Mohs micrographic surgery

Staged excision versus Mohs micrographic surgery for lentigo maligna and lentigo maligna melanoma

Dermatofibrosarcoma protuberans (DFSP) is an invasive skin tumor traditionally associated with very high recurrence rates when treated with conventional surgery (CS). To calculate the minimum margin that would have been required to achieve complete tumor clearance with hypothetical CS. To analyze DFSP characteristics and Mohs micrographic surgery (MMS) effectiveness in treatment of this tumor. Minimum margin was calculated by measuring the largest distance from the visible edge of the tumor to the edge of the surgical defect. Tumor variables (age, sex, size, time since onset, and location) were correlated with surgical variables (number of stages and minimum margin). We studied 222 cases of DFSP treated with MMS. A mean of 1.47 MMS stages and a mean minimum margin of 1.23 cm were required to achieve tumor clearance. Tumors on the head and neck required significantly more stages and a significantly wider margin. Tumor size was positively correlated with time to diagnosis, age, and number of MMS stages. Tumors located on the head and neck have greater subclinical extension. Tumor size was also a predictor of surgical difficulty, but time to diagnosis was not.

Objective To study the clinical characteristics, treatment, prognosis and pathology for mucoepidermoid carcinoma of the eyelid. Methods Eight cases diagnosed as mucoepidermoid carcinoma of Results Mucoepidermoid carcinoma of the eyelid appeared similar to basal cell carcinoma or squamous cell carcinoma, clinically. Tumors developed as erosion or nodular masses. By histopathology, tumor cells showed an admixture of epidermoid cells, mucus-secreting cells and basal cells. Eight cases were treated with Mohs surgery. The recurrence rate was 37.5% for the first operation. The cure rate for recurrent patients after operation was 100%. The ideal cutting line was 6-9mm from the borderline of tumor, confirmed by pathology. Conclusions Mucoepidermoid carcinoma of the eyelid is more common in the elder people. It only could be diagnosed by pathology. It is aggressive. Mohs surgery and eyelid reconstruction are the main treatment. Key words: Eyelid; Mucoepidermoid carcinoma; Pathology; Mohs surgery

The effectiveness of an electronic clinical-decision support tool embedded into the patient medical record at the point of care to guide Mohs surgery utilization: A cohort study

Enhancing techniques to evaluate tumor margins

Mohs micrographic surgery (MMS) has been established as an alternative to standard surgical excision for local cutaneous malignant melanoma (MM) and melanoma in situ (MIS). The use of melanocyte-specific immunohistochemical stains may improve the diagnostic accuracy of MMS frozen sections. We used MMS with immunostains to determine the maximum and minimum margins required to clear 52 melanomas, mostly MIS of the head and neck. We sought to identify the most sensitive melanocyte immunostain for use in MMS frozen sections and to improve the clinicopathologic correlation of perilesional pigmented lesions. We studied 52 consecutive cases of invasive melanoma (n = 10) and MIS (n = 42), tabulating the maximum and minimum margins required for complete tumor resection in any one direction during MMS. In 10 of these cases we studied the relative sensitivity of the immunostains MART-1, S-100, and HMB-45 in Mohs frozen sections. We describe a case highlighting the importance of the increased sensitivity of MART-1. In 12 patients we used a unique mapping technique to help determine the clinical relevance of a total of 35 perilesional pigmented foci. The maximum margin averaged 10.1 mm (range 3-26 mm) for MM and 9.4 mm (range 3-18 mm) for MIS. The minimum margin averaged 7.0 mm (range 3-13 mm) for MM and 5.5 mm (range 3-11 mm) for MIS. For individual tumors, the difference between the minimum and maximum margin averaged 3.7 mm (range 0-13 mm). This difference was >or=5 mm in 38% (20/52) and >or=10 mm in 10% (5/52), highlighting that subclinical tumor extension is often broad and asymmetric. While five of six MM less than 1.0 mm in depth would have been cleared with a routine 1 cm excision, a standard 5 mm margin would have cleared less than one-quarter of the cases of MIS (10/42). In Mohs frozen sections, MART-1 proved superior in sensitivity to both HMB-45 and S-100. Our mapping technique provided clinically relevant histologic correlation for perilesional pigmented lesions, improving the Mohs surgeon's ability to evaluate equivocal foci in frozen sections. MM, especially MIS on the head and neck, often exhibits an asymmetric growth pattern, making it quite suitable for treatment with MMS. The use of MART-1 immunostain may improve the diagnostic accuracy of Mohs surgeons. We believe that HMB-45 should not be used to rule out the diagnosis of MIS in equivocal sections because of its inferior sensitivity. We introduce a new mapping technique as an adjunctive measure to aid in the clinicopathologic evaluation of perilesional skin.

Microcystic adnexal carcinoma, or sclerosing sweat duct carcinoma, is an uncommon cutaneous neoplasm associated with extensive local invasion. The standard of care with regard to the best excisional method in treating microcystic adnexal carcinoma has not been established. To perform a retrospective study comparing patients treated by Mohs micrographic surgery with those treated by wide excision and to elucidate the epidemiological features of microcystic adnexal carcinoma. A retrospective analysis of a case series involving 48 primary and referral patients diagnosed as having microcystic adnexal carcinoma using standardized criteria. All cases were reviewed by the same dermatopathologists. Microcystic adnexal carcinoma predominantly affects the left side of the face of middle-aged women. Microcystic adnexal carcinoma is misdiagnosed 30% of the time. The recurrence rate is 1.98% per patient-year. Mohs micrographic surgery and simple excision show comparable complication rates. Clear margins were obtained in fewer procedures and, therefore, fewer office visits when the lesions were treated with micrographic surgery. The defect surface area after full extirpation following Mohs micrographic surgery was a mean of 4 times that of the clinically apparent size. The wide range of difference between the pre- and the post-Mohs micrographic surgery surface area noted in our data indicates that a margin cannot be safely predicted. Microcystic adnexal carcinoma is a predominantly left-sided, locally aggressive facial tumor, which results in significant morbidity. Our data do not support the use of standardized predictable margins. Mohs micrographic surgery is a reasonable initial treatment, as it accomplishes cure in fewer office visits and does not rely on predicted margins.

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous and subcutaneous mesenchymal malignant tumor characterized by high rates of local recurrence and low risk of metastasis. Histopathological and immumohistochemical study can be used to diagnose DFSP. Recent studies have shown that cell genetics and molecular biology, imagiology, dermatoscopy and cutaneous computed tomography (reflectance confocal microscopy) can also play an important auxiliary role in the diagnosis, treatment and evaluation of DFSP. At present, the surgical treatment of DFSP mainly includes wide local excision (WLE) and Mohs micrographic surgery (MMS) . Each of the two approaches has its advantages and disadvantages. After surgery, radiation therapy and comprehensive immunological treatment can serve as adjuvant treatment. Cryotherapy is effective in patients with recurrent DFSP, and the targeted agent imatinib can be combined for inoperable patients or patients with positive surgical margins. In addition, antiestrogenic drugs (such as tamoxifen) or the new targeted agent heparanase inhibitor roneparstat (SST0001) may have some therapeutic effects. Key words: Dermatofibrosarcoma; Pathology, clinical; Diagnosis; Mohs surgery; Therapeutic Uses

Mohs micrographic surgery (MMS) has shown promising efficacy in female genital cancers, including Extramammary Paget’s disease (EMPD), dermatofibrosarcoma protuberans (DFSP), squamous cell carcinoma (SCC), and basal cell carcinoma (BCC). However, limited consolidated research exists on the clinical outcomes following MMS in female genital cancers. The aim of this systematic review is to synthesize and evaluate recent literature on the application and utility of MMS in the management of female genital cancers. A comprehensive search was conducted of the PubMed and EMBASE databases on October 16, 2024, using the keywords "Mohs surgery" or "Mohs micrographic surgery" and "female genital" or "vulvar cancer" or "vaginal cancer" or "genital cancer" or "vulva" or "vagina." Studies were included if they directly discussed MMS for female genital cancers, particularly EMPD, DFSP, SCC, and BCC, with attention to clinical outcomes, were of the correct study type, and were published in peer-reviewed journals in English. Our results identified a 95% curative rate following MMS for EMPD, DFSP, SCC, and BCC, following analysis of 166 treated cases. MMS provides superior outcomes as compared to traditional excisional approaches, potentially secondary to its precision-guided approach and histological analysis. Future studies should utilize larger patient cohorts and investigate rarer malignancies and combination therapies to optimize treatment guidelines for female genital cancers.

When performing Mohs micrographic and dermatologic surgery for high-risk cutaneous malignancies, particularly aggressive scalp tumors, there may be positive or indeterminate deep margins overlying clinically uninvolved bony cortex (outer table). To ensure complete tumor extirpation in these situations, the authors performed superficial bone decortication and report their case series. Over six consecutive months, superficial bone decortication was performed using a microdrill with rosehead bur after 10 Mohs micrographic surgery cases and one incomplete skin cancer excision. Cases included eight squamous cell carcinomas, two pleomorphic dermal sarcomas, and one basal cell carcinoma. The mean preoperative largest tumor diameter was 37.2 mm, and the mean postoperative largest defect diameter was 49.4 mm. Patients completed mixed-methods questionnaire with a Likert scale, dichotomous, and open-questions. The median pain value was 0 (mean 0.4) during the decortication surgery. All patients receiving Mohs surgery preferred superficial bone decortication under local anesthetic on the day of Mohs rather than referral for another day under general anesthetic.Analysis of open questions determined the procedure was similar to dental drilling -noisy with a vibratory sensation but caused little discomfort. Superficial bone decortication is a well-tolerated and safe procedure in an outpatient setting and can be readily performed after Mohs micrographic surgery in clinically uninvolved bone.

Dermatofibrosarcoma protuberans (DFSP) is a relatively rare cutaneous malignancy with the potential for significant local destruction and morbidity. This neoplasm has a tendency for recurrence following excision due to its infiltrative nature. Surgical excision with wide margins has been considered the standard therapy for DFSP but has had reported recurrence rates of up to 60%. The results of 20 patients with DFSP treated with Mohs micrographic surgery (MMS) are reported. We also reviewed the world literature on the role of MMS for treatment of this tumor. Twenty patients between the ages of 20 and 82 years with DFSP were treated with MMS. The patients were followed for recurrences between 4 and 216 months (mean 56.4 months). None of the 20 patients had a recurrence of DFSP following MMS. Of 221 DFSP patients in our review of the world literature treated with MMS, only 5 (2.3%) had a recurrence. MMS is an effective treatment of DFSP.

Chapter 21 - Premalignant and Malignant Nonmelanoma Skin Tumors

Keratinocyte carcinoma (ie, cutaneous basal and squamous cell carcinoma) is the most common cancer in the United States. To determine whether topical fluorouracil could prevent surgically treated keratinocyte carcinoma. The Veterans Affairs Keratinocyte Carcinoma Chemoprevention Trial was a randomized, double-blind, placebo-controlled trial of topical fluorouracil for chemoprevention of keratinocyte carcinoma. Participants were recruited from May 2009 to September 2011 from 12 Veterans Affairs medical centers and followed until June 30, 2013. Participants were veterans (n = 932) with a history of at least 2 keratinocyte carcinomas in the past 5 years; almost all were white males and the median age was 70 years. Application of fluorouracil, 5%, (n = 468) or vehicle control cream (n = 464) to the face and ears twice daily for 2 to 4 weeks upon randomization. Surgically treated keratinocyte, basal cell, and squamous cell carcinoma risk on the face and ears in the first year after enrollment; and time to first surgically treated keratinocyte, basal cell, and squamous cell carcinoma. The a priori hypothesis was that fluorouracil would be effective in preventing these cancers. Of 932 participants (916 men [98%]; 926 white [99%]; median age, 70 years), 299 developed a basal cell carcinoma end point (95 in year 1) and 108 developed a squamous cell carcinoma end point (25 in year 1) over 4 years (median follow-up, 2.8 years). Over the entire study, there was no difference between treatment groups in time to first keratinocyte, basal cell, or squamous cell carcinoma. During the first year, however, 5 participants (1%) in the fluorouracil group developed a squamous cell carcinoma vs 20 (4%) in the control group, a 75% (95% CI, 35%-91%) risk reduction (P = .002). The 11% reduction in basal cell carcinoma risk during year 1 (45 [10%] in the fluorouracil group vs 50 [11%] in the control group) was not statistically significant (95% CI, 39% reduction to 31% increase), nor was there a significant effect on keratinocyte carcinoma risk. However, a reduction in keratinocyte carcinomas treated with Mohs surgery was observed. A conventional course of fluorouracil to the face and ears substantially reduces surgery for squamous cell carcinoma for 1 year without significantly affecting the corresponding risk for basal cell carcinoma. clinicaltrials.gov Identifier: NCT00847912.

The objective of this study was to quantitatively compare outcomes between standard excision (SE) and Mohs micrographic surgery (MMS) for basal cell carcinoma (BCC). A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines and a search of electronic databases was conducted to identify all randomised controlled trials (RCTs) and observational studies comparing the outcomes of SE versus MMS for BCC. The primary outcome was the recurrence rate for primary and recurrent BCC. The secondary outcomes included the cost of treatment, aesthetic results, the rate of incomplete excision, and the surgical defect size post excision. Five studies enrolling 2060 lesions were identified. There was a statistically significant difference between MMS and SE groups in terms of recurrence rate for primary BCCs (odds ratio (OR) = 0.44, confidence interval (CI) = 0.16 to 0.97, P = 0.04) and recurrent BCCs (OR = 0.33, CI = 0.12 to 0.97, P = 0.04). For secondary outcomes, MMS had improved results compared with SE, except for mean cost. In conclusion, both primary and secondary BCCs treated with MMS have a reduced recurrence rate and defect size thus simplifying reconstruction. However, due to higher costs and operative time attributed to MMS, it should be reserved for high-risk BCCs.

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma that frequently recurs locally, but rarely metastasizes. The purpose of this work is to present a clinical series of DFSP patients and national Danish incidence data in the period 2000–2012. Furthermore, the aim is to present guidelines on the management based on a review of the literature. Medical records of 26 consecutively treated patients at the Department of Plastic Surgery in Health Care Region Zealand were reviewed and histological specimens were reassessed. To investigate national Danish incidence in the period 2000–2012, data were extracted from the national pathology registry. Finally, a literature search was performed in Pubmed and Cochrane, and 23 major publications were reviewed. Studies on Mohs Micrographic surgery were excluded. All patients were treated with wide local excision (WLE) with a median margin of 2.8 cem and a median follow-up time of 36 months. We found a local recurrence rate of 4%. Our national incidence data were based on 374 patients. The overall incidence was 0.53 per 100,000 persons. The prevalence of DFSP in the age group 20–50 years was significantly higher than the group below 20 years (p < 0.0001). Surgery is the treatment of choice for primary DFSP, local recurrences, and metastases. If clear margins cannot be obtained by WLE or surgery is not an option because of unacceptable functional or cosmetic outcome, adjuvant radiotherapy or imatinib can be considered. Chemotherapy can be a final option if other treatments fail.