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Anais Brasileiros de Dermatologia 2021Mohs 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... (Review)
Review
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.
Topics: Carcinoma, Basal Cell; Carcinoma, Squamous Cell; Humans; Melanoma; Mohs Surgery; Skin Neoplasms
PubMed: 33849752
DOI: 10.1016/j.abd.2020.10.004 -
The Yale Journal of Biology and Medicine Jun 2015Basal cell carcinoma (BCC) is the most common malignancy. Exposure to sunlight is the most important risk factor. Most, if not all, cases of BCC demonstrate overactive... (Review)
Review
Basal cell carcinoma (BCC) is the most common malignancy. Exposure to sunlight is the most important risk factor. Most, if not all, cases of BCC demonstrate overactive Hedgehog signaling. A variety of treatment modalities exist and are selected based on recurrence risk, importance of tissue preservation, patient preference, and extent of disease. The pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management of BCC will be discussed in this review.
Topics: Antineoplastic Agents; Carcinoma, Basal Cell; Case Management; Combined Modality Therapy; Debridement; Environmental Exposure; Humans; Mohs Surgery; Prevalence; Risk Factors; Skin Neoplasms; Sunlight
PubMed: 26029015
DOI: No ID Found -
American Family Physician Sep 2020Keratinocyte carcinoma, traditionally referred to as nonmelanoma skin cancer, includes basal cell and cutaneous squamous cell carcinoma and is the most common skin... (Review)
Review
Keratinocyte carcinoma, traditionally referred to as nonmelanoma skin cancer, includes basal cell and cutaneous squamous cell carcinoma and is the most common skin cancer malignancy found in humans. The U.S. Preventive Services Task Force recommends counseling about minimizing exposure to ultraviolet radiation for people aged six months to 24 years with fair skin types to decrease their risk of skin cancer. Routine screening for skin cancer is controversial. The U.S. Preventive Services Task Force concludes that current evidence is insufficient to assess the balance of benefits and harms of a routine whole-body skin examination to screen for skin cancer. Basal cell carcinoma commonly appears as a shiny, pearly papule with a smooth surface, rolled borders, and arborizing telangiectatic surface vessels. Cutaneous squamous cell carcinoma commonly appears as a firm, smooth, or hyperkeratotic papule or plaque, and may have central ulceration. Initial tissue sampling for diagnosis is a shave technique if the lesion is raised, or a punch biopsy of the most abnormal-appearing area of skin. High-risk factors for recurrence and metastasis include prior tumors, ill-defined borders, aggressive histologic patterns, and perineural invasion. Mohs micrographic surgery has the lowest recurrence rate among treatments but is best considered for large, high-risk tumors or tumors in sensitive anatomic locations. Smaller, lower-risk tumors are treated with surgical excision, electrodesiccation and curettage, or cryotherapy. Topical imiquimod and fluorouracil are also treatment options for superficial basal cell carcinoma and squamous cell carcinoma in situ. There are no clear guidelines for follow up after an index keratinocyte carcinoma, but monitoring for recurrence is important because the five-year risk of subsequent skin cancer is 41%. After more than one diagnosis, the five-year risk increases to 82%.
Topics: Carcinoma, Basal Cell; Carcinoma, Squamous Cell; Family Practice; Humans; Mohs Surgery; Practice Patterns, Physicians'; Skin Neoplasms
PubMed: 32931212
DOI: No ID Found -
Journal of the American Academy of... Mar 2018Cutaneous squamous cell carcinoma (cSCC) is the second most common form of human cancer and has an increasing annual incidence. Although most cSCC is cured with...
Cutaneous squamous cell carcinoma (cSCC) is the second most common form of human cancer and has an increasing annual incidence. Although most cSCC is cured with office-based therapy, advanced cSCC poses a significant risk for morbidity, impact on quality of life, and death. This document provides evidence-based recommendations for the management of patients with cSCC. Topics addressed include biopsy techniques and histopathologic assessment, tumor staging, surgical and nonsurgical management, follow-up and prevention of recurrence, and management of advanced disease. The primary focus of these recommendations is on evaluation and management of primary cSCC and localized disease, but where relevant, applicability to recurrent cSCC is noted, as is general information on the management of patients with metastatic disease.
Topics: Antineoplastic Agents; Carcinoma, Squamous Cell; Dermatologic Surgical Procedures; Early Detection of Cancer; Humans; Mohs Surgery; Neoplasm Grading; Neoplasm Staging; Neoplasms, Second Primary; Radiotherapy; Skin Neoplasms
PubMed: 29331386
DOI: 10.1016/j.jaad.2017.10.007 -
The Cochrane Database of Systematic... Nov 2020Basal cell carcinoma (BCC) is the commonest cancer affecting white-skinned individuals, and worldwide incidence is increasing. Although rarely fatal, BCC is associated... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Basal cell carcinoma (BCC) is the commonest cancer affecting white-skinned individuals, and worldwide incidence is increasing. Although rarely fatal, BCC is associated with significant morbidity and costs. First-line treatment is usually surgical excision, but alternatives are available. New published studies and the development of non-surgical treatments meant an update of our Cochrane Review (first published in 2003, and previously updated in 2007) was timely.
OBJECTIVES
To assess the effects of interventions for BCC in immunocompetent adults.
SEARCH METHODS
We updated our searches of the following databases to November 2019: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS.
SELECTION CRITERIA
Randomised controlled trials (RCTs) of interventions for BCC in immunocompetent adults with histologically-proven, primary BCC. Eligible comparators were placebo, active treatment, other treatments, or no treatment.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. Primary outcome measures were recurrence at three years and five years (measured clinically) (we included recurrence data outside of these time points if there was no measurement at three or five years) and participant- and observer-rated good/excellent cosmetic outcome. Secondary outcomes included pain during and after treatment, early treatment failure within six months, and adverse effects (AEs). We used GRADE to assess evidence certainty for each outcome.
MAIN RESULTS
We included 52 RCTs (26 new) involving 6690 participants (median 89) in this update. All studies recruited from secondary care outpatient clinics. More males than females were included. Study duration ranged from six weeks to 10 years (average 13 months). Most studies (48/52) included only low-risk BCC (superficial (sBCC) and nodular (nBCC) histological subtypes). The majority of studies were at low or unclear risk of bias for most domains. Twenty-two studies were industry-funded: commercial sponsors conducted most of the studies assessing imiquimod, and just under half of the photodynamic therapy (PDT) studies. Overall, surgical interventions have the lowest recurrence rates. For high-risk facial BCC (high-risk histological subtype or located in the facial 'H-zone' or both), there may be slightly fewer recurrences with Mohs micrographic surgery (MMS) compared to surgical excision (SE) at three years (1.9% versus 2.9%, respectively) (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.16 to 2.64; 1 study, 331 participants; low-certainty evidence) and at five years (3.2% versus 5.2%, respectively) (RR 0.61, 95% CI 0.18 to 2.04; 1 study, 259 participants; low-certainty evidence). However, the 95% CI also includes the possibility of increased risk of recurrence and no difference between treatments. There may be little to no difference regarding improvement of cosmetic outcomes between MMS and SE, judged by participants and observers 18 months post-operatively (one study; low-certainty evidence); however, no raw data were available for this outcome. When comparing imiquimod and SE for nBCC or sBCC at low-risk sites, imiquimod probably results in more recurrences than SE at three years (16.4% versus 1.6%, respectively) (RR 10.30, 95% CI 3.22 to 32.94; 1 study, 401 participants; moderate-certainty evidence) and five years (17.5% versus 2.3%, respectively) (RR 7.73, 95% CI 2.81 to 21.3; 1 study, 383 participants; moderate-certainty evidence). There may be little to no difference in the number of participant-rated good/excellent cosmetic outcomes (RR 1.00, 95% CI 0.94 to 1.06; 1 study, 326 participants; low-certainty evidence). However, imiquimod may result in greater numbers of good/excellent cosmetic outcomes compared to SE when observer-rated (60.6% versus 35.6%, respectively) (RR 1.70, 95% CI 1.35 to 2.15; 1 study, 344 participants; low-certainty evidence). Both cosmetic outcomes were measured at three years. Based on one study of 347 participants with high- and low-risk primary BCC of the face, radiotherapy may result in more recurrences compared to SE under frozen section margin control at three years (5.2% versus 0%, respectively) (RR 19.11, 95% CI 1.12 to 325.78; low-certainty evidence) and at four years (6.4% versus 0.6%, respectively) (RR 11.06, 95% CI 1.44 to 84.77; low-certainty evidence). Radiotherapy probably results in a smaller number of good participant- (RR 0.76, 95% CI 0.63 to 0.91; 50.3% versus 66.1%, respectively) or observer-rated (RR 0.48, 95% CI 0.37 to 0.62; 28.9% versus 60.3%, respectively) good/excellent cosmetic outcomes compared to SE, when measured at four years, where dyspigmentation and telangiectasia can occur (both moderate-certainty evidence). Methyl-aminolevulinate (MAL)-PDT may result in more recurrences compared to SE at three years (36.4% versus 0%, respectively) (RR 26.47, 95% CI 1.63 to 429.92; 1 study; 68 participants with low-risk nBCC in the head and neck area; low-certainty evidence). There were no useable data for measurement at five years. MAL-PDT probably results in greater numbers of participant- (RR 1.18, 95% CI 1.09 to 1.27; 97.3% versus 82.5%) or observer-rated (RR 1.87, 95% CI 1.54 to 2.26; 87.1% versus 46.6%) good/excellent cosmetic outcomes at one year compared to SE (2 studies, 309 participants with low-risk nBCC and sBCC; moderate-certainty evidence). Based on moderate-certainty evidence (single low-risk sBCC), imiquimod probably results in fewer recurrences at three years compared to MAL-PDT (22.8% versus 51.6%, respectively) (RR 0.44, 95% CI 0.32 to 0.62; 277 participants) and five years (28.6% versus 68.6%, respectively) (RR 0.42, 95% CI 0.31 to 0.57; 228 participants). There is probably little to no difference in numbers of observer-rated good/excellent cosmetic outcomes at one year (RR 0.98, 95% CI 0.84 to 1.16; 370 participants). Participant-rated cosmetic outcomes were not measured for this comparison. AEs with surgical interventions include wound infections, graft necrosis and post-operative bleeding. Local AEs such as itching, weeping, pain and redness occur frequently with non-surgical interventions. Treatment-related AEs resulting in study modification or withdrawal occurred with imiquimod and MAL-PDT.
AUTHORS' CONCLUSIONS
Surgical interventions have the lowest recurrence rates, and there may be slightly fewer recurrences with MMS over SE for high-risk facial primary BCC (low-certainty evidence). Non-surgical treatments, when used for low-risk BCC, are less effective than surgical treatments, but recurrence rates are acceptable and cosmetic outcomes are probably superior. Of the non-surgical treatments, imiquimod has the best evidence to support its efficacy. Overall, evidence certainty was low to moderate. Priorities for future research include core outcome measures and studies with longer-term follow-up.
Topics: Adult; Aminolevulinic Acid; Antineoplastic Agents; Carcinoma, Basal Cell; Cryotherapy; Female; Humans; Imiquimod; Immunocompetence; Laser Therapy; Male; Mohs Surgery; Neoplasm Recurrence, Local; Photochemotherapy; Photosensitizing Agents; Radiotherapy; Randomized Controlled Trials as Topic; Skin Neoplasms; Treatment Outcome
PubMed: 33202063
DOI: 10.1002/14651858.CD003412.pub3 -
Seminars in Plastic Surgery May 2018Mohs micrographic surgery (MMS) is a specialized technique for treating skin malignancies that offers the highest cure rate by allowing histological evaluation of the... (Review)
Review
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.
PubMed: 29765269
DOI: 10.1055/s-0038-1642057 -
American Family Physician Sep 2005Mohs micrographic surgery is an approach to skin cancer removal that aims to achieve the highest possible rates of cure and to minimize the size of the wound and... (Review)
Review
Mohs micrographic surgery is an approach to skin cancer removal that aims to achieve the highest possible rates of cure and to minimize the size of the wound and consequent distortions at critical sites such as the eyes, ears, nose, and lips. Mohs micrographic surgery is a two-step, same-day procedure performed with local anesthetic. It involves removing the tumor in stages by histologically confirming clear margins on frozen sections and by addressing the resultant defect. Options for healing include second intent, primary closure, local flaps, interpolation flaps, and grafts. Larger tumors may require referral for reconstructive surgery. Mohs micrographic surgery is the treatment of choice for skin tumors in critical sites, large or recurrent tumors, tumors in sites of radiation therapy, and tumors with aggressive histologic features.
Topics: Humans; Mohs Surgery; Skin Neoplasms
PubMed: 16156344
DOI: No ID Found -
Lancet (London, England) Feb 1994
Topics: Humans; Mohs Surgery; Skin Neoplasms
PubMed: 7905951
DOI: 10.1016/s0140-6736(94)92687-5 -
Seminars in Plastic Surgery May 2018This article discusses the often unique patient presentations and management challenges of the post Mohs resection surgical patient. This includes social, economic, and... (Review)
Review
This article discusses the often unique patient presentations and management challenges of the post Mohs resection surgical patient. This includes social, economic, and health issues. Anesthesia considerations and pre- and postoperative care are also discussed in this article.
PubMed: 29765268
DOI: 10.1055/s-0038-1646961