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Dermatologic Surgery : Official... Apr 2022When treating Merkel cell carcinoma (MCC), the relation between wide local excision (WLE) margin and recurrence or survival is unclear. Mohs micrographic surgery (MMS)...
BACKGROUND
When treating Merkel cell carcinoma (MCC), the relation between wide local excision (WLE) margin and recurrence or survival is unclear. Mohs micrographic surgery (MMS) is an alternative surgical option for MCC, but it is unknown whether the local recurrence rate differs between MMS and WLE.
OBJECTIVE
To systematically assess the available literature to determine the recurrence and survival rates when treating MCC with MMS and different clinical excision margins.
MATERIALS AND METHODS
The MEDLINE, EMBASE, and CENTRAL databases were searched. Two independent reviewers selected studies that defined clear excision margins and either recurrence or survival. When possible, individual cases were extracted from case series and included in the analyses. Other studies were reviewed narratively.
RESULTS
Overall, 1108 studies were identified; of which, 19 case series (168 cases) and 12 cohort studies were eligible. None of the cohort studies showed significant differences in recurrence or survival for either excision margins or MMS. Equally, logistic and Cox regression analyses of the case series revealed no significant differences in recurrence or survival between different excision margins and MMS.
CONCLUSION
Synthesis of the available data does not indicate differences in recurrence and/or survival rates for MCC between different clinical excision margins and MMS.
Topics: Carcinoma, Merkel Cell; Humans; Margins of Excision; Mohs Surgery; Neoplasm Recurrence, Local; Retrospective Studies; Skin Neoplasms
PubMed: 35165221
DOI: 10.1097/DSS.0000000000003402 -
Cureus Nov 2021The objective of this study was to quantitatively compare outcomes between standard excision (SE) and Mohs micrographic surgery (MMS) for basal cell... (Review)
Review
The objective of this study was to quantitatively compare outcomes between standard excision (SE) and Mohs micrographic surgery (MMS) for basal cell carcinoma (BCC). A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines and a search of electronic databases was conducted to identify all randomised controlled trials (RCTs) and observational studies comparing the outcomes of SE versus MMS for BCC. The primary outcome was the recurrence rate for primary and recurrent BCC. The secondary outcomes included the cost of treatment, aesthetic results, the rate of incomplete excision, and the surgical defect size post excision. Five studies enrolling 2060 lesions were identified. There was a statistically significant difference between MMS and SE groups in terms of recurrence rate for primary BCCs (odds ratio (OR) = 0.44, confidence interval (CI) = 0.16 to 0.97, P = 0.04) and recurrent BCCs (OR = 0.33, CI = 0.12 to 0.97, P = 0.04). For secondary outcomes, MMS had improved results compared with SE, except for mean cost. In conclusion, both primary and secondary BCCs treated with MMS have a reduced recurrence rate and defect size thus simplifying reconstruction. However, due to higher costs and operative time attributed to MMS, it should be reserved for high-risk BCCs.
PubMed: 34984139
DOI: 10.7759/cureus.19981 -
Journal of the American Academy of... Jun 2022The role of adjuvant radiotherapy for high-risk cutaneous squamous cell carcinomas after surgery with negative margins is unclear. (Meta-Analysis)
Meta-Analysis
Adjuvant radiotherapy may not significantly change outcomes in high-risk cutaneous squamous cell carcinomas with clear surgical margins: A systematic review and meta-analysis.
BACKGROUND
The role of adjuvant radiotherapy for high-risk cutaneous squamous cell carcinomas after surgery with negative margins is unclear.
OBJECTIVE
To conduct a systematic review and meta-analysis examining the risk of poor outcomes for patients treated with surgery alone versus surgery and adjuvant radiotherapy.
METHODS
A comprehensive search of articles was executed in PubMed, Embase, and the Cochrane Database. Random-effected meta-analyses were conducted.
RESULTS
Thirty-three studies comprising 3867 high-risk cutaneous squamous cell carcinomas were included. There were no statistically significant differences in poor outcomes between the surgery only group and surgery with adjuvant radiotherapy group. Estimates for local recurrence for the surgery alone group versus the surgery with adjuvant radiotherapy group were 15.2% (95% confidence interval [CI], 6.3%-27%) versus 8.8% (95% CI, 1.6%-20.9%); for regional metastases, 11.5% (95% CI, 7.2%-16.7%) versus 4.4% (95% CI, 0%-18%); for distant metastases, 2.6% (95% CI, 0.6%-6%) versus 1.7% (95% CI, 0.2%-4.5%); and for disease-specific deaths, 8.2% (95% CI, 1.2%-20.6%) versus 19.7% (95% CI, 3.8%-43.7%), respectively.
LIMITATIONS
Retrospective nature of most studies with the lack of sufficient patient-specific data.
CONCLUSIONS
For patients with high-risk cutaneous squamous cell carcinomas treated with margin-negative resection, there were no significant differences in poor outcomes between the surgery only group and the surgery with adjuvant radiotherapy group. Randomized controlled trials are necessary to define the benefit of adjuvant radiotherapy in this setting.
Topics: Carcinoma, Squamous Cell; Humans; Margins of Excision; Radiotherapy, Adjuvant; Retrospective Studies; Skin Neoplasms
PubMed: 34890701
DOI: 10.1016/j.jaad.2021.11.059 -
Dermatologic Surgery : Official... Mar 2022Nail squamous cell carcinoma (nSCC) is the most common nail unit malignancy. However, no studies to date have evaluated treatment options for nSCC based on recurrence...
BACKGROUND
Nail squamous cell carcinoma (nSCC) is the most common nail unit malignancy. However, no studies to date have evaluated treatment options for nSCC based on recurrence data while controlling for invasion.
OBJECTIVE
To identify temporal trends in nSCC treatment modalities and compare treatment outcomes based on invasion.
METHODS AND MATERIALS
The authors performed a systematic review of articles published on PubMed, MEDLINE, and Scopus from inception to April 2020 reporting treatment of nSCC. The primary outcome was disease recurrence.
RESULTS
Reports of nSCC treatments have increased in the past decade. Mohs micrographic surgery (MMS) is the most common treatment reported overall. The lowest recurrence rates for in situ nSCC were seen with wide surgical excision (WSE) and MMS. For invasive disease, the recurrence rates were lowest with amputation, MMS, and WSE.
CONCLUSION
Complete surgical excision of nSCC with either WSE or MMS is associated with lower recurrence rates than limited excision and nonsurgical therapies, regardless of degree of invasion. The prognostic significance of in situ versus invasive disease remains unclear. Confirmation of complete excision may improve outcomes. Digital amputation is indicated for nSCC with bone invasion. Prospective studies and randomized controlled trials are needed to directly compare surgical modalities for nSCC.
Topics: Carcinoma, Squamous Cell; Humans; Mohs Surgery; Neoplasm Recurrence, Local; Prospective Studies; Retrospective Studies; Skin Neoplasms
PubMed: 34889218
DOI: 10.1097/DSS.0000000000003319 -
Dermatologic Surgery : Official... Feb 2022Merkel cell carcinoma (MCC) is an aggressive neoplasm with high rates of recurrences. Current guidelines recommend wide local excision (WLE) with 1 to 2 cm margins....
BACKGROUND
Merkel cell carcinoma (MCC) is an aggressive neoplasm with high rates of recurrences. Current guidelines recommend wide local excision (WLE) with 1 to 2 cm margins. However, Mohs micrographic surgery (MMS) offers a potential advantage over WLE because of its ability of sparing healthy tissue and assessing 100% of margins.
OBJECTIVE
To systematically evaluate the surgical modalities for the treatment of MCC.
MATERIALS AND METHODS
Eligible articles were identified using MEDLINE, Scopus, EMBASE, and Cochrane Library. All available studies investigating surgical treatment of MCC with WLE or MMS were considered.
RESULTS
Forty studies met the inclusion criteria. Thirty-one studies described patients treated with WLE, 3 with MMS, and 6 with either WLE or MMS. Subgroup analysis of Stage I MCC showed recurrence rates similar in both surgical modalities with local recurrence rate of 6.8% for WLE versus 8.5% for MMS (p = .64) and a regional recurrence rate of 15.2% for WLE versus 15.3% for MMS (p = .99).
CONCLUSION
Overall WLE cases were at a higher stage at presentation. Subgroup analysis showed that MMS is not inferior to WLE excision for the treatment of Stage I MCC and is a reasonable option for anatomic locations where tissue sparing is important.
Topics: Carcinoma, Merkel Cell; Humans; Margins of Excision; Mohs Surgery; Neoplasm Recurrence, Local; Retrospective Studies; Skin Neoplasms
PubMed: 34889215
DOI: 10.1097/DSS.0000000000003331 -
Dermatologic Surgery : Official... Feb 2022Complete removal of melanoma is a primary goal of excision, and local recurrence is one measure to evaluate the efficacy of surgical technique. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Complete removal of melanoma is a primary goal of excision, and local recurrence is one measure to evaluate the efficacy of surgical technique.
OBJECTIVE
To compare published local recurrence rates for melanoma treated with Mohs micrographic surgery (MMS) or staged excision versus wide local excision (WLE).
METHODS AND MATERIALS
Search of 6 databases identified comparative and noncomparative studies that reported local recurrence rates after MMS, staged excision, or WLE for melanoma. Random-effects meta-analysis was used to estimate odds ratios and 95% confidence interval (CI) from comparative studies and event rates from noncomparative studies.
RESULTS
Of the 71 studies included (16,575 patients), 12 were comparative studies (2,683 patients) and 56 were noncomparative studies (13,698 patients). Comparative studies showed increased recurrence after WLE compared with MMS or staged excision (odds ratio [OR], 2.5; 95% CI, 1.4-4.6) and compared with MMS alone (OR, 3.3; 95% CI, 1.8-5.9). Pooled data from comparative and noncomparative studies showed a local recurrence rate of 7% after WLE (95% CI, 5%-11%), 3% after staged excision (95% CI, 2%-4%), and less than 1% after MMS (95% CI, 0%-1%). Statistical heterogeneity was moderate to high.
CONCLUSION
Local recurrence of melanoma is significantly lower after MMS (<1%) and staged excision (3%) compared with WLE (7%).
Topics: Databases, Factual; Humans; Melanoma; Mohs Surgery; Neoplasm Recurrence, Local; Retrospective Studies; Skin Neoplasms
PubMed: 34889212
DOI: 10.1097/DSS.0000000000003309 -
The American Journal of Dermatopathology Dec 2021Malignant proliferating trichilemmal tumors of the scalp can exhibit aggressive presentation and recurrences. Our objective was to perform an evidence-based systematic...
OBJECTIVES
Malignant proliferating trichilemmal tumors of the scalp can exhibit aggressive presentation and recurrences. Our objective was to perform an evidence-based systematic review evaluating clinical presentation, tumor characteristics, and treatment modalities used to determine which treatment strategies had the best outcomes.
METHODS
The databases PubMed, Embase, and Cochrane Library were searched for relevant literature by the authors. Patient demographics, imaging, treatments, and other clinical characteristics were obtained. The results were reported using the Preferred Reporting Systems for Systematic Reviews and Meta-Analysis guidelines.
RESULTS
Thirty-nine studies with a total of 65 patients were identified. The most common presentation was a history of slow-growing, painless swollen mass on the scalp. In total, 10 patients (15.4%) presented with spread to the regional lymph nodes and 6 (9.2%) additional patients presented with metastasis to distant locations. In total, 61 patients (93.8%) underwent surgery. Various chemotherapy and radiation therapy regimens were used. Of the 45 cases with documented follow-up, 11 (24.4%) patients had one or multiple instances of local, lymph node or metastatic tumor recurrence.
CONCLUSIONS
Surgery is favored, and the exact approach should be based on clinical judgment. However, Mohs micrographic surgery should strongly be considered because of its superior margin control against such an invasive tumor. Radiotherapy and chemotherapy have been used as adjuvant therapy in aggressive cases or recurrence. Patients should be followed closely and examined often to frequently assess recurrence or metastasis. Randomized controlled trials are needed to further clarify these findings.
Topics: Humans; Neoplasms, Adnexal and Skin Appendage; Scalp; Skin Neoplasms
PubMed: 34797787
DOI: 10.1097/DAD.0000000000001991 -
Dermatologic Surgery : Official... Dec 2021Mohs micrographic surgery (MMS) for cutaneous melanoma is becoming more prevalent, but surgical technique varies.
BACKGROUND
Mohs micrographic surgery (MMS) for cutaneous melanoma is becoming more prevalent, but surgical technique varies.
OBJECTIVE
To define variations in published techniques for MMS for melanoma.
METHODS AND MATERIALS
A systematic review was performed of PubMed, EMBASE, and Scopus databases to identify all articles describing surgical techniques for MMS for melanoma. Technical details were recorded for the preoperative, intraoperative, and postoperative phases of MMS.
RESULTS
Twenty-four articles were included. Mohs surgeons vary in how they assess clinical margins, how wide a margin they excise on the first MMS layer, and how they process tissue to determine tumor stage and margin clearance during MMS for melanoma.
CONCLUSION
Mohs micrographic surgery for melanoma is performed with varied surgical techniques. To establish best practices, additional research is necessary to determine how different techniques affect outcomes.
Topics: Humans; Melanoma; Mohs Surgery; Skin Neoplasms
PubMed: 34743123
DOI: 10.1097/DSS.0000000000003268 -
Dermatologic Therapy Nov 2021Management of patients with locally advanced basal cell carcinoma (laBCC) with traditional strategies has yielded suboptimal outcomes. Targeted treatments including... (Review)
Review
Management of patients with locally advanced basal cell carcinoma (laBCC) with traditional strategies has yielded suboptimal outcomes. Targeted treatments including hedgehog inhibitor therapy (HHIT) present limitations when utilized as monotherapy. Herein, we report evidence-based outcomes from available literature on multimodality treatments adjuvant to HHIT in laBCC management. Utilizing a systematic search strategy in PubMed, we identified studies published from inception to April 15, 2020, screened for definitive inclusion/exclusion criteria, and performed individual study quality assessment and pooled analysis to assess impact of adjunctive treatment-based responses post-HHIT on clinical response and recurrence outcomes. Twenty-nine studies (n = 103) were included. Primary findings include a complete response (CR) rate of 90.5%, the median follow-up of 12 months post-HHIT completion. The recurrence rate was 10.8% with 12-month median time to recurrence. Mohs micrographic surgery (MMS) had 100% CR post-HHIT, while no difference was observed between surgery and radiation therapy (RT). MMS and surgery had comparable 2-year recurrence free rates (RFR) at 87% and 86% respectively, while RT had the lower 2-year RFR at 67%. Male gender portended a more advanced stage at diagnosis and worse outcomes. In a subset analysis, periorbital laBCCs with orbital involvement had a CR rate of 81.8% versus 100% in those without orbital involvement, with similar rates of recurrence. Limited available quantitative data and possible publication bias were limitations. Pooled analysis of observational data supports use of adjunctive therapies post-HHIT to improve treatment response in patients with laBCC. Longer-term follow-up is needed to study recurrence rates after combination therapy.
Topics: Anilides; Antineoplastic Agents; Carcinoma, Basal Cell; Hedgehog Proteins; Humans; Male; Pyridines; Skin Neoplasms
PubMed: 34676633
DOI: 10.1111/dth.15172 -
Dermatologic Surgery : Official... Jan 2022Recommendations for the approved use of Mohs surgery for cutaneous melanoma on the trunk and extremities remain uncertain. (Comparative Study)
Comparative Study
BACKGROUND
Recommendations for the approved use of Mohs surgery for cutaneous melanoma on the trunk and extremities remain uncertain.
OBJECTIVE
To compare survival and recurrence between patients treated with Mohs surgery versus wide excision for melanoma on the trunk and extremities.
METHODS
The databases Medline, Embase, Web of Science, CENTRAL, and EMCare were searched from inception on January 11, 2021. Contemporary comparisons were included exclusively. Meta-analysis was conducted using generic inverse variance and a fixed effects model.
RESULTS
Four studies were eligible for inclusion. The study population (n = 279,556) was 52.1% men and 97.2% White. There were no observed differences in 5-year overall survival (hazard ratio 0.98, 95% confidence interval 0.90-1.07, I2 = 0%), disease-free survival (HR 0.89, 95% CI 0.12-6.47, I2 = 0), or local recurrence among patients treated with Mohs surgery relative to wide excision. Quality of the evidence was very low.
CONCLUSION
This systematic review found survival and local recurrence were comparable among patients treated with Mohs surgery or wide excision for melanoma on the trunk and extremities. Future prospective contemporary studies with more diverse representation that report surgical complications and costs may facilitate more definitive recommendations.
Topics: Disease-Free Survival; Extremities; Humans; Melanoma; Mohs Surgery; Neoplasm Recurrence, Local; Skin Neoplasms; Torso
PubMed: 34608076
DOI: 10.1097/DSS.0000000000003250