Understanding Mohs Micrographic Surgery: A Review and Practical Guide for the Nondermatologist

Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors

Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.

Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors

Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.

Rapidly Growing and Aggressive Squamous Cell Carcinoma of the Forearm: A Report of Successful Treatment With Mohs Surgery and Complex Reconstruction With Rhombic Triple Z-Plasty

Reconstruction of complex post-surgical wounds requires functional and aesthetic considerations. We present a case of a complex radial-dorsal forearm defect in a patient who underwent Mohs surgery for an aggressive and rapidly growing squamous cell carcinoma. Following complete tumor excision, we utilized a modified rhombic flap for complete wound coverage with long-term conservation of extensor function. The rhombic flap modification included three Z-plasties at the flap base to add rotational components to the flap transposition. Long-term follow-up showed acceptable cosmesis, preserved extensor tendon function, and no evidence of tumor recurrence.

Salvage re-irradiation in non-melanoma skin cancers: A multicenter analysis

BACKGROUND AND PURPOSE

We conducted a multicentre real-world study to assess the outcomes of radical salvage re-irradiation for non-melanoma skin cancer (nMSC) recurrences following definitive or postoperative radiotherapy.

MATERIALS AND METHODS

Data on patients treated between 2006 and 2022 with re-irradiation for nMSCs were retrospectively collected from five high-volume brachytherapy centers. The primary endpoint was local control (LC). Secondary endpoints included overall survival, progression-free survival, and adverse events (AEs). The Kaplan-Meier estimator and Cox Proportional-Hazards Model were utilised in the analysis.

RESULTS

A total of 58 patients with a median age of 78.4 years with recurrences of previously irradiated nMSC in the head and neck region were included in the analysis. The majority had cutaneous basal cell carcinoma (BCC; 91.4%), and were irradiated with high-dose-rate brachytherapy (HDR-BT; 91.4%). The most common locations included the nasal region (36.2%) and external ear (18.9%). The 1-year LC was 73.1% and decreased to 41.7% at three years. The size of the re-irradiated lesion was the single independent prognostic factor in Cox analysis (per mm; HR 1.07; 95% CI 1.04-1.11; p < 0.001). Grade 3 or worse AEs were reported in 7 cases (12.1%).

CONCLUSION

Re-irradiation for nMSCs, predominantly administered with brachytherapy for radiorecurrent BCC, is associated with high recurrence rates, and the risk of failure significantly increases with the size of the treated lesion. Re-irradiation could be an option for selected elderly patients with small, localised, inoperable recurrences after RT to achieve local control or defer systemic treatment; however, prospective trials are necessary to confirm its safety and efficacy.

Repair of Defects of the Nasal Tip After Mohs Surgery

INTRODUCTION

Mohs Micrographic Surgery (MMS) is a treatment option for high-risk facial nonmelanoma skin cancer with high cure rates. Especially on the nasal tip, the tissue sparing properties of MMS are appealing. The nasal tip is a common location of nonmelanoma skin cancer and can be a challenging anatomical structure for reconstructive surgery due to its prominent location in the face, the shortage of spare tissue, as well as the stiffness and composition of different skin types, cartilage and bone.

OBJECTIVES

The aim of the present paper is to review and demonstrate how reconstruction of the nasal tip can be done successfully to improve the care for patients undergoing MMS in this area.

METHODS

Using selected literature on the area and the surgeons experience, each method of repair are described including their individual advantages and challenges. Pictures and consent were selected from one patient who underwent each repair method and three photos are presented in this paper: one after tumor resection, one immediately after repair, and one minimum 6 months post-surgery.

RESULTS

We present eight surgical methods as well as pictures from previous surgeries.

CONCLUSIONS

The results demonstrate obtainable results using very different surgical methods and the importance of an individualized approach to repairing cutaneous defects of the nasal tip.

Slow Mohs micrographic surgery for nail apparatus melanoma in situ

BACKGROUND

Nail apparatus melanoma is a malignant tumor with a high incidence in Chinese melanoma patients. Slow Mohs micrographic surgery is an emerging technique for treating nail apparatus melanoma in situ (NAMIS).

OBJECTIVE

This study evaluated the efficacy and safety of slow Mohs micrographic surgery for treating NAMIS.

METHODS

Patients were enrolled in this retrospective study and treated in a single center from October 1, 2016, to June 30, 2022. Each patient underwent standard slow Mohs micrographic surgery, and follow-up was regularly conducted at clinics.

RESULTS

Ten patients were enrolled in the study. Two patients underwent one Mohs stage, seven underwent two Mohs stages, and one underwent seven Mohs stages. The resection margin ranged from 5 to 25 mm. No severe complications were reported in the treatment, and recurrence of NAMIS was not observed during the follow-up period.

CONCLUSION

Slow Mohs micrographic surgery is a valuable surgical method to treat NAMIS that preserves digit function and can be well tolerated by patients.

Wide local excision, Mohs micrographic surgery, and reconstructive options for treatment of dermatofibrosarcoma protuberans of the breast: A retrospective case series from Mayo Clinic

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) of the breast is a dermal fibroblastic neoplasm requiring wide excisional margins due to recurrence rates ranging from 26 to 60%. The current literature on reconstructive options and utility of Mohs micrographic surgery for DFSP of the breast is scarce. We describe surgical management of DFSP of the breast at our institution with the largest case series reported to date.

METHODS

A retrospective review was performed of women who underwent surgery for DFSP of the breast at our institution between 1990 and 2019. Continuous data was summarized using mean, median, and range; categorical data was summarized with frequency count and percentage. Preoperative lesion size and postoperative defect size were evaluated using 2-sided Fisher exact test, and p-values < 0.05 were considered statistically significant.

RESULTS

Nine patients underwent wide local excision (WLE) with reconstruction including pedicled latissimus dorsi flaps (n = 2), local flap advancement (n = 2), mastectomy with implant (n = 1), oncoplastic breast reduction (n = 1), and skin grafts (n = 3). Nine underwent Mohs micrographic surgery (MMS) with complex primary closure. Mean postoperative maximum wound defect size for WLE was 10.8 cm versus 7.0 cm for MMS with no statistical significance (p = 0.77). Mean preoperative maximum lesion size for WLE was 6.4 cm versus 3.3 cm for MMS with no statistical significance (p = 0.07). Complications with WLE included wound dehiscence in three patients and seroma in one patient. No complications were reported with MMS and primary closure. Recurrence was reported in one WLE patient, which was successfully detected despite flap coverage and resected without complications. Median follow-up for the patients without recurrence was 5.0 years, with two patients in MMS cohort lost to follow-up. Five-year overall survival was 100%.

CONCLUSIONS

MMS and WLE are both viable surgical options for managing DFSP of the breast. MMS could potentially minimize reconstructive needs due to smaller average defect size and result in fewer complications but may also result in asymmetry. Immediate flap reconstruction, especially in larger defects, can achieve excellent aesthetic outcomes for patients with DFSP of the breast without compromising detection of disease recurrence.

Adequacy of surgical margins, re-excision, and evaluation of factors associated with recurrence: a retrospective study of 769 basal cell carcinomas

BACKGROUND

Achieving adequate surgical margins and preventing recurrence are important in the treatment of basal cell carcinoma (BCC).

OBJECTIVES

The objectives of this study were to evaluate the adequacy of surgical margins and the re-excision rates in patients with primary BCC who underwent standard surgical treatment using our proposed algorithm and to define the risk factors in patients with recurrent BCC.

METHODS

The medical records of patients who were histopathologically diagnosed with BCC were reviewed. An algorithm created based on previous literature was used to determine the distribution of optimal surgical margins adequacy and re-excision rates.

RESULTS

Statistically significant differences were observed between the cases with and without recurrence in age at diagnosis (p=0.004), tumor size (p=0.023), tumor location in the H zone of the face (p=0.005), and aggressive histopathological subtype (p=0.000). When the tumors were evaluated for adequacy of deep and lateral surgical margins and re-excision rates, higher rates of adequate excision (457 cases, 68.0%) and re-excision (43 cases, 33.9%) were noted for tumors in the H or M zone.

STUDY LIMITATIONS

Inadequate follow-up of newly diagnosed patients in terms of recurrence and metastasis and the retrospective application of our proposed algorithm are the limitations of the present study.

CONCLUSIONS

Our results showed that if BCC was detected at an early age and at an early stage, recurrence was lower. The H and M zones were the regions with the highest rates of optimal surgical outcomes.

Local control comparison of early-stage non-melanoma skin Cancer (NMSC) treated by superficial radiotherapy (SRT) and external beam radiotherapy (XRT) with and without dermal image guidance: a meta-analysis

BACKGROUND

Various treatments exist for non-melanoma skin cancer (NMSC), but the mainstay is surgical removal. Superficial radiotherapy (SRT) is one non-surgical technique that has been used for over a century but fell out of favor due to the advent of Mohs micrographic surgery (MMS). A new technology that combines a 22 megahertz (MHz) dermal ultrasound with SRT (US-SRT) enables tumor visualization before, during, and after treatment, and demonstrates increased cure rates and reduced recurrences.

METHODS

We conducted a meta-analysis comparing the local control (LC) of four studies using traditional non-image-guided forms of radiotherapy for NMSC treatment to two seminal studies utilizing high-resolution dermal ultrasound-guided SRT (HRUS-SRT). The four traditional radiotherapy studies were obtained from a comprehensive literature search used in an article published by the American Society of Radiation Oncology (ASTRO) on curative radiation treatment of basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and squamous cell carcinoma in-situ (SCCIS) lesions. The meta-analysis employed a logit as the effect size indicator with Q-statistic to test the null hypothesis.

RESULTS

LC rates for the 2 US-SRT studies were statistically superior to the 4 traditional therapies individually and collectively. When stratified by histology, statistically superior outcomes for US-SRT were observed in all subtypes with p-values ranging from p < 0.0001 to p = 0.0438. These results validated an earlier analysis using a logistic regression statistical method showing the same results.

CONCLUSION

US-SRT is statistically superior to non-image-guided radiotherapies for NMSC treatment. This modality may represent the future standard of non-surgical treatment for early-stage NMSC.

Bupivacaine to Reduce Pain and Narcotic Use After Mohs Micrographic Surgery

BACKGROUND

Limited data exists for bupivacaine injection after Mohs micrographic surgery (MMS).

OBJECTIVE

Evaluate how bupivacaine affects postoperative pain and narcotic use.

MATERIALS AND METHODS

In this multicenter, single-blinded, prospective randomized controlled trial, patients received bupivacaine or saline (placebo) immediately after MMS with flap reconstructions identified by American Academy of Dermatology expert consensus as high-risk for pain and narcotic use. For 48 hours postoperatively, patients logged analgesic use, pain scores (0-10), and whether pain was controlled.

RESULTS

One hundred seventy-four patients were included. Narcotic analgesic use was higher in the placebo group during the first 24 hours (odds ratio 2.18; confidence interval [CI]: 1.08-4.41; p = .03), second 24 hours (odds ratio 2.18; CI: 0.91-5.29; p = .08), and 48 hours combined (odds ratio 2.58; CI: 1.28-5.24; p < .01). Pain scores were lower in the bupivacaine group during the first 8 hours (mean difference 1.6; CI: 0.73-2.38; p < .001). Overall analgesic use (narcotic and non-narcotic) and percentage of patients reporting pain under control were similar between groups. There were no significant differences in demographics or surgical characteristics. No adverse events occurred.

CONCLUSION

Single-dose bupivacaine decreased postoperative pain and narcotic analgesic use after MMS with reconstructions likely to cause significant pain. Bupivacaine may have a role in postoperative pain management and reducing narcotic use in this population.

Modulation of Hedgehog Signaling for the Treatment of Basal Cell Carcinoma and the Development of Preclinical Models

Basal Cell Carcinoma (BCC) is the most commonly diagnosed cancer worldwide. While the survivability of BCC is high, many patients are excluded from clinically available treatments due to health risks or personal choice. Further, patients with advanced or metastatic disease have severely limited treatment options. The dysregulation of the Hedgehog (Hh) signaling cascade drives onset and progression of BCC. As such, the modulation of this pathway has driven advancements in BCC research. In this review, we focus firstly on inhibitors that target the Hh pathway as chemotherapeutics against BCC. Two therapies targeting Hh signaling have been made clinically available for BCC patients, but these treatments suffer from limited initial efficacy and a high rate of chemoresistant tumor recurrence. Herein, we describe more recent developments of chemical scaffolds that have been designed to hopefully improve upon the available therapeutics. We secondly discuss the history and recent efforts involving modulation of the Hh genome as a method of producing in vivo models of BCC for preclinical research. While there are many advancements left to be made towards improving patient outcomes with BCC, it is clear that targeting the Hh pathway will remain at the forefront of research efforts in designing more effective chemotherapeutics as well as relevant preclinical models.

Ex vivo confocal microscopy for surgical margin assessment: A histology-compared study on 109 specimens

Background

The assessment of surgical margins is mandatory to prevent local recurrence or distant dissemination of skin cancers. Histological examination of haematoxylin and eosin (H&E)-stained slides from paraffin-embedded or frozen samples is the gold standard for margin assessment, but is a time-consuming procedure. Ex vivo confocal laser scanning microscopy (CLSM) is an upcoming technique that scans unfixed fresh tissue rapidly, allowing fast per-operative margin assessment.

Objective

Here, we propose to assess the efficiency of a new ex vivo confocal microscope for the per-operative assessment of surgical margins.

Methods

We analyzed 16 biopsies and 93 surgical specimens of basal cell and squamous cell carcinomas by ex vivo CLSM using Histolog® Scanner V2. Surgical specimens included fusiform excisions, slow-Mohs peripheral and deep compartments, and Mohs excisions. The time required from surgical excision to image analysis was recorded and the quality of the images obtained for each specimen assessed. The presence or absence of tumour was estimated based on ex vivo CLSM images and compared with conventional H&E-stained sections from paraffin-embedded or frozen (Mohs) specimens.

Results

Mean time for specimen processing using Histolog Scanner was 5.1 ± 3.4 min. We obtained 89% of high quality images. Mean time for confocal image analysis was 1 ± 0.76 min. The diagnostic sensitivity and specificity for ex vivo CLSM compared to classical H&E procedures were respectively 93% and 100% when performed on tumour biopsies. The overall sensitivity and specificity for ex vivo CLSM for margin assessment compared to classical H&E procedures were respectively 61.5% and 95%, with variations depending on the type of tumour or surgical specimen analyzed. In particular, we obtained 80% sensitivity and 100% specificity for the assessment of BCC surgical margins.

Conclusion

Our data suggest that ex vivo CLSM using Histolog® Scanner V2 could be a valid help for surgeons for a fast and accurate per-operative margin analysis.

Mohs micrographic surgery revisited: A multidisciplinary, collaborative approach for the treatment of aggressive and recurrent basal cell carcinoma on the head and neck

Mohs micrographic surgery is the preferred surgical option for high-risk basal cell carcinomas. In our institution, the method is exclusively used for the treatment of aggressive and recurrent facial tumours selected via multidisciplinary team meetings and consistently managed using a multidisciplinary approach. The aim of this retrospective patient-record study was to examine the outcomes for basal cell carcinomas managed with Mohs micrographic surgery and to present our experience from multidisciplinary team meetings and interdisciplinary collaborations. All patients treated between September 2009 and March 2019 at Karolinska University hospital were included. In a total of 143 facial basal cell carcinomas in 138 patients, 86 primary and 57 recurrent, the recurrence rate was 4.9% after a median follow-up of 24 months. In regions, where highly specialised Mohs surgeons performing all the steps of the procedure are limited, interdisciplinary collaboration can be an effective strategy for appropriate patient selection and for performing all steps of Mohs surgery with dermatosurgeons eradicating the tumour, pathologists evaluating the histopathology, followed by reconstructive surgery by plastic surgeons. The approach we present here provides a robust and functioning Mohs surgical service during the build-up of the organisation, while providing the opportunity to train new surgeons. Once the clinic has been set up, the multidisciplinary approach should always be considered and applied when dealing with complex cases.

Risk factors for local atypical fibroxanthoma recurrence and progression to pleomorphic dermal sarcoma: A meta-analysis of individualized participant data

Background

Risk factors for local atypical fibroxanthoma (AFX) recurrence and progression to pleomorphic dermal sarcoma (PDS) have not previously been identified.

Objective

To identify risk factors and provide follow‐up suggestions for local AFX recurrence and progression to PDS.

Methods and Materials

A literature search was performed in the PubMed, EMBASE, and Cochrane databases. The PRISMA and MOOSE guidelines were followed. The risks of local AFX recurrence and progression to PDS were presented as Kaplan–Meier plots and risk factors were presented as hazard ratios (HRs) calculated with univariate and multivariate Cox regression.

Results

Five hundred and ninety‐eight patients with AFX from 14 studies were included. Age >74 years and male sex significantly increased the risk of local recurrence (HR: 7.31 [95% confidence interval [CI]: 1.78–30.0], p < 0.01 and HR: 2.89 [95% CI: 1.04–8.01], p < 0.05, respectively). There was no difference when comparing wide local excision and Mohs' micrographic surgery (p = 0.89). The risks of local AFX recurrence and progression to PDS after 2 years were <1%.

Conclusion

A more intensive follow‐up regimen could be considered in patients >74 years old and males due to the higher risk of local AFX recurrence.

Online Readability Analysis: Mohs Micrographic Surgery Postsurgical Wound Care

OBJECTIVE

Although various treatment modalities exist for skin cancer care, Mohs micrographic surgery (MMS) is one of the most effective and cosmetically sensitive surgical techniques. The readability of online informational materials specifically related to MMS postsurgical wound care is extremely relevant for patients given the high rates of skin cancer in the US and the number of patients utilizing the internet for information.

METHODS

Investigators conducted Google searches to evaluate the current state of readability on MMS postsurgical wound care using the specific keywords "healing after Mohs surgery" and "wound care Mohs surgery." The readabilities of individual websites were analyzed using the WebFX online software. Health-specific click-through rate was used to select the number of samples assessed.

RESULTS

Based on the 33 unique websites evaluated, the aggregate readability of online MMS postsurgical wound care materials was 11.3, corresponding to an 11th-grade reading level by US standards.

CONCLUSIONS

Although this level of readability is an improvement in online MMS postsurgical wound care information relative to prior literature, there is still considerable work to be done by the dermatologic community in improving the readability of online patient materials regarding MMS.

Recurrence rate of basal cell carcinoma among different micrographic surgery techniques: Systematic review with meta-analysis

In high-risk basal cell carcinomas (BCCs), micrographic surgery (MS) has high tissue preservation and low recurrence rates. The Mohs technique is the most commonly used technique, with limited use of other MS techniques. No studies have been designed to compare the MS methods. This review aimed to assess BCC recurrence rates of different MS techniques. A systematic review and meta-analysis was conducted to search for related studies in PubMed, LILACS, EMBASE, SCOPUS, WEB OF SCIENCE, CINHAL, and COCHRANE until March 2021. Randomized clinical trials (RCTs) and observational studies involving patients with BCC and indications for different MS techniques were included. Study selection and data extraction were performed independently by three peer reviewers, as was the risk of bias assessment using the Joanna Briggs Institute tool. Pooled estimates were assessed using the random-effects model (Logit), and heterogeneity was assessed by the chi-square test (χ² ). Stata Software version 17.0 was used for analysis. Eighteen studies were included, 2 RCTs and 16 observational studies. The overall recurrence rate was 2% (95% CI, 1.0-3.0%; χ² = 46.2; p = 0.00; 18 studies, 10,424 BCCs). In studies using the Mohs technique, the recurrence rate was 3.0% (95% CI, 1.0-5.0%; χ² = 11.0; p = 0.00; 6 studies; 1,582 BCCs), with the Munich technique 3.0% (95% CI, 2.0-5.0%; χ² = 0.0; no heterogeneity; 3 studies; 404 BCCs), with Tubingen technique 1% (95% CI, 1.0-2.0%; χ² = 12.1; p = 0.00; 8 studies; 8,374 BCCs) and with the Muffin technique 0.0% (95% CI, 0.0-6.0%; 1 study; 64 BCCs). Relapse rates between MS techniques were low and appeared to be similar. However, the design of this review and the absence of primary studies that directly compare the techniques do not allow us to assert the superiority between them.

Optical imaging guided- 'precision' biopsy of skin tumors: a novel approach for targeted sampling and histopathologic correlation

Dermoscopy and reflectance confocal microscopy (RCM) are two noninvasive, optical imaging tools used to facilitate clinical diagnosis. A biopsy technique that produces exact correlation with optical imaging features is not previously reported. To evaluate the applications of a novel feature-focused 'precision biopsy' technique that correlates clinical-dermoscopy-RCM findings with histopathology. This was a prospective case-series performed during August 2017 and June 2019 at a tertiary care cancer. We included consecutive patients requiring a precise dermoscopy-RCM-histopathologic correlation. We performed prebiopsy dermoscopy and both wide probe and handheld RCM of suspicious lesions. Features of interest were isolated with the aid of paper rings and a 2 mm punch biopsy was performed in the dermoscopy- or RCM-highlighted area. Tissue was processed either en face or with vertical sections. One-to-one correlation with histopathology was obtained. Twenty-three patients with 24 lesions were included in the study. The mean age was 64.6 years (range 22-91 years); there were 16 (69.6%) males, 14 (58.3%) lesions biopsied were on head and neck region. We achieved tissue-conservation diagnosis in 100% (24/24), 13 (54.2%) were clinically equivocal lesions, six (25%) were selected for 'feature correlation' of structures on dermoscopy or RCM, and five (20.8%) for 'correlation of new/unknown' RCM features seen on follow-up. The precision biopsy technique described herein is a novel method that facilitates direct histopathological correlation of dermoscopy and RCM features. With the aids of optical imaging devices, accurate diagnosis may be achieved by minimally invasive tissue extraction.

Modular approach in OPHL: are there preoperative predictors?

Objective

Open partial horizontal laryngectomies (OPHLs) nowadays represent the first line surgical choice for the conservative treatment of locally intermediate and selected advanced stage laryngeal cancers. Among the peculiarities of OPHLs, there is the possibility of intraoperatively modulating the procedure. It would be useful for the surgeon to recognise preoperative endoscopic and radiological factors that can predict the possibility to modulate the laryngectomy.

Methods

The present study retrospectively reviewed a cohort of 72 patients who underwent OPHL for glottic LSCC, in order to identify preoperative (endoscopic and radiological) parameters that are able to predict modulation surgery.

Results

The hypoglottic extension of the glottic tumour was the preoperative finding that was most informative in predicting OPHL modulation. However, it had no significant impact on oncological outcomes.

Conclusions

Patients affected by tumours with hypoglottic extension and eligible for OPHL type II should be preoperatively informed about the possibility of an intraoperative switch towards OPHL type III.

Auricular reconstruction after Mohs micrographic surgery: analysis of 101 cases

Background

The ear is a region that has a high prevalence of cutaneous carcinomas and several guidelines indicate Mohs micrographic surgery as the first-choice treatment in such cases. Although the technique allows maximum preservation of healthy tissue, many auricular surgical wounds constitute a challenge due to the peculiar local anatomy, with evident curves and reliefs. Auricular reconstruction should prioritize function before aesthetics, but without leaving the latter aside, since postoperative distortions can have a significant psychological impact.

Objective

To describe the authors’ experience in auricular reconstruction after Mohs surgery and to evaluate the most frequently used repair methods.

Methods

Retrospective study of consecutive cases submitted to Mohs surgery and auricular reconstruction, over a period of 3 years.

Results

One hundred and one cases were included and the most common repair method was primary closure (n = 35), followed by full-thickness skin graft (n = 30) and flaps (n = 24). In thirty cases, reconstruction methods were associated. Seven patients had complications (partial graft necrosis, postoperative bleeding or infection).

Study limitations

Retrospective design and the absence of long-term follow-up of some cases.

Conclusions

The dermatologic surgeon should be familiarized with different options for auricular reconstruction. Primary closure and skin grafts were the most frequently used repair methods.

Association between surgical excision margins and outcomes in patients with dermatofibrosarcoma protuberans: A meta-analysis

Dermatofibrosarcoma protuberans (DFSP) is a tumor with low-grade malignancy and high recurrence rates. Wide local excision (WLE) is essential for DFSP, but its surgical excision margin is controversial. This study aimed to examine whether resection margin is associated with the prognosis of patients with DFSP by systematically reviewing related literature. Studies that evaluated the relationship between excision margins and outcomes after WLE were retrieved from the Cochrane Library, PubMed, Embase, and Web of Science databases. Relative risk (RR) estimates and 95% confidence intervals (CIs) were measured via a random-effect model to evaluate the subsequent outcomes: recurrence rate, mortality, and positive surgical margin rate. Sensitivity and subgroup analyses were simultaneously carried out. The meta-analysis of eight observational literatures demonstrated a significant positive correlation of ≥3 cm margin with the recurrence rate (RR = 0.17, 95% CI 0.09-0.31) and the positive surgical margin rate (RR = 0.09, 95% CI 0.02-0.46). The same result was observed in the recurrence rate in all subgroups. The stability of the above outcomes was authenticated via sensitivity analyses. Our meta-analysis illustrated that excision with <3 cm surgical margin exhibited an increased risk of poor DFSP prognosis (high recurrence rate and increasing positive margin rate).

Mohs micrographic surgery: a review of indications, technique, outcomes, and considerations

Mohs micrographic surgery is a specialized form of skin cancer surgery that has the highest cure rates for several cutaneous malignancies. Certain skin cancers can have small extensions or “roots” that may be missed if an excised tumor is serially cross-sectioned in a “bread-loaf” fashion, commonly performed on excision specimens. The method of Mohs micrographic surgery is unique in that the dermatologist (Mohs surgeon) acts as both surgeon and pathologist, from the preoperative considerations until the reconstruction. Since Dr. Mohs’s initial work in the 1930s, the practice of Mohs micrographic surgery has become increasingly widespread among the dermatologic surgery community worldwide and is considered the treatment of choice for many common and uncommon cutaneous neoplasms. Mohs micrographic surgery spares the maximal amount of normal tissue and is a safe procedure with very few complications, most of them managed by Mohs surgeons in their offices. Mohs micrographic surgery is the standard of care for high risks basal cell carcinomas and cutaneous squamous cell carcinoma and is commonly and increasingly used for melanoma and other rare tumors with superior cure rates. This review better familiarizes the dermatologists with the technique, explains the difference between Mohs micrographic surgery and wide local excision, and discusses its main indications.

The Treatment of Non-Melanoma Skin Cancer with Image-Guided Superficial Radiation Therapy: An Analysis of 2917 Invasive and In Situ Keratinocytic Carcinoma Lesions

Introduction

An image-guided form of superficial ionizing radiation therapy (IGSRT) is becoming a commonly used alternative to surgery for non-melanoma skin cancer (NMSC). However, there is little literature evidence evaluating the efficacy and safety of this approach. This study evaluates the efficacy and safety of IGSRT in treating a large number of patients with NMSC.

Methods

The medical records of 1632 stage 0–II patients with 2917 invasive and in situ NMSC lesions treated from years 2017 to 2020 were reviewed. No patients had clinical evidence of regional lymph node or distant disease at presentation.

Results

Treatment, guided by pre-treatment ultrasound imaging to adjust radiation energy and dose, combined with a fractionation treatment schedule of 20 or more treatment fractions, was safe and well tolerated. Of 2917 NMSC lesions treated, local tumor control was achieved in 2897 lesions, representing a 99.3% rate of control.

Conclusion

IGSRT should be considered as a first-line option for treating NMSC tumors in suitable early stage patients. Cure rates observed in this initial period of follow-up are similar, and potentially superior with further follow-up, to traditional superficial radiation therapy (SRT) and surgical options.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40487-021-00138-4.

MOHS micrographic surgery for head and neck nonmelanoma skin cancer: An approach for ENT surgeons

Surgery is the main approach for skin cancer, with Mohs micrographic surgery (MMS) allowing the highest cure rates, best esthetics and superior functional outcomes. Ear, nose, and throat (ENT) surgeons are often challenged with patients presenting skin cancer, needing appropriate expertise to its adequate management. This paper highlights the most important aspects of MMS, enabling ENT surgeons to become familiar with its fundamental aspects. A review of the literature was performed, concomitantly presenting the author's outcomes as an ENT surgeon. A total of 51 MMSs were performed in 41 patients, and 78.4% of the tumors were cutaneous basal cell carcinomas (cBCCs), 19.6% were cutaneous squamous cell carcinomas (cSCCs), and one case was a microcystic adnexal carcinoma. Most tumors were located in high-risk areas (88.2%), and 84.3% of them were ≥10 mm in diameter. Most tumors (90.2%) required no more than two MMS excision steps to be completely removed. All cases were managed by reconstruction either using flaps or grafts. Recurrence occurred in only 2% of the cases. This study addressed the main issues of MMS, which may be important in ENT surgeons' daily practice.

Sleep during Mohs micrographic surgery: A prospective study

Mohs micrographic surgery (MMS) is a highly specialized technique for treating skin cancer. Drawbacks of MMS are the multi-step procedure and long surgery time. Some patients sleep during surgery and involuntary movements during sleeping can interfere with surgery, which increases the risk of a fall injury. However, to our knowledge, there have been no studies regarding the characteristics of patients' sleep during MMS. This study aimed to investigate the prevalence and characteristics of sleeping patients during MMS. We performed a prospective study and included patients with skin cancers impending MMS. All patients rated their anxiety levels and sleep status using the State-Trait Anxiety Inventory, an anxiety visual analog scale, the Pittsburgh Sleep Quality Index, and the Leeds Sleep Evaluation Questionnaire. Our data showed that 21.9% of patients were asleep during MMS. Multivariable analysis showed that older age (odds ratio [OR], 1.142; p=0.003), lesion size >150 mm² (OR, 7.904; p=0.031), and multi-stage MMS (OR, 12.201; p=0.011) were significantly associated factors of sleep. This study is the first to report the prevalence and associated factors of sleep during MMS. Physicians should monitor patients with risk factors during MMS to prevent possible medical accidents.

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 10-year review of surgical management of dermatofibrosarcoma protuberans

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare skin cancer. Standard treatment in the UK is either wide local excision (WLE) or Mohs micrographic surgery (MMS). It is unclear which approach has the lower recurrence rate.

OBJECTIVES

We undertook a retrospective comparative review of surgical management of DFSP in the UK National Health Service in order to define (i) current surgical practice for primary and recurrent DFSP, (ii) local recurrence rates for primary DFSP and (iii) survival outcomes for DFSP.

METHODS

A retrospective clinical case-note review of patients with histologically confirmed DFSP (January 2004 to December 2013) who have undergone surgical treatment.

RESULTS

The surgical management of 483 primary and 64 recurrent DFSP in 11 plastic surgery and 15 dermatology departments was analysed. Almost 75% of primary DFSP (n = 362) were treated with WLE and 20% (n = 97) with MMS. For recurrent DFSP, 69% (n = 44) and 23% (n = 15) of patients underwent WLE and MMS, respectively. Recurrent primary DFSP occurred in six patients after WLE and none after MMS. The median follow-up time was 25·5 months (interquartile range 6·8-45·1) for new and 19·8 (IQR 4·5-44·5) for recurrent DFSP [Correction added on 1 Feb 2021, after first online publication: 4.8 years (interquartile range 3.5-5.8) was incorrect], with eight reported deaths during the follow-up analysis period (one confirmed to be DFSP related).

CONCLUSIONS

WLE was the most common surgical modality used to treat DFSP across the UK. The local recurrence rate was very low, occurring only after WLE. Although a prospective randomized controlled trial may provide more definitive outcomes, in the absence of a clearly superior surgical modality, treatment decisions should be based on patient preference, clinical expertise and cost.

Localized sebaceous carcinoma treatment: Wide local excision verses Mohs micrographic surgery

The optimal surgical management of sebaceous carcinoma (SC) has yet to be determined between Mohs micrographic surgery (MMS) and wide local excision (WLE). To investigate overall survival (OS) differences for SC undergoing WLE or MMS, The National Cancer Database (NCDB) was queried for all SC from 2004 to 2015 (n = 2863). Cases missing staging data, undergoing palliative care, showing lymph node extension, or of AJCC Stage III/IV were omitted. Chi-squared tests were used to analyze patient demographics, cancer characteristics, and treatment modalities. Kaplan-Meier and Cox proportional hazards regression modeling analyzed OS outcomes. A total of 554 cases met inclusion criteria (WLE [n = 243], MMS [n = 311]). Multivariate analysis revealed that cases treated in academic facilities (ref: non-acad; OR = 2.273; CI95% [1.448-3.568]; P < .001] were independently associated with greater MMS rates, whereas those with primaries on the trunk (ref: head/neck OR = 0.359; CI95%[0.203-0.634]; P < .001) and extremities (ref: head/neck OR = 0.399; CI95% [0.182-0.877]; P = .022) held lower MMS rates. Between surgical modalities, Kaplan-Meier survival showed no significant difference in outcomes (P = .611), with WLE and MMS demonstrating 5-year OS rates of 65.8% and 61.4%, respectively. On Cox proportional hazard regression, the survival outcomes of MMS and WLE did not show any significant differences in OS (HR = 0.832; CI95% [0.996-3.662]; P = .334). MMS and WLE of localized SC demonstrate similar overall survival outcomes. MMS may be preferred for margin control, tissue conservation, and cosmesis.

A topical naltrexone formulation for surgical wound healing: A case report

BACKGROUND

In current guidelines, there is no specific therapeutic recommendation for promoting surgical wound healing. Proper postsurgical wound care regimen can speed up wound healing and prevent abnormal scarring.

AIMS

The purpose of this case study was to evaluate the effectiveness of a compounded topical formulation containing naltrexone in managing surgical wound in a patient after Mohs micrographic surgery (MMS).

PATIENTS/METHODS

A patient started to apply the topical naltrexone formulation two days after the MMS on his hand. Images of the wound and a Patient Scar Assessment Questionnaire (PSAQ) were used to evaluate the clinical outcomes.

RESULTS

The wound completely healed, and the hand function was fully recovered following application of the formulation for 2 weeks. No abnormal scarring was formed, and the scar was only slightly noticeable after 2 months.

CONCLUSION

This case study demonstrated the effectiveness of the topical naltrexone formulation in surgical wound management.

Comparison of basal cell carcinoma subtypes observed in preoperative biopsy and Mohs micrographic surgery

Background

The treatment of basal cell carcinoma depends on its histological subtype. Therefore, a biopsy should be performed before definitive treatment. However, as the biopsy is only a sample of the tumor, it does not always shows every histological subtype present in the neoplasm. Few studies have compared the histological findings of biopsies with the findings of Mohs micrographic surgery. By evaluating the totality of the peripheral margins, in addition to sampling large tumor areas, this technique provides a more representative amount of tissue than preoperative biopsy.

Objectives

a) Determine the agreement between the histological subtype of basal cell carcinoma from punch biopsy and the findings of Mohs surgery; b) To assess, among the discordant cases, the prevalence of non-aggressive tumors in the preoperative biopsy that were reclassified as aggressive by Mohs surgery.

Methods

Retrospective analysis of 79 cases of basal cell carcinomas submitted to punch biopsy and subsequent Mohs surgery.

Results

The agreement between the classification of the subtypes in the biopsy and in Mohs surgery was 40.5%. Punch biopsy was able to predict the most aggressive basal cell carcinoma growth pattern in 83% of cases.

Study limitations

Retrospective nature, sample size, and biopsies performed by different professionals.

Conclusions

The agreement between the histopathological subtypes of basal cell carcinoma as seen in preoperative biopsy and Mohs surgery was low. However, preoperative biopsy presented good accuracy (83%) in detecting aggressive histopathological subtypes.

Research Techniques Made Simple: Optical Clearing and Three-Dimensional Volumetric Imaging of Skin Biopsies

Skin histology is traditionally carried out using two-dimensional tissue sections, which allows for rapid staining, but these sections cannot accurately represent three-dimensional structures in skin such as nerves, vasculature, hair follicles, and sebaceous glands. Although it may be ideal to image skin in a three-dimensional manner, it is technically challenging to image deep into tissue because of light scattering from collagen fibrils in the dermis and refractive index mismatch owing to the presence of differing biological materials such as cytoplasm, and lipids in the skin. Different optical clearing methods have been developed recently, making it possible to render tissues transparent using different approaches. Here, we discuss the steps involved in tissue preparation for three-dimensional volumetric imaging and provide a brief overview of the different optical clearing methods as well as different imaging modalities for three-dimensional imaging.

Mohs Surgery versus Standard Local Excision for Basal Cell Carcinoma, Squamous Cell Carcinoma, and Melanoma Skin Cancer

Basal cell carcinoma, squamous cell carcinoma, and melanoma represent the three most common skin cancers that occur on the face. The most common surgical treatments for facial skin cancers are Mohs' surgery and standard local excision. The effective utilization of either of these techniques is based on tumor and patient risk stratification incorporating known risk factors for occult invasion and local recurrence, combined with patient comorbidities, expectations, and desires. Best available evidence highlights multiple and consistent risk factors for each specific skin cancer type, and dictate local control rates reported in the literature. Recognizing gaps in the literature, we compare and review surgical treatment guidelines and data for standard local excision versus Mohs' surgery for cutaneous nonmelanoma and melanoma skin cancer. This article serves as a resource for optimal therapeutic decision making for surgical management of skin cancer on the face.

Surgical margins required for basal cell carcinomas treated with Mohs micrographic surgery according to tumor features

BACKGROUND

Basal cell carcinomas (BCCs) with high-risk features are preferably treated by Mohs micrographic surgery. Studies have shown clinicopathologic characteristics that may predict more stages required for clearance. However, few studies have correlated such factors with the number of millimeters removed per stage.

OBJECTIVE

To determine margins necessary for BCC clearance according to tumor features, especially for tumors less than 6 mm, and to suggest initial margins for Mohs micrographic surgery and margins for wide local excision.

METHODS

Retrospective analysis of 295 consecutive Mohs micrographic surgeries for primary BCCs. Variables analyzed included patient age, sex, immunostatus, lesion size, location, histologic subtype, borders, stage number, and millimeters excised per stage.

RESULTS

BCCs less than 6 mm had a clearance rate of 96% with 3-mm margins. In adjusted multivariable analysis, superficial, micronodular, infiltrative, and morpheaform subtypes were associated with larger margins, whereas clinically well-defined tumors were associated with smaller margins.

LIMITATIONS

Because of the limited sample of certain subtypes, a 3-mm margin is better suited for nodular tumors.

CONCLUSION

These data help guide initial Mohs micrographic surgery and wide local excision margins required for tumor clearance according to tumor features. Nodular BCCs less than 6 mm may be cleared with 3-mm margins instead of the current 4-mm margin recommendation.

Treatment of keratinocyte carcinoma in elderly patients - a review of the current literature

A large percentage of the patients with keratinocyte carcinoma (KC, formerly known as non‐melanoma skin cancer) is of advanced age and often too frail for standard therapies. However, no specific treatment recommendations are given for this population. This review aimed to give an overview of the current literature on the best practice for the treatment of elderly patients with KC. A literature search was performed in MEDLINE, using ‘keratinocyte carcinoma’, ‘elderly’, ‘treatment’ and various synonyms. Case reports, reviews, comments, non‐English literature and studies with a sample size <15 were excluded. After selection, a total of 47 studies were reviewed. Two types of studies were identified, focusing on (I) the effect of age on treatment outcomes and (II) alternative treatment schedules for elderly patients. Studies on surgery, the gold standard, describe larger lesions and defect size in the elderly population. Recurrence rate, complication rate and disease‐specific survival were not affected by age. Depending on the expected morbidity of a suggested (re‐)excision and patient preferences, a conservative watchful waiting policy can be agreed upon as a shared decision. Other common treatment modalities, such as adjuvant radiotherapy, photodynamic therapy and systemic therapy for basal cell carcinoma (BCC), show comparable results in the elderly and younger population. Alternative treatment schedules for elderly patients include primary hypofractionated radiotherapy, which seems effective and well‐tolerated, although research is limited to case series. Additionally, localized and topical treatments seem safe and effective especially for low‐risk tumours. Data are lacking on the efficacy of systemic therapies of metastatic KC in elderly patients. Efficacy of most treatments (with the exception of photodynamic therapy) is not dependent on age. There is need for more research on the efficacy of adjusted treatment modalities, such as hypofractionated radiotherapy and palliative or curative systemic treatment.

Radiation therapy techniques in the treatment of skin cancer: an overview of the current status and outlook

Nonmelanoma skin cancer (NMSC) is a major health concern due to its high incidence rate, its negative impact on the quality of life of patients as well as the associated economic burden to the healthcare system. Surgery is currently the primary treatment offered for skin cancer patients but not applicable or available in all cases. Radiation therapy (RT), with its long successful history in the management of cancer, has shown to be an effective alternative or complementary method in cutaneous oncology. Specifically, for dermatology applications, RT is very often the preferred option due to its favorable cosmetic results, besides the excellent control rate of the tumor. During the last 120 years since the introduction of treatments based on ionizing radiation, several techniques in this area have been developed. Radionuclide brachytherapy, electronic brachytherapy, X-ray therapies with kilovolt (kV) to megavolt (MV) photons and electron beam therapy are the established methods that are currently used on skin cancer patients. The purpose of this article is to overview these techniques and discuss the pros and cons of these methods in dermatology practices. Additionally, a new approach of beta RT of superficial skin tumors is discussed, which may offer exciting features in the management of NMSC.

Mohs Micrographic Surgery: Development, Technique, and Applications in Cutaneous Malignancies

Mohs micrographic surgery (MMS) is a specialized technique for treating skin malignancies that offers the highest cure rate by allowing histological evaluation of the entire peripheral and deep margins. MMS also maximally preserves as much uninvolved, normal adjacent tissue as possible, allowing for the best cosmetic and functional outcomes. When used for appropriate indications, this technique is also more cost-effective than other treatment modalities. In this article, the authors will discuss the development of MMS, the steps involved in this procedure, and the indications for this technique. They will also review the use of MMS for basal cell carcinoma, squamous cell carcinoma, melanoma in situ, and some less common skin malignancies.