Use Of Mohs Micrographic Surgery Research Articles

Mohs Micrographic Surgery With Melanocytic Immunostains for T1a/b Invasive Melanoma Yields

The use of Mohs micrographic surgery with melanocytic immunostains (MMS-I) for cutaneous melanoma is increasing. To assess local recurrence, melanoma-specific death rates in patients with invasive melanoma treated with MMS-I. A single-center retrospective review of patients with invasive melanoma treated with MMS-I from January 2008 to December 2018. Three hundred fifty-two patients (359 melanomas) were included. The median age was 71 years; most patients were male (252%; 71.6%). Most tumors were T1a/b (341, 95%), H/N (322; 89.7%), and lentigo maligna subtype (281, 78.3%). At a median follow-up of 4.3 years, local recurrence rates were 1.4% (5) and 0.9% (3) among all-stage and T1a/b tumors, respectively. There were 3 melanoma-related deaths (0.9%). MMS-I is associated with <1% risk of local recurrence and disease-specific mortality for T1a/b melanomas.

52336 The Use of Mohs Micrographic Surgery in Pleomorphic Dermal Sarcoma

52336 The Use of Mohs Micrographic Surgery in Pleomorphic Dermal Sarcoma

Mohs micrographic surgery for the treatment of invasive melanoma: A systematic review with meta-analyses.

The use of Mohs micrographic surgery (MMS) in melanoma treatment has divided opinion and evidence-based guidelines are lacking. This systematic review aimed to analyse clinical outcomes for patients with invasive melanomas treated with Mohs rather than wide local excision (WLE). Embase, MEDLINE and Cochrane databases (to 30 August 2023) were searched for studies using Mohs to treat invasive melanoma. Outcomes of interest were local recurrence and death from melanoma. Thirty-five articles involving 41,499 patients with invasive melanoma treated with Mohs were identified. Sixteen studies compared Mohs with WLE and 19 were Mohs-only, non-comparative studies. Patients treated with Mohs differed significantly from those undergoing WLE, in particular Mohs patients were older and had thinner melanomas. Two comparative studies using the same data source reported adjusted hazard ratios for melanoma-specific death and both showed no significant difference between Mohs and WLE-treated patients; 0.87 (95% CI 0.55-1.35) and 1.20 (95% CI 0.71-20.36). There was also no statistically significant difference in local recurrence risk; the unadjusted risk ratio for patients treated with Mohs was 0.46 (95% CI 0.14-1.51 p = 0.20) with moderate heterogeneity (I2 = 62%). No studies reported multivariable analyses for risk of local recurrence. Many studies generated from relatively few and often overlapping data sets have reported the use of Mohs to treat patients with invasive melanoma. Fewer studies were comparative between Mohs and WLE and these reported substantially different baseline risks of recurrence and death from melanoma between the groups. Mohs has generally been used for thinner melanomas in older patients; therefore, comparisons based on univariable analyses are likely to have been misleading. On the basis of currently available data, it is not possible to reliably assess whether outcomes differ if invasive melanomas with comparable features are treated with Mohs or WLE, and randomized trial evidence will be required for reliable conclusions to be reached.

A primary cutaneous carcinosarcoma of the retro auricular region, how to treat and literature review.

Carcinosarcomas are malignant biphasic tumours of epithelial and mesenchymal tissue. They are most often found in visceral organs, but also appear on the skin. Older age, male sex and chronic sun exposure are risk factors for its development. In this article we report a case and provide a review of literature regarding primary cutaneous carcinosarcoma (CCS) with special regard to its management. A manual electronic search of the PubMed Medline and Web of Science Core Collection databases was performed encompassing all included reports until 30th November 2022 to identify studies that reported primary CCS. CCS is a rare and aggressive tumour. Diagnosis requires histological examination and immunoreactivity of epithelial and mesenchymal components to specific markers. On its diagnosis, possibility of metastasis of a visceral carcinosarcoma should always be excluded. Surgical excision with clear margins, including the use of Mohs micrographic surgery (MMS), is the primary treatment for CCS. Reconstruction the excision defect should be performed. Regular follow-up for 5 to 10 years after initial treatment is advised. Awareness for CCS is necessary in the diagnostic evaluation of skin tumours. Further research is needed to better understand the underlying mechanisms of CCS and to establish optimal management strategies for this challenging malignancy. We recommend complete surgical excision using MMS as the treatment modality for this type of skin cancer. Dermatological follow-up for at least 5 years should be conducted to monitor for recurrence.

Dermatofibrosarcoma Protuberans; Case Report in a Pediatric Patient

Dermatofibrosarcoma protuberans (DFSP) is a rare and locally aggressive mesenchymal neoplasm arising from the dermal and subcutaneous tissues. It typically manifests as a slow-growing, firm, protuberant or plaque-like lesion on the skin. DFSP predominantly affects young to middle-aged adults, with a slight predilection for females. This tumor exhibits a distinctive infiltrative growth pattern, characterized by tumor cells invading the surrounding tissues, including the deep subcutaneous layers and the underlying fascia. Histopathologically, DFSP presents characteristic features, such as the presence of spindle-shaped tumor cells arranged in a "storiform" pattern, as well as the presence of a prominent "honeycomb" appearance due to the presence of multinucleated giant cells. Immunohistochemical staining is essential to confirm the diagnosis, with positivity for CD34 being a hallmark of DFSP. Although DFSP rarely metastasizes, its extensive local invasion and high recurrence rate necessitate a wide surgical excision with clear margins as the mainstay of treatment. The use of Mohs micrographic surgery or adjuvant radiation therapy has demonstrated favorable outcomes in cases with challenging anatomical locations or microscopically positive margins. Imatinib mesylate, a tyrosine kinase inhibitor, has also emerged as a promising systemic therapy for advanced or unresectable DFSP, particularly cases with the COL1A1-PDGFB gene fusion, which represents the molecular hallmark of DFSP. Early diagnosis and appropriate management are crucial to achieving optimal outcomes in DFSP. This article provides a comprehensive review of the clinical, histopathological, and molecular aspects of DFSP, highlighting the significance of a multidisciplinary approach to ensure accurate diagnosis and tailored therapeutic strategies for patients affected by this rare dermatological neoplasm.

Practice Patterns for Mohs Surgeons of Varying Clinical Experience: A Cross-Sectional Analysis of a Medicare Claims Database.

Use of Mohs micrographic surgery (MMS) is highly prevalent, but little data are available on how surgeon experience affects surgical practice patterns. To determine differences in use of MMS among surgeons of varying experience. This cross-sectional study sampled from clinicians billing ≥200 mean annual Mohs surgery claims from the 2012 to 2018 Medicare Public Use File. The primary outcome was mean annual Mohs surgery claims for clinicians of varying experience. Secondary outcomes included use of flaps/grafts and prescribing of oral antibiotics, benzodiazepines, and opioids. Among 1,759 unique surgeons, those with 16 to 20 years of experience performed the most mean annual (95% confidence interval) Mohs surgical cases (578.7 [556.7-600.6]). Surgeons with 21 to 25 years of experience prescribed the most antibiotics (240.2 [216.5-263.8] mean annual claims), whereas those with >35 years of experience prescribed the longest courses (15.3 [14.2-16.4] days). Midcareer surgeons performed the most mean annual Mohs surgery cases, whereas later career surgeons prescribed more frequent and longer courses of antibiotics suggesting changing practice patterns with additional years of experience.

33159 Predictors of use of Mohs micrographic surgery in the treatment of dermatofibrosarcoma protuberans of the head and neck: An analysis of the National Cancer Database

Objectives: Dermatofibrosarcoma protuberans of the head and neck (DFSPHN) is a locally infiltrative sarcoma. Mohs micrographic surgery (MMS) has been associated with reduced recurrence and comorbidities over wide local excision (WLE). However overall survival remains high regardless. This study analyzes predictors of the use of MMS in the treatment of DFSPHN, its role as the SOC, and its widespread availability for patients.

Institutional Adherence to Current Mohs Surgery Appropriate Use Criteria With Reasons for Nonadherence and Recommendations for Future Versions.

The appropriate use criteria (AUC) were established to optimize the use of Mohs micrographic surgery (MMS) and confer the highest possible clinical benefit to the patient. We documented our adherence to AUC and review reasons for nonadherence regarding lesions classified as inappropriate, in the hopes of informing future versions of the AUC. A retrospective review of 1,000 consecutive patients who underwent MMS at a single institution. A total of 1,318 biopsy-proven nonmelanoma skin cancers were treated with MMS, and each skin cancer that underwent MMS was classified as appropriate, uncertain, or inappropriate based on the AUC. Data were collected on 1,318 lesions with 1,237 (93.9%) categorized as appropriate, 59 (4.5%) uncertain, and 22 (1.7%) not appropriate. The primary variables that determined appropriateness were type of cancer (p = .001), size (p < .001), and area of body (p < .001). Institutional adherence to AUC was high, with 93.9% of treated tumors classified as appropriate, 4.5% as uncertain and 1.7% as inappropriate. By far the most commonly reported reason for performing MMS on an inappropriate lesion in our review was the treatment of adjacent lesions in 1 session.

Nail unit squamous cell carcinoma: updates on diagnosis, surgical approach, and the use of mohs micrographic surgery.

Nail unit squamous cell carcinoma (NSCC) is a malignant neoplasm that can arise from any part of the nail unit including the nail bed, nail matrix, nail groove, and nail fold. Nail unit SCC is the most common malignant nail neoplasm, and yet its diagnosis often is delayed, partly due to the clinical presentation of NSCC mimicking benign conditions such as onychomycosis, warts, and paronychia. Nail unit SCC has a low rate of metastasis; however, a delayed diagnosis often can result in local destruction and bone invasion. It is imperative for dermatologists who are early in their training to recognize this entity and refer for treatment. Many approaches have been used to treat NSCC, including wide local excision, digital amputation, cryotherapy, topical modalities, and recently Mohs micrographic surgery (MMS).

The Current State of Mohs Surgery for the Treatment of Melanoma: A Nationwide Cross-Sectional Survey of Mohs Surgeons.

The increased use of Mohs micrographic surgery (MMS) to treat melanoma has been accompanied by wide variations in practice patterns and a lack of best practice guidelines. The present study was a nationwide cross-sectional survey of Mohs surgeons to elucidate commonalities and variations in their use of MMS to treat melanoma. A cross-sectional analysis was performed using survey responses of Mohs surgeons with membership in the American College of Mohs Surgery. A total of 210/513 (40.9%) participants used MMS to treat melanoma of any subtype and 123/210 (58.6%) participants within this group treated invasive T1 melanoma (AJCC Eighth Edition) with MMS. A total of 172/210 (81.9%) participants debulked melanoma in situ (MIS). Average margin size of the first Mohs stage for MIS was 4.96 ± 1.74 mm. A total of 149/210 (71.0%) participants used immunohistochemical stains, with 145/149 (97.3%) using melanoma antigen recognized by T-cells 1 (MART-1) in 96.5% of melanoma cases treated with MMS. Over half of surveyed Mohs surgeons treating melanoma with MMS are treating early invasive melanoma with MMS. Most Mohs surgeons treating melanoma with MMS debulk MIS and virtually all use MART-1 when excising invasive melanoma with MMS.

State of the art of Mohs surgery for rare cutaneous tumors in the Spanish Registry of Mohs Surgery (REGESMOHS).

The use of Mohs micrographic surgery (MMS) for rare cutaneous tumors is poorly defined. We aim to describe the demographics, tumor presentation and topography, surgery characteristics and complications of MMS for rare cutaneous tumors in a national registry. Prospective cohort study of patients treated with MMS in Spain between July 2013 and June 2018. The inclusion criteria were patients with cutaneous tumors with final diagnosis different from basal cell carcinoma, squamous cell carcinoma, dermatofibrosarcoma protuberans, or any kind of melanoma. Five thousand and ninety patients were recorded in the registry, from which only 73 tumors (1.4%) fulfilled the inclusion criteria: atypical fibroxanthoma (18), microcystic adnexal carcinoma (10), extramammary Paget's disease (7), Merkel cell carcinoma (5), dermatofibroma (4), trichilemmal carcinoma (4), desmoplastic trichoepithelioma (4), sebaceous carcinoma (3), leiomyosarcoma (2), porocarcinoma (2), angiosarcoma (2), trichoblastoma (1), superficial acral fibromyxoma (1), and others (10). No intra-surgery morbidity was registered. Postsurgery complications appeared in six patients (9%) and were considered mild. Median follow-up time was 0.9years during which three Merkel cell carcinomas, one angiosarcoma, one microcystic adnexal carcinoma, and four others recurred (12.3%). This national registry shows that rare cutaneous tumors represent a negligible part of the total MMS performed in our country with a low complication rate.

Recurrence of periocular basal cell carcinoma and squamous cell carcinoma after Mohs micrographic surgery: a retrospective cohort study.

SummaryBackgroundDespite the widespread use of Mohs micrographic surgery (MMS) for periocular basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) – together called keratinocyte carcinoma (KC) – follow‐up data regarding recurrences are limited.ObjectivesTo investigate the recurrence rate for periocular KCs after MMS and to describe our experience with interdisciplinary collaborations.MethodsPatients with periocular KCs treated with MMS between 2006 and 2016 in a tertiary MMS referral hospital were included in this retrospective cohort study. Descriptive statistics were used to describe the MMS procedure‐related characteristics. Using follow‐up data from the electronic patient records and linkage with the Dutch nationwide network and registry of histopathology and cytopathology on 30 June 2017, the recurrence rate was evaluated and calculated using a cumulative incidence curve.ResultsIn total, 683 (93·7%) periocular BCCs and 46 (6·3%) SCCs were treated with MMS. Three‐quarters (n = 549) were primary tumours and the majority were located at the medial canthus or lower eyelid (n = 649, 89·0%). In 505 MMS procedures (69·3%) an oculoplastic surgeon participated, and in 63 patients (8·6%) a plastic surgeon performed the reconstruction. After a median follow‐up of 46 months the recurrence rate was 3·0%, based on 22 recurrences (20 BCCs and two SCCs).Conclusions MMS is an excellent treatment option for periocular KCs, with a low recurrence rate. Due to this specific anatomical location an interdisciplinary approach should pre‐eminently be considered.

Appropriate use of Mohs micrographic surgery in immunocompromised patients is high, and published indications for Mohs decrease inappropriate use

To the Editor: The number of immunosuppressed patients continues to rise,1 and they are at a significantly elevated risk of skin cancer.2 Inappropriate use of Mohs micrographic surgery (MMS) may be more common in immunosuppressed patients.3 The impact of published MMS appropriate use criteria (AUC) on the rate of inappropriate utilization of Mohs micrographic surgery in the immunosuppressed population is uncertain.

Ex Vivo High-Frequency Ultrasound for Assessment of Basal Cell Carcinoma.

The use of Mohs micrographic surgery for poorly defined cutaneous tumors is present in a few departments in Spain. Reintervention is occasionally necessary when the margins of the surgical specimen are invaded by the tumor. We propose the use of ultrasound to assess these margins by imaging the surgical specimen once excised.

Treating melanoma in situ and lentigo maligna with Mohs micrographic surgery in Australia.

There is a paucity of Australian data on the use of Mohs micrographic surgery for treating melanoma in situ and lentigo maligna. We share an Australian centre's experience with the technique. A total of 62 patients with 62 lesions of melanoma in situ and lentigo maligna referred for treatment between 2015 and 2017 comprised the study group. All melanomas were excised with Mohs micrographic surgery utilising melanoma-associated antigen recognised by T-cells (MART-1) immunostaining. Follow up ranged from 3 to 30 months with no reported recurrences or melanoma-related deaths. 94% (58/62) of lesions were primary melanomas and 6% were locally recurrent. 89% of lesions involved head and neck sites with 11% involving trunk or limbs. In total 55% (12/62) of lesions were cleared with 3-mm clinical margins, 68% with 6 mm, 92% with 9 mm and 100% with 12-mm. The mean clinical excision margin was 6.7 mm. All lesions with a tumour diameter greater than 2.2 cm required a 9-mm clinical margin or greater for excision. The mean clinical excision margin for recurrent tumours was 9 mm. We provide the first Australian data on the use of Mohs micrographic surgery for melanoma.

Mohs Micrographic Surgery for Treatment of Non-melanoma Skin Cancer

The aims of this report are to review literature supporting the use of Mohs micrographic surgery for treatment of non-melanoma skin cancer and to address indications and potential limitations of this form of therapy for non-melanoma skin cancer. The first randomized controlled trial comparing standard excision to Mohs micrographic surgery for treatment of facial basal cell carcinoma has recently been published, demonstrating a lower recurrence rate after Mohs surgery compared to standard excision after a 5-year and 10-year follow-up period, supporting its use in the treatment of high-risk basal cell skin cancer. Mohs micrographic surgery is indicated for treatment of basal cell carcinomas and cutaneous squamous cell carcinomas at high risk of recurrence and for tumors located in areas where tissue conservation and/or functional preservation is desired.

Tumor recurrence of keratinocyte carcinomas judged appropriate for Mohs micrographic surgery using Appropriate Use Criteria

The use of Mohs micrographic surgery (MMS) has increased greatly to treat basal cell and cutaneous squamous cell carcinomas (keratinocyte carcinoma [KC]), and consensus-based Appropriate Use Criteria (AUC) were developed to identify tumors for which MMS is appropriate. We sought to compare recurrence rates after different treatments in tumors judged appropriate for MMS. We used data from an observational prospective cohort study and retrospectively categorized consecutive tumors as appropriate for MMS according to the AUC. Among appropriate tumors, we used survival analyses to compare 5-year recurrence rates after treatments. Among tumors appropriate for MMS (N=1483), adjusted 5-year recurrence rates were 2.9% (range, 1.4-4.3%) after MMS, 5.5% (range, 3.1-7.9%) after excision, 4.0% (range, 0.6-7.2%) after destruction, and 5.9% (range, 1.5-10.2%) after other treatments. In tumors treated only with MMS or excision (the most similar subgroups), the adjusted hazard ratio of 5-year recurrence after MMS was 0.6 (95% confidence interval, 0.3-1.0; P=.06). This study is limited by its uncertain generalizability, lack of randomization, and unmeasured characteristics. The AUC identified tumors for which recurrence would be less common after MMS than after excision, but the absolute difference in recurrence rates was small.

The use of Mohs micrographic surgery (MMS) for melanoma in situ (MIS) of the trunk and proximal extremities

Evaluation of the entire surgical margin results in high rates of complete excision, low local recurrence rates, and maximal tissue conservation. Although well recognized for melanoma of the head and neck, few studies have focused exclusively on the trunk and proximal extremities. We sought to evaluate the efficacy of Mohs micrographic surgery for melanoma in situ (MIS) of the trunk and proximal extremities, and determine adequate excision margins for MIS when total margin evaluation is not used. Long-term outcomes in 882 cases of MIS treated with Mohs micrographic surgery were analyzed and compared with historical controls. Rates of complete excision were determined for increasing surgical margin intervals. One local recurrence occurred in our cohort (0.1%). Only 83% of MIS were excised with a 6-mm margin. Margins of 9mm were needed to excise 97% of MIS, statistically equivalent to thin melanomas. We used a nonrandomized, single-institution, retrospective design. Mohs micrographic surgery may cure the 17% of MIS that exceed traditional excision margins of 5mm and is a valuable option for these patients. Surgical margins of at least 0.9cm should be considered for MIS of the trunk and extremities when total margin evaluation is not used.

Laser Revision and Rehabilitation of Mohs Micrographic Surgical Scars

The use of Mohs micrographic surgery has become standard of care to treat a multitude of skin cancers to ensure tissue preservation. However, with any skin surgery, a cutaneous scar is the byproduct, and thus, laser scar revision has become mainstay of treatment. By utilizing varying laser wavelengths, different components that make up a particular scar can be targeted. Lasers are being used to improve scar texture, vascularity, pigmentation, and thickness, and it is important to understand the different uses and applications. Herein, we will review current practices for utilizing lasers or combination treatments to improve post Mohs surgery scars.

Why appropriate use criteria for Mohs micrographic surgery?

T he Boards of the American Academy of Dermatology, the American College of Mohs Surgery, theAmerican Society forDermatologic Surgery Association, and the American Society for Mohs Surgery recently approved the extraordinary work of the Mohs Surgery Appropriate Use Criteria (AUC) Ad Hoc Task Force chaired by Dr Suzanne Connolly. The AUC are published in this edition of the Journal of theAmericanAcademy ofDermatology and concurrently in Dermatologic Surgery, and serve as a decisive statement for the proper use of Mohs micrographic surgery; theywill bean invaluable resource for all ethical Mohs surgeons. The success of this document is underscored by the wide breadth of individuals involved in its development, including Mohs surgeons, medical dermatologists, and dermatopathologists from across the country, representing both academic and private practice. Importantly, the majority of the ratings panelists were not Mohs surgeons. The use of Mohs micrographic surgery for skin cancer has grown dramatically in the past 15 years, from approximately 1 in 20 skin cancers to approximately 1 in 4. This is partially a result of the skin cancer epidemic, and partially a result of the increase in the numbers of dermatologists who practice Mohs micrographic surgery, which increases the availability and treatment option of this technique. There were many very good reasons to develop these AUC. Although the availability of Mohs micrographic surgery has undoubtedly benefited patients who have skin cancer, there has been backlash at the federal level and by other third-party payers as use and the associated cost of the procedure has attracted notice.Any rapid increase inuse is often automatically and incorrectly assumed to indicate that a procedure is overvalued. There is no recognition or allowance in