Predictive Value of Preoperative Periocular Skin Cancer Measurements for Final Mohs Defect Size

Management of periocular keratinocyte carcinomas with Mohs micrographic surgery and predictors of complex reconstruction: a retrospective study

BACKGROUND

Skin cancer is the most frequent cancer worldwide and the most frequent periocular tumor. Keratinocyte Carcinomas (KC) located in periorificial areas, such as periocular tumors, are considered high-risk tumors. Mohs Micrographic Surgery (MMS) is considered the first line for the treatment of high-risk KC, providing a lower recurrence rate than conventional wide excision.

OBJECTIVE

To describe the clinical-pathological features of periocular KC treated with MMS in a tertiary university center in Chile.

METHODS

A single-center, retrospective study of patients with KC located on the periocular area, that underwent MMS between 2017‒2022. MMS details were recorded.

RESULTS

One hundred thirteen patients with periocular carcinomas were included. The mean age was 59 ± 13 years; 52% were women. The most frequent location was the medial canthus (53%), followed by the lower eyelid (30.1%). The most frequent BCC histology was the nodular variant (59.3%). Regarding MMS, the average number of stages was 1.5 ± 0.7, and 54% of the cases required only 1 stage to achieve clear margins. To date, no recurrence has been reported. Tumors larger than 8.5 mm in largest diameter or 43.5 mm2 were more likely to require complex reconstruction.

STUDY LIMITATIONS

Retrospective design and a relatively low number of patients in the SCC group. Possible selection bias, as larger or more complex cases, may have been referred to oculoplastic surgeons directly.

CONCLUSION

The present study confirms the role of MMS for the treatment of periocular KCs. Periocular KCs larger than 8.5 mm might require complex reconstruction. These results can be used to counsel patients during pre-surgical visits.

Mohs micrographic surgery for keratinocyte carcinomas: clinicopathological predictors of the number of stages

Background

The number of Mohs stages needed to remove a keratinocyte carcinoma affects resource use, expenses, and repair complexity. This study aimed to identify clinicopathological predictors associated with increased or decreased stages and areas for further research.

Methods

A retrospective review was conducted from a single private practice with two Mohs surgeons of 2788 consecutive Mohs cases between January 2017 and December 2021, analyzing the average number of stages taken versus national norms (P = 0.21) and subgroups using unpaired t tests (*<0.05).

Results

Several tumor features were significantly associated with fewer stages: squamous cell carcinomas, Mohs appropriate use criteria score of 7 or 8, preoperative size <0.25 cm2, tumors on the lips and extremities (including hands/fingers), and smoking. Clinicopathological features significantly associated with more stages included Mohs appropriate use criteria score of 9, recurrent skin cancers, basal cell carcinomas, tumor size of 2.25-3.99 cm2, cancers on ears, solid organ transplant patients, treatment delays >180 days, and patients ≥90 years old.

Conclusions

Significant predictors exist for both increased and decreased numbers of Mohs micrographic surgery stages required to eradicate a tumor, which may help Mohs surgeons facilitate, plan, and allocate resources more effectively. Areas for further research in Mohs micrographic surgery are identified.

Phase II Open-Label, Single-Arm Trial to Investigate the Efficacy and Safety of Topical Remetinostat Gel in Patients with Basal Cell Carcinoma

PURPOSE

The mainstay of treatment for basal cell carcinoma (BCC) is surgical excision, which can result in significant associated morbidity, particularly for patients with recurrent tumors. We previously conducted a drug repositioning screen using molecular data from human BCCs and identified histone deacetylase (HDAC) inhibitors as a potential treatment for BCC. Here we conduct the first proof-of-principle study of a topical pan-HDAC inhibitor, remetinostat, in human BCC.

PATIENTS AND METHODS

We conducted a phase II, open-label, single-arm, single-institution trial of a topical HDAC inhibitor. Participants with at least one BCC were recruited. All participants applied 1% remetinostat gel three times daily for 6 weeks, with measurements of tumor diameter conducted at baseline and week 8. Surgical excision of the remaining tumor was conducted at the end of the study and microscopic evaluation was performed.

RESULTS

Thirty-three per-protocol tumors from 25 participants were included in the analysis. The overall response rate, defined as the proportion of tumors achieving more than 30% decrease in the longest diameter from baseline to week 8, was 69.7% [90% confidence interval (CI), 54%-82.5%]. On pathologic examination, 54.8% of tumors demonstrated complete resolution. Pharmacodynamic analysis demonstrated similar levels of acetylated histone H3 in skin tissue before and after treatment, however, phosphorylation was increased. No systemic adverse events were reported.

CONCLUSIONS

The HDAC inhibitor remetinostat is a well-tolerated and effective topical treatment for reducing BCC disease burden in a clinically significant manner. This provides in-human validation of HDAC inhibitors as a therapy for BCC.

The Management of Periocular Basal Cell Carcinoma: Mohs Micrographic Surgery Versus Wide Excision with Later Reconstruction. Predictors for Margin of Resection >4 mm in Mohs Micrographic Surgery

Purpose

To determine the margin of resection (MOR) for periocular basal cell carcinoma (BCC) and compare the outcomes of BCC treatment, namely Mohs micrographic surgery (MMS) and wide excision with later reconstruction (WELR).

Methods

This is a retrospective, comparative, interventional study of patients who underwent surgical treatment of periocular BCC. One hundred forty-two patients were included. One hundred patients were treated with MMS and 42 with WELR. Inclusion criteria were primary periocular BCC with postoperative follow-up of ≥6 months, age more than 18-year-old. Exclusion criteria were, orbital extension, BCC origin outside the periocular area, or those associated with Gorling or nevoid BCC. The main outcome measure was variables associates with MOR >4 mm.

Results

There was a positive correlation between the preoperative tumor horizontal and vertical diameter with the corresponding MOR, of 0.27 (p = 0.01) and 0.28 (p = 0.007), respectively. Receiver operating characteristics suggest that a tumor with a horizontal diameter ≥5 mm or a vertical diameter of ≥6 mm, might need MOR >4 mm. One patient in the MMS group had BCC recurrence compared to none in the WELR group, and one patient in the WELR had a positive surgical margin, which was cleared during the reconstruction.

Conclusions

BCC tumor margins may extend far beyond clinical margins and the MOR required is often more than 3–4 mm. MMS ensures clear tumor margins but is not practical for all patients. A stratification system could help divide patients between the treatment strategies.