Mohs micrographic surgery for the treatment of cutaneous leiomyosarcoma

Clinical Variables Influencing Outcomes in Patients with Atypical Intradermal Smooth Muscle Neoplasms (Formerly Cutaneous Leiomyosarcomas): Single-Institution Study of 95 Surgical Patients

BACKGROUND

Atypical intradermal smooth muscle neoplasm, also commonly termed cutaneous leiomyosarcoma, is a soft tissue tumor with a low risk of aggressive behavior. These lesions arise in the dermis with possible superficial subcutaneous extension, demonstrate cytologic atypia, and often show mitotic activity.

METHODS

A retrospective review of patient demographics, tumor characteristics, and treatment methods was conducted in a consecutive series of patients presenting to MD Anderson Cancer Center (MDACC) from 2002 to 2021 (n = 95). All pathology was reviewed by MDACC pathologists and determined to be atypical intradermal smooth muscle neoplasm.

RESULTS

Median age at diagnosis was 58 years (range 22-86), and 74% were male. Ninety-five percent (n = 90) of patients identified as White, non-Hispanic. Most tumors were slow-growing, solitary, and painless nodules. Tumors were in the lower extremities (44.2%), followed by the upper extremity (28.4%), trunk (22.1%), and head and neck (5.2%). All patients (n = 44, 46.3%) who had a punch/incisional biopsy for diagnostic purposes had a subsequent tumor excision. Unplanned excision or excisional biopsy was performed on the remaining 46 (48%) patients. Of this subset, 41 of the 46 aforementioned patients (89%) had positive margins and underwent re-excision. Final pathology in 25/38 (66%) re-excision specimens was negative for residual tumor despite an initial positive margin. Two patients in the cohort had local recurrence 2 and 3 years after initial surgery. Both patients had positive margins, underwent excision of the recurrent tumor, and remain free of disease. After median follow-up of 6.9 years (range 1 day-18 years), 5-year recurrence-free survival was 96% and overall survival (OS) of the entire cohort was 78%.

CONCLUSION

In this study of consecutive patients presenting with atypical intradermal smooth muscle neoplasm, we found good OS and local control after definitive surgical excision with negative margins, including excisional biopsy with close margins. Atypical intradermal smooth muscle neoplasm is unlikely to metastasize and has an excellent prognosis. Guidelines to determine optimal surveillance strategies for these patients should be revisited.

Cutaneous leiomyosarcoma: a retrospective review of 45 cases

Primary cutaneous leiomyosarcoma (LMS) is a rare soft tissue tumour type with two subtypes, dermal and subcutaneous. As deeper tumours confer a worse prognosis, they require a more aggressive approach. Conversely, a more conservative surgical approach for dermal LMS has been suggested. Few studies have comprehensively reported both clinical surgical and histological excision margins. Therefore, we sought to provide margin recommendations based on our experience and review of the existing literature. We undertook a retrospective case-note review (1998-2019) of cutaneous LMS management to establish histological/surgical margins using pathology/electronic patient records. The diagnosis was made and classified by an experienced dermatopathologist according to the World Health Organization classification. In the dermal LMS cohort (n = 35), mean peripheral and deep histological margins were 5.4 mm (range 0.5-20) and 5.6 mm (range 0.1-14.5), respectively. The incomplete excision rate was 31% (11 of 35). There were no recurrences. In the subcutaneous LMS cohort (n = 10), mean peripheral and deep histological margins were 5.7 mm (range 0.2-14) and 1.1 mm (range 0.2-1.7), respectively. The incomplete excision rate was 40% (4 of 10). The recurrence rate was 20% (2 of 10) despite achieving histological clearance after 1 year. One lung metastasis occurred 1 year following an adequately excised primary scalp LMS. Thus, for dermal LMS we propose a clinical margin of 5-10 mm (depending on lesion size) at the initial excision or at scar re-excision following involved/close histological peripheral and/or deep margins (i.e. < 1 mm). For subcutaneous LMS, we suggest a clinical margin of 15-20 mm (depending on lesion size) to achieve a peripheral histological clearance of 10 mm and negative deep margin (i.e. > 1 mm), down to the periosteum/fascia/muscle according to anatomical site. If this is not achieved, a re-excision would be recommended. However, prospective studies are needed for optimal guidance.

Cutaneous soft tissue sarcomas: survival-related factors

Cutaneous sarcomas are a heterogeneous group of rare mesenchymal neoplasms representing less than 1% of malignant tumors. Histology report remains the cornerstone for the diagnosis of these tumors. The most important clinicopathologic parameters related to prognosis include larger tumor size, high mitotic index, head and neck location, p53 mutations, depth of infiltration and histological grade, vascular and perineural invasion as well as the surgical margins status. Applying advanced biopsy techniques might offer more precise assessment of surgical margins, which constitutes a significant precondition for the management of these tumors. The management of cutaneous soft tissue sarcomas requires a multidisciplinary approach. Surgery remains the standard treatment, nonetheless adjuvant therapy may be required, consisting of radiotherapy, chemotherapy, and molecular targeted therapies to improve treatment outcomes. The role of molecular profiling in the treatment of uncontrolled disease is promising, but it may be offered to a relatively small proportion of patients and its use is still considered experimental in this setting. Due to the rarity of the disease, there is a need for knowledge and experience to be shared, pooled, organized and rationalized so that recent developments in medical science can have a major impact on the disease course. Multicenter clinical trials are needed to improve the care of patients with cutaneous sarcomas.

Cutaneous Sarcomas

Cutaneous sarcomas represent a rare group of tumors presenting in the head and neck. In this article, we discuss specific sarcoma tumor types and their presentation, pathogenesis, histologic findings, and management recommendations. Tumors to be reviewed include dermatofibrosarcoma protuberans, atypical fibroxanthoma, pleomorphic dermal sarcoma, cutaneous leiomyosarcoma, and angiosarcoma.

Treatment outcome of superficial leiomyosarcoma

BACKGROUND

Nonuterine leiomyosarcomas (LMS) are common extremity soft-tissue sarcomas. Deep LMS are at an increased risk for recurrence; however, few studies have focused on superficial LMS.

METHODS

We reviewed the clinicopathological features of 82 patients with a primary superficial LMS. The mean age and follow-up were 57 ± 15 and 7 ± 5 years. Depth was classified as dermal (based in the skin; n = 35, 43%) and subcutaneous (based below the dermis, above the fascia; n = 47, 57%) on the final resection specimen. Dermal cases were treated with negative margin resection, while subcutaneous tumors were evaluated by a multidisciplinary team for consideration of possible adjuvant therapy.

RESULTS

The 10-year disease-specific survival (DSS) for superficial LMS was 90% with no difference (p = .18) in the 10-year DSS between patients with dermal (100%) and subcutaneous (86%) LMS. All disease recurrences occurred in subcutaneous LMS (17% vs. 0%, p = .02) and subcutaneous tumors had a worse10-year metastatic free survival (81% vs. 100%, p = .03).

CONCLUSIONS

The results of this study suggest that dermal LMS can be managed with a negative margin resection alone. Although the prognosis for patients with subcutaneous LMS is quite favorable, there is some risk for local and distant recurrence, and such patients will benefit from multidisciplinary care.

Systematic review of Mohs micrographic surgery in children: Identifying challenges and practical considerations for successful application

BACKGROUND

Few data exist to guide the application of Mohs micrographic surgery (MMS) in the pediatric population.

OBJECTIVE

We sought to summarize the clinical characteristics of children undergoing MMS, identify challenges that limit the use of MMS in this population, and examine how these challenges can be overcome.

METHODS

A systematic review of PubMed and EMBASE, from inception of databases to November 2, 2019, identified all cases of pediatric skin lesions treated with MMS.

RESULTS

A total of 111 patients were included. The median patient age was 11 years (range 6 weeks to 17 years). The most commonly treated tumor was dermatofibrosarcoma protuberans (n = 62), followed by basal cell carcinoma (n = 30). The most common location was the head and neck (n = 34), followed by the trunk (n = 28) and the extremities (n = 23). The most commonly cited challenges in the application of MMS in children included patient cooperation, concerns for the safety of prolonged general anesthesia, availability of a MMS service in the pediatric setting, and access to a histopathology laboratory experienced in MMS sectioning.

LIMITATIONS

Many articles did not report specific patient characteristics.

CONCLUSION

Multiple obstacles limit the application of MMS in pediatric patients. This review describes practical methods to circumvent these obstacles to facilitate the appropriate use of MMS in children.

A Systematic Review of the Treatment of Superficial Leiomyosarcoma With Mohs Micrographic Surgery

BACKGROUND

Wide local excision (WLE) with 2 to 5 cm margins has been conventionally used for the treatment of superficial leiomyosarcoma (LMS). Because margin control is the strongest predictor of clinical recurrence, many dermatologic surgeons have recently recommended Mohs micrographic surgery (MMS) over wide local excision (WLE) as the primary treatment modality.

OBJECTIVE

To determine the aggregate rate of local recurrence after treatment of superficial LMS with MMS among the few reports in the literature.

METHODS

A systematic literature search using the PubMed/MEDLINE database and the Cochrane Library was performed from inception to June 2017. One case report from our institution was included.

RESULTS

A meta-analysis of 14 reports of 48 cases of superficial LMS treated with MMS showed a mean recurrence rate of 2.08% to 6.25% with a mean follow-up period of 1570.9 days, compared to reported recurrence rates of 30% to 50% for WLE. Among these cases there were no reports of distant metastases.

CONCLUSION

Treatment of superficial leiomyosarcoma with MMS shows markedly lower rates of recurrence compared to reported rates of recurrence after WLE. Further prospective trials with larger sample sizes are needed to compare both modalities.

Leiomyosarcoma of the skin: review of the literature with an emphasis on prognosis and management

Leiomyosarcoma (LMS) of the skin is rare, and no management guideline currently exists. Although LMS is historically classified as either dermal (cutaneous) or subcutaneous, definition for its classfication is inconsistent in the literature. Studies on the managenent of LMS are scarce, and there is no consensus on the appropriate surgical margin for the treatment of LMS. While a 1 cm margin may be sufficient in cutaneous LMS, wider margins may be required for subcutaneous tumors. Mohs micrographic surgery is a promising surgical modality for the treatment of cutaneous LMS. In this review, current knowledge on LMS is summarized and a practical approach to the management of this rare neoplasm is proposed.

Cutaneous leiomyosarcoma on the trunk: An unusual presentation with an aggressive course - Case report and review of literature

Primary cutaneous leiomyosarcoma (PCL) are soft-tissue sarcoma, arising in the dermis, with or without extension into the subcutis. They are thought to have an indolent course compared to their subcutaneous counterparts, they may recur but rarely metastases. We report the case of a patient with a PCL arising in the anterior trunk wall who developed pulmonary, bone and retroperitoneal metastases 6 years after wide surgical excision of the primary tumor.

Leiomyosarcoma and Pleomorphic Dermal Sarcoma: Guidelines for Diagnosis and Treatment

There are 3 types of leiomyosarcoma of the skin: dermal, subcutaneous, and metastatic cutaneous. Dermal leiomyosarcoma arises from smooth muscle fibers in arrector pili muscles, genital dartos muscles, and the nipple-areola complex. It is an intermediate-grade tumor associated with a tendency for local recurrence (24%) and low metastatic potential (4%). Subcutaneous leiomyosarcoma originates from smooth muscle in blood vessel walls and has higher rates of local recurrence (37%) and metastasis (43%). Plemorphic dermal sarcoma typically affects elderly patients and arises in sun-exposed areas (e.g., the scalp). Its histologic and immunohistochemical characteristics are similar to those of atypical fibroxanthoma, but it is more aggressive (metastasis rate of 10-20%). Histologically, it can be distinguished from atypical fibroxanthoma by the observation of subcutaneous tissue invasion, perineural invasion, and foci of necrosis.

Primary leiomyosarcoma of the skin: a comprehensive review on diagnosis and treatment

Sarcomas are a heterogeneous group of mesenchymal tumors which can affect bone and soft tissue. Leiomyosarcoma (LMS) is a rare subtype localized to the skin or subcutaneous tissue. Due to the heterogeneity of sarcomas, reviews and guidelines with an in-depth focus specifically on primary LMS of the skin are sparse. This article is intended to provide an up to date and systematic overview on diagnosis, treatment, and surveillance of this rare entity to provide a framework for decision making and management for dermato-oncologists. We discuss novel treatment options for advanced disease such as targeted therapy with kinase inhibitors and immune checkpoint blockade which may improve the prognosis even in advanced stages of LMS.

Cutaneous Smooth Muscle Tumors: A Review

Smooth muscle tumors occur infrequently in the skin. They consist of a diverse group of lesions representing hamartomas as well as benign and malignant neoplasms. They may arise from arrector pili muscle, specialized smooth muscle of the genitalia, or vascular smooth muscle. Although rare, accurate diagnosis and classification of cutaneous smooth muscle proliferations is important as they can exhibit a range of clinical behavior and may be associated with underlying syndromes. This review summarizes the clinicopathologic spectrum of smooth muscle tumors involving the skin.

Mohs micrographic surgery for cutaneous malignancies: A focus review of its indications in pediatric age groups

Mohs micrographic surgery (MMS) is a highly specialized technique that has been successful in the treatment of a variety of skin tumors. The technique can be performed as an outpatient procedure and encompasses surgical excision and intraoperative assessment of tumor margins in one setting by the same physician. The process ensures precise margin control with maximal preservation of healthy tissues. Mohs micrographic surgery has been practiced worldwide, including in the United States, Europe (United Kingdom, Germany, Spain, Netherlands, Switzerland), and Australia. Although it is commonly performed in adults with greater success, it has been discussed less frequently in children. In this article, we describe several cutaneous tumors in children and the role of Mohs micrographic surgery in their management. A PubMed search was conducted to review the most common cutaneous tumors in children treated using Mohs micrographic surgery. In this review, we discuss indications for Mohs micrographic surgery and pertinent studies examining success rates in children. Mohs micrographic surgery has been used to treat several tumors in children and offers the advantage of high cure rates and tissue conservation. This report emphasizes the benefits of Mohs micrographic surgery in children and highlights several cutaneous tumors for which it has been used to treat successfully.

Clinical and Histopathologic Findings of Cutaneous Leiomyosarcoma: Correlation with Prognosis in 12 Patients

INTRODUCTION

Cutaneous leiomyosarcoma is a malignant neoplasm derived from smooth muscle cells. Its low incidence hampers the development of specific protocols for diagnosis and treatment.

OBJECTIVES

To describe the clinical and histopathologic characteristics of a series of primary and secondary cutaneous leiomyosarcomas and to determine how these characteristics correlate with prognosis.

MATERIAL AND METHODS

We performed an observational, descriptive, retrospective study based on 17 cutaneous leiomyosarcomas in 12 patients diagnosed between January 1, 2000 and December 31, 2015. We recorded demographic data, clinical and histopathologic characteristics, outcome, and response to treatment.

RESULTS

We included 5 men and 7 women, all aged more than 50 years at diagnosis. There were 4 cutaneous leiomyosarcomas (23%) in 4 patients, 2 subcutaneous leiomyosarcomas (11.5%) in 2 patients, and 11 skin metastases of leiomyosarcoma (65%) in 6 patients. The most frequently affected sites were the scalp (41%), lower limbs (17%), and trunk (17%). During follow-up, 50% of the cutaneous leiomyosarcomas recurred, 50% of the subcutaneous leiomyosarcomas presented distant metastases, and 83% of the patients with skin metastases of leiomyosarcoma died of their disease.

LIMITATIONS

Ours was a retrospective review of a small case series at a single center.

CONCLUSIONS

Cutaneous leiomyosarcoma is an uncommon malignant neoplasm. Our approach to diagnosis and therapy must take into account the marked heterogeneity in the prognosis of the various subtypes.

Treatment of Porocarcinoma With Mohs Micrographic Surgery: The Mayo Clinic Experience

BACKGROUND

Eccrine porocarcinoma (EPC) is a rare malignant adnexal neoplasm with reported metastatic potential and undefined optimal treatment.

OBJECTIVE

This study reviews the clinical characteristics and outcomes of patients with EPC treated with Mohs micrographic surgery (MMS).

MATERIALS AND METHODS

The authors performed a retrospective chart review of patients with EPC treated by MMS at the Mayo Clinic from 1995 to 2013, recording patient demographics, tumor characteristics, MMS stages to clearance, follow-up, recurrence, metastasis, and mortality.

RESULTS

A total of 9 patients underwent MMS for EPC in 19 years. The average age was 64.2 years, with 6 males and 3 females. All patients were Caucasian. The head and lower extremity were the most common locations (44% each), with 1 on the forearm. Of the 9 tumors, 8 were located on the right side of the body. The mean preoperative tumor size and postoperative defect were 2.9 and 7.8 cm, respectively, when 2 outliers were excluded. An average of 1.3 MMS stages was required for clearance. The mean postoperative follow-up was 3.3 years (range: 1-60 months). No tumors treated with MMS recurred, metastasized, or led to disease-related mortality.

CONCLUSION

Mohs micrographic surgery seems to be a useful treatment modality for EPC. This is one of the largest single-center series of EPC treated with MMS.

Mohs micrographic surgery for the treatment of hidradenocarcinoma: the Mayo Clinic experience from 1993 to 2013

BACKGROUND

Hidradenocarcinoma (HAC) is a rare malignant adnexal neoplasm with reported metastatic potential and undefined optimal treatment.

OBJECTIVE

To review clinical characteristics and outcomes of patients with HAC treated with Mohs micrographic surgery (MMS).

MATERIALS AND METHODS

The authors performed a retrospective chart review of patients with HAC treated by MMS at Mayo Clinic from 1993 to 2013, recording patient demographics, tumor characteristics, MMS stages to clearance, follow-up, recurrence, metastasis, and mortality.

RESULTS

Ten patients underwent MMS for HAC more than 20 years. The average age was 62.8 years, with 6 females and 4 males. Occipital scalp was the most common location (40%), followed by extremities (30%) and face (20%). In 5 of 7 cases (71%), "cyst" was the working clinical diagnosis. The average preoperative lesion area was 3.18 cm, with an average of 1.5 MMS stages required for clearance. Mean postoperative follow-up was 7 years (range, 5-205 months). No tumors treated with MMS recurred, metastasized, or led to disease-related mortality.

CONCLUSION

Mohs micrographic surgery seems to be a useful treatment modality for HAC. This is the largest reported series of HAC treated with MMS with long-term follow-up.

Cutaneous leiomyosarcoma: treatment and outcomes with a standardized margin of resection

BACKGROUND

Cutaneous leiomyosarcoma is primarily a low-grade malignancy that affects elderly male Caucasians. It is a rare dermal-based tumor for which treatment algorithms have been poorly defined.

METHODS

We retrospectively reviewed the use of a median 1-cm margin for resection to treat patients with cutaneous leiomyosarcoma referred for treatment between 2005 and 2010.

RESULTS

Thirty-three patients with cutaneous leiomyosarcoma were treated. Of these, 76% were male, 97% were Caucasian (median age: 63.5 years), and 67% of tumors were located on the extremities. Preoperative staging was negative for distant metastasis in all patients. A majority of the tumors (88%) were low grade (median size: 1.3 cm). All of the tumors were positive for smooth-muscle actin. A total of 94% of patients underwent primary surgical resection with a median margin of 1 cm. Final resection margin was negative in 97% of patients. Adjuvant radiotherapy was used in 15%. No metastatic spread or recurrences were present, and 100% of patients were alive at last follow-up (median: 15.5 months).

CONCLUSIONS

Good oncological control and excellent outcomes are possible with a 1-cm resection margin in most cases of cutaneous leiomyosarcoma.

Recurrent subcutaneous trunk leiomyosarcoma: Management and review of the literature

Superficial leiomyosarcomas are rare malignant smooth-muscle tumors accounting for 4-6.5% of all soft-tissue sarcomas, less than 2-3% of cutaneous soft-tissue neoplasms and 0.04% of all cancers. They are divided into cutaneous or dermal and subcutaneous leiomyosarcomas. Subcutaneous tumors have been reported to be associated with an increased risk of local recurrences and distant metastases, compared to their cutaneous counterparts. In this study, we describe a rare case of a recurrent subcutaneous trunk leiomyosarcoma in a 68-year-old male patient. Local recurrence developed two years after the complete surgical resection with wide margins and adjuvant postoperative radiotherapy. The management of the patient is discussed along with a review of the literature. We conclude that subcutaneous leiomyosarcoma is a rare clinical entity which may be associated with an atypical clinical presentation. Physicians should be aware of the misleading features of this tumor in order to avoid delay in diagnosis and treatment. Early complete surgical resection with wide margins of at least 2 cm is the cornerstone of treatment and has been reported to mostly influence the prognosis. However, the tumor has a high tendency to recur locally and metastasize. Recurrence may develop despite wide resection and radiotherapy. Long-term follow-up is mandatory.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Needs assessment for Mohs micrographic surgery

Mohs micrographic surgery (MMS) is a unique technique that can offer the highest cure rates and maximum tissue conservation in the management of specific primary and recurrent skin cancers. However, there are many areas of controversy that surround MMS, including appropriate indications for its use, technical quandaries, and outcomes. Recent efforts in these areas need to be assessed to identify research gaps in MMS to help fuel further work. The usefulness of MMS and its methods for delivery need more stringent, evidence-based, rigorous study.