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Cutis Feb 2023Epithelioma cuniculatum (EC) is a subtype of verrucous carcinoma (VC) that affects the feet. Treatment involves complete tumor removal by wide local excision (WLE) or...
Epithelioma cuniculatum (EC) is a subtype of verrucous carcinoma (VC) that affects the feet. Treatment involves complete tumor removal by wide local excision (WLE) or Mohs micrographic surgery (MMS). Extensive local destruction may require amputation. We sought to compare reported treatment methods for EC and determine their efficacy by assessing for tumor recurrence and treatment-associated complications. A systematic review of the literature spanning multiple databases was performed. To date, surgical excision is recommended as the standard of care for treatment of EC, with amputation considered in more advanced cases. Mohs micrographic surgery appears to be a promising treatment modality for EC and may have lower recurrence rates than WLE but requires further investigation.
Topics: Humans; Carcinoma, Verrucous; Foot Diseases; Mohs Surgery; Amputation, Surgical; Male; Female; Adolescent; Young Adult; Adult; Middle Aged; Aged, 80 and over; Aged; Skin Neoplasms; Treatment Outcome
PubMed: 37075193
DOI: 10.12788/cutis.0720 -
Dermatologic Surgery : Official... Apr 2023Few prospective studies have evaluated local recurrence rates (LRR) after excision of desmoplastic melanoma (DM); however, several retrospective studies have reported... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Few prospective studies have evaluated local recurrence rates (LRR) after excision of desmoplastic melanoma (DM); however, several retrospective studies have reported high LRR.
OBJECTIVE
To determine LRR after excision of DM and evaluate factors affecting LRR.
MATERIALS AND METHODS
Systematic review of the PubMed, Embase, and Web of Science databases was performed to identify studies reporting local recurrence after excision of DM with conventional wide local excision (WLE), Mohs micrographic surgery (MMS), or staged excision (SE). Meta-analysis was performed to calculate summary LRR and pooled risk ratios (RR).
RESULTS
Literature search identified 4 studies evaluating MMS or SE (total n = 61 DM). 53 studies assessed WLE ( n = 3,080) and were analyzed quantitatively. The overall LRR after WLE of DM was 21% (95% CI, 0.16-0.28; n = 2,308). Local recurrence rate was higher with positive/unknown histologic excision margins (49%, 95% CI, 0.25-0.74; n = 91) versus negative histologic margins (11%, 95% CI, 0.07-0.17; n = 1,075; [ p < .01]). Neurotropism was also associated with increased LRR (RR, 1.79; 95% CI, 1.34-2.38, p < .01; n = 644).
CONCLUSION
DM has high LRR after WLE. Local recurrence risk was greatest with positive excision margins, indicating the importance of achieving negative microscopic margins. Greater study of MMS and SE for DM is required.
Topics: Humans; Skin Neoplasms; Retrospective Studies; Margins of Excision; Prospective Studies; Neoplasm Recurrence, Local; Mohs Surgery; Melanoma
PubMed: 36857167
DOI: 10.1097/DSS.0000000000003699 -
Archives of Dermatological Research Oct 2023Basal cell carcinosarcoma (BCCS) is a rare malignant biphasic tumor of the skin, composed of epithelial and mesenchymal components, and may be underdiagnosed. We sought... (Review)
Review
Basal cell carcinosarcoma (BCCS) is a rare malignant biphasic tumor of the skin, composed of epithelial and mesenchymal components, and may be underdiagnosed. We sought to summarize the current understanding of BCCS including its reported history, clinical presentation, diagnosis, and treatment. We also reappraise and present our recommendations of histological interpretation for its diagnosis and treatment. A systematic review of PubMed and EMBASE, from inception of databases to December 1, 2022, identified all reported cases of basal cell carcinosarcoma. A total of 34 reports containing 54 patients with basal cell carcinosarcoma were included. The neoplasm was most commonly associated in areas of sun-exposed skin and primarily affected the elderly. Diagnosis was made on histology specimens using H&E. To address underdiagnosis, additional immunohistochemical markers have been proposed due to unreliable phenotypic appearance in this poorly differentiated neoplasm. Treatment consists of excision of the tumor, typically with Mohs surgery, and is curative in most cases. There are limited treatment options for metastatic disease. There were limitations to this study as various immunohistochemical stains used on suspected BCCS without providing an explanation as to why certain markers were included and others were excluded. Continued efforts in characterizing this complex neoplasm are critical in establishing reliable and accurate diagnostic tests and accompanying treatment options, especially in cases of metastatic disease.
Topics: Humans; Aged; Skin Neoplasms; Mohs Surgery; Carcinoma, Basal Cell; Skin; Carcinosarcoma
PubMed: 36790451
DOI: 10.1007/s00403-023-02551-3 -
Dermatologic Surgery : Official... Feb 2023Current consensus guidelines have discouraged the use of sub-0.5-cm (in situ) and sub-1-cm (invasive) margins when performing Mohs micrographic surgery (Mohs) for... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Current consensus guidelines have discouraged the use of sub-0.5-cm (in situ) and sub-1-cm (invasive) margins when performing Mohs micrographic surgery (Mohs) for melanoma, with minimal evidence to guide this recommendation.
OBJECTIVE
To compare melanoma local recurrence rates after Mohs based on initial margin size.
MATERIALS AND METHODS
A systematic review and meta-analysis was conducted with search terms including Mohs micrographic surgery, surgical margin, recurrent disease, and melanoma.
RESULTS
Forty-three studies were included. The 5- to 10-mm margin category had a statistically significant lower local recurrence compared with 1- to 5-mm and 5-mm categories. Recurrence for 1- to 5-mm, 5-mm, 5- to 10-mm, and 10-mm categories were 2.3% (CI 0.8-3.5, p < .001), 1.4% (CI 0.6-2.2, p < .001), 0.3% (CI 0.2-0.5, p < .001), and 6.1% (CI -6.7 - 18.8, p = .349), respectively. Number of stages for 1 to 5, 5, 5 to 10, and 10-mm categories were 1.8, 1.8, 1.6, and 1.6, respectively. There was no statistically significant difference between the groups (p = .694).
CONCLUSION
Five- to 10-mm margins were associated with the lowest local recurrence rates. A 5- to 10-mm initial margin should be considered where other factors (tumor characteristics, anatomical or functional considerations) allow.
Topics: Humans; Mohs Surgery; Melanoma; Skin Neoplasms; Margins of Excision; Neoplasm Recurrence, Local; Melanoma, Cutaneous Malignant
PubMed: 36728060
DOI: 10.1097/DSS.0000000000003683 -
Journal of the European Academy of... May 2023Because of an increased risk of local recurrence following surgical treatment of lentigo maligna (melanoma) (LM/LMM), the optimal surgical technique is still a matter of... (Meta-Analysis)
Meta-Analysis Review
Because of an increased risk of local recurrence following surgical treatment of lentigo maligna (melanoma) (LM/LMM), the optimal surgical technique is still a matter of debate. We aimed to evaluate the effect of different surgical techniques and reflectance confocal microscopy (RCM) on local recurrence and survival outcomes. We searched MEDLINE, Embase and PubMed databases through 20 May 2022. Randomized and observational studies with ≥10 lesions were eligible for inclusion. Bias assessment was performed using the Methodological Index for Non-Randomized Studies instrument. Meta-analysis was performed for local recurrence, as there were insufficient events for the other clinical outcomes. We included 41 studies with 5059 LM and 1271 LMM. Surgical techniques included wide local excision (WLE) (n = 1355), staged excision (n = 2442) and Mohs' micrographic surgery (MMS) (n = 2909). Six studies included RCM. The guideline-recommended margin was insufficient in 21.6%-44.6% of LM/LMM. Local recurrence rate was lowest for patients treated by MMS combined with immunohistochemistry (<1%; 95% CI, 0.3%-1.9%), and highest for WLE (13%; 95% CI, 7.2%-21.6%). The mean follow-up varied from 27 to 63 months depending on surgical technique with moderate to high heterogeneity for MMS and WLE. Handheld-RCM decreased both the rate of positive histological margins (p < 0.0001) and necessary surgical stages (p < 0.0001). The majority of regional (17/25) and distant (34/43) recurrences occurred in patients treated by WLE. Melanoma-associated mortality was low (1.5%; 32/2107), and more patients died due to unrelated causes (6.7%; 107/1608). This systematic review shows a clear reduction in local recurrences using microscopically controlled surgical techniques over WLE. The use of HH-RCM showed a trend in the reduction in incomplete resections and local recurrences even when used with WLE. Due to selection bias, heterogeneity, low prevalence of stage III/IV disease and limited survival data, it was not possible to determine the effect of the different surgical techniques on survival outcomes.
Topics: Humans; Hutchinson's Melanotic Freckle; Skin Neoplasms; Melanoma; Mohs Surgery; Margins of Excision; Microscopy, Confocal; Neoplasm Recurrence, Local; Retrospective Studies
PubMed: 36652277
DOI: 10.1111/jdv.18880 -
Archives of Dermatological Research Sep 2023There are many articles in the literature on periorbital reconstruction after Mohs micrographic surgery (MMS) or surgical excision, however, the literature lacks a... (Review)
Review
There are many articles in the literature on periorbital reconstruction after Mohs micrographic surgery (MMS) or surgical excision, however, the literature lacks a comprehensive systematic review of these reports. We performed a systematic review of published data on periorbital defect reconstruction to identify trends in the literature. A comprehensive search of eight databases was performed. To be included in the study, articles had to be published in English between 2005 and 2020 and contain repair data for MMS or excision defects in the periorbital region. Studies with less than four patients, literature or systematic reviews, and abstract-only publications were excluded. Data extracted from eligible articles included the authors' medical specialties, study design, subject number and demographics, defect characteristics, procedure type, reconstructive methods, complications, outcome measures, and method of outcome assessment. 53 studies met the inclusion criteria. The first and last authors' specialties were ophthalmology (47%), plastic and reconstructive surgery (23%), dermatology (13%), otolaryngology (4%), or were multi-specialty collaborations (13%). Only 5 of the studies were prospective. Defects were located on the lower eyelid (55%), medial canthus (31%), upper eyelid (8%), lateral canthus (4%), or a combination of these sites (2%). Reconstructive methods were reported for 3678 cases and included linear repair (18%), advancement flap (8%), rotation flap (5%), transposition flap (3%), island pedicle flap (1%), unspecified local skin flap (21%), skin graft (23%), secondary intention (4%), tarsoconjunctival flap (3%), and combined reconstruction techniques (13%). Thirty-three of 53 articles specified the periorbital subunit for each reconstructive technique that was employed. Among these 33 articles which allowed for correlation between defect location and reconstructive technique, the most utilized repair method for lower eyelid defects was local skin flap. Defects on the upper eyelid or medial canthus were most frequently repaired with a skin graft. Forty articles commented on cosmetic outcomes, however, only 3 of these articles utilized a defined grading system, objective measurements, or independent reviewers to assess the cosmetic outcomes. The methods of reconstruction in this review were diverse, however, local skin flaps and grafts were the most utilized techniques. In future reports, increased reporting of reconstructive technique by defect location as well as increased use of standardized assessments of aesthetic outcomes can help strengthen this body of literature.
Topics: Humans; Plastic Surgery Procedures; Eyelid Neoplasms; Mohs Surgery; Prospective Studies; Surgical Flaps; Retrospective Studies
PubMed: 36646921
DOI: 10.1007/s00403-022-02523-z -
Dermatologic Surgery : Official... Feb 2023
Topics: Humans; Mohs Surgery; Dermatofibrosarcoma; Dermatologic Surgical Procedures; Skin Neoplasms; Neoplasm Recurrence, Local
PubMed: 36630424
DOI: 10.1097/DSS.0000000000003694 -
JAMA Dermatology Feb 2023Primary cutaneous squamous cell carcinoma is usually curable; however, a subset of patients develops poor outcomes, including local recurrence, nodal metastasis, distant... (Meta-Analysis)
Meta-Analysis
Association of Patient Risk Factors, Tumor Characteristics, and Treatment Modality With Poor Outcomes in Primary Cutaneous Squamous Cell Carcinoma: A Systematic Review and Meta-analysis.
IMPORTANCE
Primary cutaneous squamous cell carcinoma is usually curable; however, a subset of patients develops poor outcomes, including local recurrence, nodal metastasis, distant metastasis, and disease-specific death.
OBJECTIVES
To evaluate all evidence-based reports of patient risk factors and tumor characteristics associated with poor outcomes in primary cutaneous squamous cell carcinoma and to identify treatment modalities that minimize poor outcomes.
DATA SOURCES
PubMed, Embase, and SCOPUS databases were searched for studies of the topic in humans, published in the English language, from database inception through February 8, 2022.
STUDY SELECTION
Two authors independently screened the identified articles and included those that were original research with a sample size of 10 patients or more and that assessed risk factors and/or treatment modalities associated with poor outcomes among patients with primary cutaneous squamous cell carcinoma.
DATA EXTRACTION AND SYNTHESIS
Data extraction was performed by a single author, per international guidelines. The search terms, study objectives, and protocol methods were defined before study initiation. A total of 310 studies were included for full-text assessment. Owing to heterogeneity of the included studies, a random-effects model was used. Data analyses were performed from May 25 to September 15, 2022.
MAIN OUTCOMES AND MEASURES
For studies of risk factors, risk ratios and incidence proportions; and for treatment studies, incidence proportions.
RESULTS
In all, 129 studies and a total of 137 449 patients with primary cutaneous squamous cell carcinoma and 126 553 tumors were included in the meta-analysis. Several patient risk factors and tumor characteristics were associated with local recurrence, nodal metastasis, distant metastasis, disease-specific death, and all-cause death were identified. Among all factors reported by more than 1 study, the highest risks for local recurrence and disease-specific death were associated with tumor invasion beyond subcutaneous fat (risk ratio, 9.1 [95% CI, 2.8-29.2] and 10.4 [95% CI, 3.0- 36.3], respectively), and the highest risk of any metastasis was associated with perineural invasion (risk ratio, 5.0; 95% CI, 2.3-11.1). Patients who received Mohs micrographic surgery had the lowest incidence of nearly all poor outcomes; however, in some results, the 95% CIs overlapped with those of other treatment modalities.
CONCLUSIONS AND RELEVANCE
This meta-analysis identified the prognostic value of several risk factors and the effectiveness of the available treatment modalities. These findings carry important implications for the prognostication, workup, treatment, and follow-up of patients with primary cutaneous squamous cell carcinoma.
TRIAL REGISTRATION
PROSPERO Identifier: CRD42022311250.
Topics: Humans; Carcinoma, Squamous Cell; Skin Neoplasms; Prognosis; Mohs Surgery; Risk Factors
PubMed: 36576732
DOI: 10.1001/jamadermatol.2022.5508 -
Dermatology Practical & Conceptual Nov 2022Several studies investigated the use of dermoscopy in the delineation of basal cell carcinoma (BCC) for Mohs micrographic surgery (MMS) with conflicting results. (Review)
Review
INTRODUCTION
Several studies investigated the use of dermoscopy in the delineation of basal cell carcinoma (BCC) for Mohs micrographic surgery (MMS) with conflicting results.
OBJECTIVES
The purpose of this systematic review with meta-analysis was to evaluate the effectiveness of the use of dermoscopy-guided MMS in the treatment of BCC.
METHODS
We included all comparative studies. Cases of BCC treated using dermoscopy-guided MMS (or slow MMS) were compared to those treated with curettage-guided MMS or "standard" MMS.
RESULTS
A total of 6 studies including 508 BCCs were reviewed. There was no statistically significant difference in the proportion of total margin clearance on the first MMS stage between BCCs removed using dermoscopy-guided MMS and those that had curettage or visual inspection. However, lateral margin involvement was significantly lower in BCCs that had dermoscopy-guided MMS.
CONCLUSIONS
Dermoscopy allows visualization of structures up to 1mm into the dermis. Therefore, it is rational to use it for lateral margin evaluation. Currently, there are two comparative studies showing the efficacy of dermoscopy for lateral margin evaluation during MMS. Future studies are required to develop an evidence-based recommendation regarding the utility of dermoscopy in MMS.
PubMed: 36534540
DOI: 10.5826/dpc.1204a176 -
Dermatologic Surgery : Official... Jan 2023Histologic perineural invasion (PNI) in basal cell carcinomas (BCC) lacks evidence-based treatment guidelines. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Histologic perineural invasion (PNI) in basal cell carcinomas (BCC) lacks evidence-based treatment guidelines.
OBJECTIVE
Systematically review and analyze treatment outcomes of BCC with histologic PNI (PNBCC).
MATERIALS AND METHODS
PubMed, Embase, and Cochrane Reviews were searched through June 25, 2021. Thirteen eligible cohort studies were meta-analyzed.
RESULTS
502 of 713 PNBCC were treated with Mohs Surgery (MMS), wide local excision (WLE), or surgery (MMS or WLE) with adjuvant radiation (Surg + RT). Overall 5-year local control (LC) was 97.2% and cancer-specific survival (CSS) was 99.6%. Surg and Surg + RT did not differ in recurrence (2.1% vs 4.7%; p-value 0.56; RR 1.51 [0.37, 6.20]), LC (97.9% vs 96.2%; p-value 0.19; RR 0.98 [0.96, 1.01]) or CSS (100% vs 99.1%; p-value 0.40; RR 0.99 [0.95, 1.02]).
LIMITATIONS
No randomized controlled trials were found. Outcome data were often lacking.
CONCLUSION
Overall LC and CSS were high at median 5-year follow-up for surgery alone and Surg + RT. Surgery alone and Surg + RT demonstrated statistically equivalent outcomes. We do not recommend adjuvant radiation therapy for solely histologic PNBCC if clear margins are achieved.
Topics: Humans; Radiotherapy, Adjuvant; Skin Neoplasms; Neoplasm Recurrence, Local; Carcinoma, Basal Cell; Mohs Surgery
PubMed: 36533788
DOI: 10.1097/DSS.0000000000003640