Arizona, Scottsdale, AZ"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Divya","family":"Srivastava","sequence":"additional","affiliation":[{"name":"Department of Dermatology, University of Texas Southwestern School of Medicine, Dallas, TX"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rajiv I.","family":"Nijhawan","sequence":"additional","affiliation":[{"name":"Department of Dermatology, University of Texas Southwestern School of Medicine, Dallas, TX"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David G.","family":"Brodland","sequence":"additional","affiliation":[{"name":"Zitelli and Brodland P.C., Pittsburgh, PA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John A.","family":"Zitelli","sequence":"additional","affiliation":[{"name":"Zitelli and Brodland P.C., Pittsburgh, PA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tyler J.","family":"Willenbrink","sequence":"additional","affiliation":[{"name":"Zitelli and Brodland P.C., Pittsburgh, PA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily S.","family":"Ruiz","sequence":"additional","affiliation":[{"name":"Department of Dermatology, Brigham and Women\u2019s Hospital, Boston, MA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"4047","reference":[{"key":"B1","series-title":"J Am Acad Dermatol","first-page":"388","article-title":"United States burden of melanoma and non-melanoma skin cancer from 1990 to 2019","volume":"85","author":"Aggarwal P","year":"2021","unstructured":"Aggarwal P, Knabel P, Fleischer AB. United States burden of melanoma and non-melanoma skin cancer from 1990 to 2019. J Am Acad Dermatol 2021;85:388\u2013395."},{"key":"B2","series-title":"Lancet Oncol","first-page":"713","article-title":"Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study","volume":"9","author":"Brantsch KD","year":"2008","unstructured":"Brantsch KD, Meisner C, Sch\u00f6nfisch B,  Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. Lancet Oncol 2008;9:713\u2013720."},{"key":"B3","series-title":"J Surg Oncol","first-page":"811","article-title":"The incidence of metastasis from cutaneous squamous cell carcinoma and the impact of its risk factors","volume":"106","author":"Brougham NDLS","year":"2012","unstructured":"Brougham NDLS, Dennett ER, Cameron R, Tan ST. The incidence of metastasis from cutaneous squamous cell carcinoma and the impact of its risk factors. J Surg Oncol 2012;106:811\u2013815."},{"key":"B4","series-title":"JAMA Dermatol","first-page":"402","article-title":"Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma and a proposed alternative tumor staging system","volume":"149","author":"Jambusaria-Pahlajani A","year":"2013","unstructured":"Jambusaria-Pahlajani A, Kanetsky PA, Karia PS,  Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma and a proposed alternative tumor staging system. JAMA Dermatol 2013;149:402\u2013410."},{"key":"B5","series-title":"JAMA Dermatol","first-page":"541","article-title":"Factors predictive of recurrence and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort study","volume":"149","author":"Schmults CD","year":"2013","unstructured":"Schmults CD, Karia PS, Carter JB Factors predictive of recurrence and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort study. JAMA Dermatol 2013;149:541\u2013547."},{"key":"B6","series-title":"J Craniomaxillofac Surg","first-page":"443","article-title":"Cutaneous head and neck SCCs and risk of nodal metastasis \u2013 UK experience","volume":"37","author":"Mourouzis C","year":"2009","unstructured":"Mourouzis C, Boynton A, Grant J,  Cutaneous head and neck SCCs and risk of nodal metastasis \u2013 UK experience. J Craniomaxillofac Surg 2009;37:443\u2013447."},{"key":"B7","series-title":"J Am Acad Dermatol","first-page":"957","article-title":"Cutaneous squamous cell carcinoma: estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012","volume":"68","author":"Karia PS","year":"2013","unstructured":"Karia PS, Han J, Schmults CD. Cutaneous squamous cell carcinoma: estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012. J Am Acad Dermatol 2013;68:957\u2013966."},{"key":"B8","series-title":"J Am Acad Dermatol","first-page":"288","article-title":"Comparison of methods for checking surgical margins","volume":"23","author":"Rapini RP","year":"1990","unstructured":"Rapini RP. Comparison of methods for checking surgical margins. J Am Acad Dermatol 1990;23:288\u2013294."},{"key":"B9","series-title":"Mayo Clin Proc","first-page":"1261","article-title":"Understanding Mohs micrographic surgery: a review and practical guide for the nondermatologist","volume":"92","author":"Tolkachjov SN","year":"2017","unstructured":"Tolkachjov SN, Brodland DG, Coldiron BM,  Understanding Mohs micrographic surgery: a review and practical guide for the nondermatologist. Mayo Clin Proc 2017;92:1261\u20131271."},{"key":"B10","series-title":"J Am Acad Dermatol","first-page":"469","article-title":"Accuracy of serial transverse cross-sections in detecting residual basal cell carcinoma at the surgical margins of an elliptical excision specimen","volume":"53","author":"Kimyai-Asadi A","year":"2005","unstructured":"Kimyai-Asadi A, Goldberg LH, Jih MH. Accuracy of serial transverse cross-sections in detecting residual basal cell carcinoma at the surgical margins of an elliptical excision specimen. J Am Acad Dermatol 2005;53:469\u2013474."},{"key":"B11","article-title":"NCCN Clinical Practice Guidelines in Oncology: Squamous Cell Skin Cancer. Version 2.2025","author":"Bordeaux J","unstructured":"Bordeaux J, Aasi SZ, Alam M,  NCCN Clinical Practice Guidelines in Oncology: Squamous Cell Skin Cancer. Version 2.2025. Accessed March 21, 2025. To view the most recent version, visit https:\/\/www.nccn.org"},{"key":"B12","series-title":"JAMA Dermatol","first-page":"728","article-title":"Validation of the 2022 National Comprehensive Cancer Network risk stratification for cutaneous squamous cell carcinoma","volume":"159","author":"Stevens JS","year":"2023","unstructured":"Stevens JS, Murad F, Smile TD,  Validation of the 2022 National Comprehensive Cancer Network risk stratification for cutaneous squamous cell carcinoma. JAMA Dermatol 2023;159:728\u2013735."},{"key":"B13","series-title":"JAMA Dermatol","first-page":"508","article-title":"Mohs surgery versus wide local excision in primary high-stage cutaneous squamous cell carcinoma","volume":"161","author":"Wang D","unstructured":"Wang D, Vestita M, Murad F,  Mohs surgery versus wide local excision in primary high-stage cutaneous squamous cell carcinoma. JAMA Dermatol 2025;161:508\u2013514."},{"key":"B14","series-title":"J Natl Compr Canc Netw","first-page":"e247037","article-title":"Achieving adherence with NCCN non-melanoma skin cancer guidelines regarding peripheral and deep en face margin assessment (PDEMA)","volume":"22","author":"Xu Y","year":"2024","unstructured":"Xu Y, Lim Y, Bordeaux J,  Achieving adherence with NCCN non-melanoma skin cancer guidelines regarding peripheral and deep en face margin assessment (PDEMA). J Natl Compr Canc Netw 2024;22:e247037."},{"key":"B15","series-title":"Multivariate Behav Res","first-page":"399","article-title":"An introduction to propensity score methods for reducing the effects of confounding in observational studies","volume":"46","author":"Austin PC","year":"2011","unstructured":"Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res 2011;46:399\u2013424."},{"key":"B1","series-title":"J Am Acad Dermatol","first-page":"388","article-title":"United States burden of melanoma and non-melanoma skin cancer from 1990 to 2019","volume":"85","author":"Aggarwal P","year":"2021","unstructured":"Aggarwal P, Knabel P, Fleischer AB. United States burden of melanoma and non-melanoma skin cancer from 1990 to 2019. J Am Acad Dermatol 2021;85:388\u2013395."},{"key":"B2","series-title":"Lancet Oncol","first-page":"713","article-title":"Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study","volume":"9","author":"Brantsch KD","year":"2008","unstructured":"Brantsch KD, Meisner C, Sch\u00f6nfisch B,  Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. Lancet Oncol 2008;9:713\u2013720."},{"key":"B3","series-title":"J Surg Oncol","first-page":"811","article-title":"The incidence of metastasis from cutaneous squamous cell carcinoma and the impact of its risk factors","volume":"106","author":"Brougham NDLS","year":"2012","unstructured":"Brougham NDLS, Dennett ER, Cameron R, Tan ST. The incidence of metastasis from cutaneous squamous cell carcinoma and the impact of its risk factors. J Surg Oncol 2012;106:811\u2013815."},{"key":"B4","series-title":"JAMA Dermatol","first-page":"402","article-title":"Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma and a proposed alternative tumor staging system","volume":"149","author":"Jambusaria-Pahlajani A","year":"2013","unstructured":"Jambusaria-Pahlajani A, Kanetsky PA, Karia PS,  Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma and a proposed alternative tumor staging system. JAMA Dermatol 2013;149:402\u2013410."},{"key":"B5","series-title":"JAMA Dermatol","first-page":"541","article-title":"Factors predictive of recurrence and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort study","volume":"149","author":"Schmults CD","year":"2013","unstructured":"Schmults CD, Karia PS, Carter JB Factors predictive of recurrence and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort study. JAMA Dermatol 2013;149:541\u2013547."},{"key":"B6","series-title":"J Craniomaxillofac Surg","first-page":"443","article-title":"Cutaneous head and neck SCCs and risk of nodal metastasis \u2013 UK experience","volume":"37","author":"Mourouzis C","year":"2009","unstructured":"Mourouzis C, Boynton A, Grant J,  Cutaneous head and neck SCCs and risk of nodal metastasis \u2013 UK experience. J Craniomaxillofac Surg 2009;37:443\u2013447."},{"key":"B7","series-title":"J Am Acad Dermatol","first-page":"957","article-title":"Cutaneous squamous cell carcinoma: estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012","volume":"68","author":"Karia PS","year":"2013","unstructured":"Karia PS, Han J, Schmults CD. Cutaneous squamous cell carcinoma: estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012. J Am Acad Dermatol 2013;68:957\u2013966."},{"key":"B8","series-title":"J Am Acad Dermatol","first-page":"288","article-title":"Comparison of methods for checking surgical margins","volume":"23","author":"Rapini RP","year":"1990","unstructured":"Rapini RP. Comparison of methods for checking surgical margins. J Am Acad Dermatol 1990;23:288\u2013294."},{"key":"B9","series-title":"Mayo Clin Proc","first-page":"1261","article-title":"Understanding Mohs micrographic surgery: a review and practical guide for the nondermatologist","volume":"92","author":"Tolkachjov SN","year":"2017","unstructured":"Tolkachjov SN, Brodland DG, Coldiron BM,  Understanding Mohs micrographic surgery: a review and practical guide for the nondermatologist. Mayo Clin Proc 2017;92:1261\u20131271."},{"key":"B10","series-title":"J Am Acad Dermatol","first-page":"469","article-title":"Accuracy of serial transverse cross-sections in detecting residual basal cell carcinoma at the surgical margins of an elliptical excision specimen","volume":"53","author":"Kimyai-Asadi A","year":"2005","unstructured":"Kimyai-Asadi A, Goldberg LH, Jih MH. Accuracy of serial transverse cross-sections in detecting residual basal cell carcinoma at the surgical margins of an elliptical excision specimen. J Am Acad Dermatol 2005;53:469\u2013474."},{"key":"B11","article-title":"NCCN Clinical Practice Guidelines in Oncology: Squamous Cell Skin Cancer. Version 2.2025","author":"Bordeaux J","unstructured":"Bordeaux J, Aasi SZ, Alam M,  NCCN Clinical Practice Guidelines in Oncology: Squamous Cell Skin Cancer. Version 2.2025. Accessed March 21, 2025. To view the most recent version, visit https:\/\/www.nccn.org"},{"key":"B12","series-title":"JAMA Dermatol","first-page":"728","article-title":"Validation of the 2022 National Comprehensive Cancer Network risk stratification for cutaneous squamous cell carcinoma","volume":"159","author":"Stevens JS","year":"2023","unstructured":"Stevens JS, Murad F, Smile TD,  Validation of the 2022 National Comprehensive Cancer Network risk stratification for cutaneous squamous cell carcinoma. JAMA Dermatol 2023;159:728\u2013735."},{"key":"B13","series-title":"JAMA Dermatol","first-page":"508","article-title":"Mohs surgery versus wide local excision in primary high-stage cutaneous squamous cell carcinoma","volume":"161","author":"Wang D","unstructured":"Wang D, Vestita M, Murad F,  Mohs surgery versus wide local excision in primary high-stage cutaneous squamous cell carcinoma. JAMA Dermatol 2025;161:508\u2013514."},{"key":"B14","series-title":"J Natl Compr Canc Netw","first-page":"e247037","article-title":"Achieving adherence with NCCN non-melanoma skin cancer guidelines regarding peripheral and deep en face margin assessment (PDEMA)","volume":"22","author":"Xu Y","year":"2024","unstructured":"Xu Y, Lim Y, Bordeaux J,  Achieving adherence with NCCN non-melanoma skin cancer guidelines regarding peripheral and deep en face margin assessment (PDEMA). J Natl Compr Canc Netw 2024;22:e247037."},{"key":"B15","series-title":"Multivariate Behav Res","first-page":"399","article-title":"An introduction to propensity score methods for reducing the effects of confounding in observational studies","volume":"46","author":"Austin PC","year":"2011","unstructured":"Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res 2011;46:399\u2013424."}],"container-title":["Journal of the National Comprehensive Cancer Network"],"original-title":[],"link":[{"URL":"https:\/\/jnccn.org\/view\/journals\/jnccn\/23\/12\/article-p531.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/jnccn.org\/downloadpdf\/journals\/jnccn\/23\/12\/article-p531.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/jnccn.org\/downloadpdf\/journals\/jnccn\/23\/12\/article-p531.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,17]],"date-time":"2025-12-17T13:56:23Z","timestamp":1765979783000},"score":1,"resource":{"primary":{"URL":"https:\/\/jnccn.org\/view\/journals\/jnccn\/23\/12\/article-p531.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12]]},"references-count":30,"journal-issue":{"issue":"12"},"URL":"https:\/\/doi.org\/10.6004\/jnccn.2025.7072","relation":{},"ISSN":["1540-1405","1540-1413"],"issn-type":[{"value":"1540-1405","type":"print"},{"value":"1540-1413","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12]]}}}