Mohs micrographic surgery in immunosuppressed vs immunocompetent patients: Results of a prospective nationwide cohort study (REGESMOHS, Spanish registry of Mohs surgery).

BACKGROUND: Immunosuppressed (IS) patients, particularly solid organ transplant recipients and those on immunosuppressive therapy, face a higher incidence and recurrence of nonmelanoma skin cancers (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Mohs micrographic surgery (MMS) is the preferred treatment for high-risk NMSC due to its high cure rate and margin examination capabilities. However, IS patients may experience more complications, such as surgical site infections, and a greater risk of recurrence, making their outcomes a subject of interest. OBJECTIVES: This study aimed to compare IS and immunocompetent (IC) patients undergoing MMS for NMSC in terms of baseline characteristics, intra- and post-surgical complications, and postoperative recurrence rates. METHODS: The study utilized data from the REGESMOHS registry, a 7-year prospective cohort study in Spain. It included 5226 patients, categorizing them into IC (5069) and IS (157) groups. IS patients included solid organ transplant recipients, those on immunosuppressive treatments, individuals with haematological tumours and HIV-positive patients. Patient data, tumour characteristics, surgical details and outcomes were collected and analysed. RESULTS: IS patients demonstrated a higher proportion of SCC, multiple synchronous tumours and tumours invading deeper structures. Complex closures, unfinished MMS and more surgical sections were observed in the IS group. Although intra-operative morbidity was higher among IS patients, this difference became non-significant when adjusted for other variables such as year of surgery, antiplatelet/anticoagulant treatment or type of closure. Importantly, IS patients had a substantially higher recurrence rate (IRR 2.79) compared to IC patients. CONCLUSIONS: This study suggests that IS patients may be at a higher risk of development of AE such as bleeding or tumour necrosis and are at a higher risk of tumour recurrence. Close follow-up and consideration of the specific characteristics of NMSC in IS patients are crucial. Further research with extended follow-up is needed to better understand the long-term outcomes for this patient group.

Development and validation of a model to predict complex Mohs micrographic surgery in clinical practice: REGESMOSH scale.

INTRODUCTION: There is still a need to develop a simple algorithm to identify patients likely to need complex Mohs micrographic surgery (MMS) and optimize MMS schedule. The main objectives of this study are to identify factors associated with a complex MMS and develop a predictor model of the number of stages needed in surgery and the need for a complex closure. MATERIALS AND METHODS: A nationwide prospective cohort study (REGESMOHS, the Spanish Mohs surgery registry) was conducted including all patients with a histological diagnosis of basal cell carcinoma (BCC). Factors related to three or more stages and a complex closure (that needing a flap and/or a graft) were explored and predictive models were constructed and validated to construct the REGESMOSH scale. RESULTS: A total of 5226 patients that underwent MMS were included in the REGESMOHS registry, with 4402 (84%) having a histological diagnosis of BCC. A total of 3689 (88.9%) surgeries only needed one or two stages and 460 (11.1%) required three or more stages. A model to predict the need for three or more stages included tumour dimension, immunosuppression, recurrence, location in risk areas, histological aggressiveness and previous surgery. Regarding the closure type, 1616 (38.8%) surgeries were closed using a non-complex closure technique and 2552 (61.2%) needed a complex closure. A model to predict the need for a complex closure included histological aggressiveness, evolution time, patient age, maximum tumour dimension and location. CONCLUSION: We present a model to predict MMS needing ≥3 stages and a complex closure based on epidemiological and clinical data validated in a large population (with real practice variability) including different centres that could be easily implemented in clinical practice. This model could be used to optimize surgery schedule and properly inform patients about the surgery duration.

Complications Associated with Mohs Micrographic Surgery: Data from the Nationwide Prospective Cohort REGESMOHS.

BACKGROUND: Large prospective studies on the safety of Mohs micrographic (MMS) surgery are scarce, and most focus on a single type of surgical adverse event. Mid-term scar alterations and functional loss have not been described. OBJECTIVES: To describe the risk of MMS complications and the risk factors for them. METHODS: A nationwide prospective cohort collected all adverse events on consecutive patients in 22 specialised centres. We used multilevel mixed-effects logistic regression to find out factors associated with adverse events. RESULTS: 5,017 patients were included, with 14,421 patient-years of follow-up. 7.0% had some perioperative morbidity and 6.5% had mid-term and scar-related complications. The overall risk of complications was mainly associated with use of antiaggregant/anticoagulant and larger tumours, affecting deeper structures, not reaching a tumour-free border, and requiring complex repair. Age and outpatient setting were not linked to the incidence of adverse events. Risk factors for haemorrhage (0.9%) were therapy with antiaggregant/anticoagulants, tumour size, duration of surgery, and unfinished surgery. Wound necrosis (1.9%) and dehiscence (1.0%) were associated with larger defects and complex closures. Immunosuppression was only associated with an increased risk of necrosis. Surgeries reaching deeper structures, larger tumours and previous surgical treatments were associated with wound infection (0.9%). Aesthetic scar alterations (5.4%) were more common in younger patients, with larger tumours, in H-area, and in flap and complex closures. Risk factors for functional scar alterations (1.7%) were the need for general anaesthesia, larger tumours that had received previous surgery, and flaps or complex closures. CONCLUSIONS: MMS shows a low risk of complications. Most of the risk factors for complications were related to tumour size and depth, and the resulting need for complex surgery. Antiaggregant/anticoagulant intake was associated with a small increase in the risk of haemorrhage, that probably does not justify withdrawal. Age and outpatient setting were not linked to the risk of adverse events.

Mohs micrographic surgery in dermatofibrosarcoma protuberans: Rate and risk factors for recurrence in a prospective cohort study from the Spanish Registry of Mohs Surgery (REGESMOHS) and review of the literature.

Characterization of patients, surgery procedures and the risk factors for dermatofibrosarcoma protuberans (DFSP) recurrences is poorly defined. In this study, we aimed to describe the demographics, tumor characteristics and interventions of DFSP treated with Mohs micrographic surgery (MSS) to determine the rate and risk factors for recurrence. Data were collected from REGESMOHS, a nationwide prospective cohort study of patients treated with MMS in Spain. From July 2013 to February 2020, 163 patients with DFSP who underwent MMS were included. DFSP was mostly located on trunk and extremities. Recurrent tumors had deeper tumor invasion and required higher number of MMS stages. Paraffin MMS was the most frequently used technique. Overall recurrence rate was 0.97 cases/100 person-years (95% IC = 0.36-2.57). No differences were found in epidemiological, tumor, surgery characteristics or surgical technique (frozen or paraffin MMS [p = 0.6641]) in terms of recurrence. Median follow-up time was 28.6 months with 414 patient-years of follow-up. In conclusion, we found an overall low recurrence rate of DFSP treated with MMS. None of the studied risk factors, including MMS techniques, was associated with higher risk for recurrence.

Risk Factors and Rate of Recurrence after Mohs Surgery in Basal Cell and Squamous Cell Carcinomas: A Nationwide Prospective Cohort (REGESMOHS, Spanish Registry of Mohs Surgery).

Randomized studies to assess the efficacy of Mohs micrographic surgery in basal cell and squamous cell carcinomas are limited by methodological and ethical issues and a lack of long follow-up periods. This study presents the "real-life" results of a nationwide 7-years cohort on basal cell carcinoma and squamous cell carcinoma treated with Mohs micrographic surgery. A prospective cohort was conducted in 22 Spanish centres (from July 2013 to February 2020) and a multivariate analysis, including characteristics of patients, tumours, surgeries and follow-up, was performed. A total of 4,402 patients followed up for 12,111 patient-years for basal cell carcinoma, and 371 patients with 915 patient-years of follow-up for squamous cell carcinoma were recruited. Risk factors for recurrence included age, non-primary tumours and more stages or unfinished surgeries for both tumours, and immunosuppression for squamous cell carcinoma. Incidence rates of recurrence were 1.3 per 100 person-years for basal cell carcinoma (95% confidence interval 1.1-1.5) and 4.5 for squamous cell carcinoma (95% confidence interval 3.3-6.1), being constant over time (0-5 years). In conclusion, follow-up strategies should be equally intense for at least the first 5 years, with special attention paid to squamous cell carcinoma (especially in immunosuppressed patients), elderly patients, non-primary tumours, and those procedures requiring more stages, or unfinished surgeries.

Effects of COVID-19 Lockdown on Tumour Burden of Melanoma and Cutaneous Squamous Cell Carcinoma.

The aim of this study was to compare tumour burden in patients who underwent surgery for melanoma and cutaneous squamous cell carcinoma during nationwide lockdown in Spain due to COVID-19 (for the period 14 March to 13 June 2020) and during the same dates in 2019 before the COVID-19 pandemic. In addition, associations between median tumour burden (Breslow thickness for melanoma and maximum clinical diameter for cutaneous squamous cell carcinoma) and demographic, clinical, and medical factors were analysed, building a multivariate linear regression model. During the 3 months of lockdown, there was a significant decrease in skin tumours operated on (41% decrease for melanoma (n = 352 vs n = 207) and 44% decrease for cutaneous squamous cell carcinoma (n = 770 vs n = 429)) compared with the previous year. The proportion of large skin tumours operated on increased. Fear of SARS-CoV-2 infection, with respect to family member/close contact, and detection of the lesion by the patient or doctor, were related to thicker melanomas; and fear of being diagnosed with cancer, and detection of the lesion by the patient or relatives, were related to larger size cutaneous squamous cell carcinoma. In conclusion, lockdown due to COVID-19 has resulted in a reduction in treatment of skin cancer.

Multisystemic Langerhans cell histiocytosis mimicking diffuse neonatal hemangiomatosis.

We report the first case of multisystemic Langerhans cell histiocytes mimicking diffuse neonatal hemangiomatosis clinically. This has been described in patients with congenital self-healing reticulohistiocytosis but not in patients with acute, disseminated, and multisystemic disease. In our experience, dermoscopic findings did not help to diagnose the condition.

[Surgical treatment of melanoma liver metastases]. / Tratamiento quirúrgico de las metástasis hepáticas de melanoma.

The appearance of liver metastases during the follow-up of a patient with a skin melanoma has classically been considered a sign of a very poor prognosis. There are limited therapeutic options, since these lesions are non-resectable and form part of a disseminated disease in several organs. In certain cases, in those where the disease is restricted to the liver or accompanied by a resectable extra-hepatic disease, hepatectomy can be useful, obtaining acceptable survivals of about 25% at 5 years, although hepatic or skin recurrence is usually early. The limited number of patient cases published, the absence of randomised studies, and the heterogeneity of the series, makes it difficult to reach conclusions to be able to recommend which patients may benefit from liver resection, with an acceptable level of scientific evidence, and thus define its real usefulness. There are also no action plans defined as to when and what type of adjuvant therapy we should use.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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 0.9 years during which three Merkel cell carcinomas, one angiosarcoma, one microcystic adnexal carcinoma, and four others recurred (12.3%). CONCLUSION: 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.

Tratamiento quirúrgico de las metástasis hepáticas de melanoma / Surgical treatment of melanoma liver metastases

La aparición de metástasis hepáticas durante el seguimiento de un paciente con melanoma cutáneo se ha considerado clásicamente un signo de muy mal pronóstico. Las opciones terapéuticas son escasas ya que habitualmente estas lesiones son irresecables y forman parte de una enfermedad diseminada en varios órganos. En ciertos casos, en los que la enfermedad está restringida al hígado o acompañada de enfermedad extrahepática resecable, la hepatectomía puede ser útil, obteniendo supervivencias aceptables, cercanas al 25% a los 5 años, aunque la recidiva hepática o cutánea suele ser temprana. El escaso número de casos publicados, la ausencia de estudios aleatorizados y la heterogeneidad de las series no permiten extraer unas conclusiones para poder recomendar qué pacientes se benefician de la resección hepática con un nivel de evidencia científica aceptable, y así definir su utilidad real. Tampoco están definidas las pautas de actuación de cuándo y qué tipo de terapia adyuvante debemos emplear (AU)

The appearance of liver metastases during the follow-up of a patient with a skin melanoma has classically been considered a sign of a very poor prognosis. There are limited therapeutic options, since these lesions are non-resectable and form part of a disseminated disease in several organs. In certain cases, in those where the disease is restricted to the liver or accompanied by a resectable extra-hepatic disease, hepatectomy can be useful, obtaining acceptable survivals of about 25% at 5 years, although hepatic or skin recurrence is usually early. The limited number of patient cases published, the absence of randomised studies, and the heterogeneity of the series, makes it difficult to reach conclusions to be able to recommend which patients may benefit from liver resection, with an acceptable level of scientific evidence, and thus define its real usefulness. There are also no action plans defined as to when and what type of adjuvant therapy we should use (AU)

Tratamiento tópico con cantaridina de moluscos contagiosos / Tropical treatment of molluscum contagiosum with cantharidin

Introducción: El molusco contagioso es una infección viral común para la que no se dispone de terapia antiviral específica. Los tratamientos con curetaje o crioterapia resultan muy efectivos, pero el dolor y el trauma emocional que ocasionan limitan su uso. En 1998, la Food and Drug Administration (FDA) reincluyó la cantaridina entre las terapias aplicables por el dermatólogo en consulta. No hay publicaciones relativas al uso de cantaridina en los países europeos. Material y métodos. En 2001 fueron tratados en nuestra unidad 28 pacientes con molusco contagioso aplicando cantaridina al 0,7% en colodión flexible. Resultados: Se incluyeron 28 pacientes, 15 mujeres y 13 varones, entre 3 y 43 años de edad, con dos grupos bien diferenciados: 21 con menos de 12 años (media: 6) y siete con más de 20 (media: 29). El tiempo de evolución osciló entre 3 semanas y 2 años, con una media de 5,7 meses. El número total de lesiones osciló entre 1 y 53, con una media de 16 lesiones. Las localizaciones más frecuentes fueron el tronco (11 casos) y las extremidades (en ocho las superiores y en ocho las inferiores). Hubo 6 casos con lesiones en genitales-ingles, cuatro en las axilas y tres en la cara y el cuello. Dos pacientes se perdieron en el seguimiento, y los 26 restantes se curaron, para lo que precisaron entre uno y cinco tratamientos (media: 1,96). Doce pacientes (46%) necesitaron una única sesión de tratamiento con cantaridina; ocho (31%), dos sesiones, y seis (23%), tres o más. El 89% (26/29) presentó como efecto secundario vesiculación y el 73% (19/26), inflamación, que fue generalmente leve (14/19); también fueron comunes el prurito (9/29), el dolor leve (molestia en 10/29) y la hipopigmentación (10/29) que aparecieron en el 33% de los casos. El grado de satisfacción fue alto o muy alto en el 88% (23/26) para los pacientes, en el 87% (20/23) para los padres y en el 81% (22/27) para el médico. En ningún caso fue bajo o muy bajo. Conclusiones: La cantaridina constituye una alternativa eficaz y segura en el tratamiento del molusco contagioso, cuya principal ventaja frente a la crioterapia y el curetaje es la ausencia de molestias en el momento de la aplicación (AU)