High-frequency ultrasound-assisted Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a superficial sarcoma characterized by infiltrative growth with tentacle-like borders. Mohs micrographic surgery (MMS) is the preferred treatment option for DFSP. However, the imprecise boundary localization in MMS leads to an increased number of Mohs layers required and a longer surgery time. High-frequency ultrasound has excellent tissue recognition capability for DFSP, allowing for precise boundary marking. MATERIALS AND METHODS: In this study, we retrospectively analyzed 14 cases of DFSP treated with MMS using preoperative ultrasound localization and three-dimensional reconstruction at Xiangya Hospital over the past 5 years. We also reviewed previous studies on MMS for DFSP treatment. RESULTS: It was found that the average number of Mohs layers for patients after preoperative ultrasound localization was 1.57, ranging from 1 to 3, which was less than the previously reported 1.86 layers, ranging from 1 to 12. This effectively reduced the number of Mohs layers required. CONCLUSIONS: By utilizing preoperative high-frequency ultrasound to determine the boundaries and depth of DFSP, the number of Mohs layers can be effectively reduced, leading to less workload for pathological examination, shorter operation time, and reduced surgical risks for patients. Ultrasound imaging data can be used for three-dimensional reconstruction, enabling less experienced Mohs surgeons to have a visual understanding of the morphology and extent of infiltration of the lesions. This aids in developing optimal surgical plans, smoothing the learning curve, and promoting the wider adoption of MMS.

Primary Extramammary Paget's Disease Following Previously Treated Secondary Extramammary Paget's Disease Over the Scrotum: A Rare Case Successfully Treated With Mohs Micrographic Surgery.

Extramammary Paget's disease (EMPD) is a rare cutaneous neoplasm that can be classified as either primary or secondary, depending on the presence or absence of an associated internal malignancy. Primary EMPD arises as an intraepithelial adenocarcinoma, while secondary EMPD results from the extension of an underlying visceral malignancy. This case report presents a unique instance of primary EMPD developing 10 years after a diagnosis of secondary EMPD in the same anatomical location, a phenomenon not previously documented in the literature. The patient, initially treated for secondary EMPD with wide local excision, later developed primary EMPD, as confirmed through histopathological and immunohistochemical analysis. This rare occurrence raises questions about the potential mechanisms, including field cancerization, persistent risk factors, or a coincidental event. The case underscores the importance of long-term follow-up and surveillance for EMPD patients. Mohs micrographic surgery remains the gold standard for treating EMPD due to its high precision in margin control and lower recurrence rates compared to conventional surgical methods. This case highlights the need for meticulous diagnostic approaches and continuous monitoring to manage and understand the complexities of EMPD effectively.

3D models for mohs micrographic surgery: a review on its use in patient education.

The use of a 3D model for patient education has shown encouraging results in surgical specialties like plastic surgery and neurosurgery, amongst many others; however, there is limited research on the clinical application of 3D models for Mohs Micrographic Surgery. This study delves into the utilization of 3D models for patient education in Mohs Surgery by juxtaposing different 3D modalities, highlighting their differences, and exploring potential avenues for future integration of 3D models into clinical practice. A literature search in the scientific database MEDLINE through PubMed and OVID and on the ProQuest Health & Medical Collection database was performed on the use of a 3D model for patient education. We limited the search to articles available in English and considered those mentioning the educational use of 3D models, especially for patient education, after excluding duplicate titles. We did not exclude articles based on publication year due to limited availability of literature. Utilizing 3D models for patient education within the framework of Mohs Micrographic surgery, including a 3D multicolored clay model and a 3D model accompanied by an educational video intervention, presents substantial advantages. 3D models offer a visual and tactile means to improve patients' comprehension of the Mohs procedure, the affected area, and possible outcomes. They hold the potential to reduce patient anxiety and improve decision-making. Currently, literature on the use of 3D models for patient education in Mohs Micrographic Surgery is limited, warranting further research in this area.

Factors Influencing Margin Clearance and the Number of Stages of Mohs Micrographic Surgery in Basal Cell Carcinoma: A Retrospective Chart Review.

How patient and tumor factors influence clearance margins and the number of Mohs Micrographic Surgery (MMS) stages when treating basal cell carcinoma (BCC) remains widely uncharacterized. It is important to elucidate these relationships, as surgical outcomes may be compared nationally between colleagues. Our objective is to evaluate the relationships between defect size and patient demographics, as well as between BCC subtypes and the number of MMS stages. Our second objective is to compare practice patterns and characteristics of patients requiring MMS at academic centers and private practices. A retrospective chart review was performed using data collected at academic centers (2015-2018) and private practices (2011-2018) of BCC patients older than 18 years old who underwent MMS. In total, 7651 patients with BCC requiring MMS were identified. Academic center adjusted analyses demonstrated clearance margins 0.1 mm higher for every year's increase in age (p < 0.0001) and 0.25 increase in MMS stages for high-risk BCC (p < 0.0001). Private practice adjusted analyses demonstrated clearance margins 0.04 mm higher for every year's increase in age (p < 0.0001). Clearance margins correlate with older age, and additional MMS stages correlate with high-risk BCC, suggesting the role patient and tumor factors may play in predicting tumor clearance and MMS stages.

Mohs Micrographic Surgery for Cutaneous Squamous Cell Carcinoma.

BACKGROUND: The first-line treatment of the localized form of cutaneous squamous cell carcinoma (cSCC) remains surgical excision. Either conventional excision (CE) with margins or Mohs micrographic surgery (MMS) may be preferred, depending on the risk factors of cSCC, the characteristics of the tumor, and the available technical facilities. METHODS: This article presents a systematic review of the current literature spanning from 1974 to 2023, comparing outcomes of cSCC treated with MMS versus cSCC treated with conventional excision. RESULTS: Out of the 6821 records identified through the database search, a total of 156 studies were screened, of which 10 were included in the review. The majority of the included studies showed that treatment of cSCC with MMS consistently exhibits a significantly lower risk of recurrence compared to treatment with CE. In addition, MMS is emerging as the preferred technique for the resection of cSCC located in aesthetically or functionally challenging anatomical areas. CONCLUSION: The studies generally demonstrate that MMS is a safer and more effective treatment of cSCC than CE. Nevertheless, outcomes such as recurrence rates and cost-effectiveness should be assessed more precisely, in order to allow for a more tailored approach in determining the appropriate indication for the use of MMS.

Early Post-Operative Water Exposure Does Not Increase Complications in Cutaneous Surgeries: A Randomized, Investigator-Blinded, Controlled Trial.

BACKGROUND: Patients are often advised to keep the initial post-operative dressings dry and undisturbed for 24 to 72-hours. However, these requirements may result in significant disruption of patients' activities of daily living, such as bathing, leisure, and exercise. OBJECTIVE: Compare standard management of keeping wounds dry and covered (48-hours) with early (6-hours) post-operative water exposure METHODS: Investigator-blinded, randomized (1:1), controlled trial evaluating rate of infection and additional outcomes of interest. RESULTS: Overall, 437 patients randomized to either the early (6-hour) water exposure (n = 218) intervention group or the standard cohort (n = 219). The incidence of culture-proven infection in the intervention group (1.8%) was similar to the standard group (1.4%) (p>0.99). There was also no difference in rates of bleeding or bruising. Scar assessment using the Patient and Observer Scar Assessment Scale (POSAS) revealed similar scar outcomes. LIMITATIONS: Single site, academic center. CONCLUSION: Surgical wounds can be allowed to get wet in the immediate post-operative period with no increased incidence of infection or other complications and with similar cosmesis.

Establishing Consensus for Mohs Micrographic Surgical Techniques in the Treatment of Melanoma in Situ for Future Clinical Trials: A Modified Delphi Study.

BACKGROUND: Mohs micrographic surgery (MMS) is a promising treatment modality for melanoma in situ (MIS). However, variations in surgical technique limit the generalizability of existing data and may impede future study of MMS in clinical trials. METHODS: A modified Delphi method was selected to establish consensus on optimal MMS techniques for treating MIS in future clinical trials. The Delphi method was selected due to the limited current data, the wide range of techniques used in the field, and the intention to establish a standardized technique for future clinical trials. A literature review and interviews with experienced MMS surgeons were performed to identify dimensions of the MMS technique for MIS that (1) likely impacted costs or outcomes of the procedure, and (2) showed significant variability between surgeons. A total of 8 dimensions of technical variation were selected. The Delphi process consisted of 2 rounds of voting and commentary, during which 44 expert Mohs surgeons across the United States rated their agreement with specific recommendations using a Likert scale. RESULTS: Five of eight recommendations achieved consensus in Round 1. All 3 of the remaining recommendations achieved consensus in Round 2. Techniques achieving consensus in Round 1 included the use of a starting peripheral margin of ≤5 mm, application of immunohistochemistry, frozen tissue processing, and resecting to the depth of subcutaneous fat. Consensus on the use of Wood's lamp, dermatoscope, and negative tissue controls was established in Round 2. CONCLUSIONS: This study generated 8 consensus recommendations intended to offer guidance for Mohs surgeons treating MIS. The adoption of these recommendations will promote standardization to facilitate comparisons of aggregate data in multicenter clinical trials.

Bibliometric Analysis of the Top 100 Most Cited Papers in Mohs Surgery.

BACKGROUND: Mohs micrographic surgery is a specialized tissue-sparing technique used to treat skin cancers. OBJECTIVE: By understanding the attributes that make a research paper one of the top 100 cited papers on Mohs surgery, we hope to illuminate seminal research in this field. METHODS AND MATERIALS: The global literature about Mohs surgery published between 1900 and 2023 was searched on the Web of Science. Publication data for all results meeting the search criteria were exported and analyzed. RESULTS: In total, 4,961 publications with 81,405 citations were identified. Dermatologic Surgery was the most cited journal, with 1,073 publications. Papers from the top 100 most cited that were published in the year 2000 or prior had an average of 22.1 citations in the first five years after publication, whereas papers published after 2001 had an average of 56.0 citations in the first five years. CONCLUSION: Analysis of the most cited papers on Mohs surgery demonstrates the influential role of the Dermatological Surgery journal in advancing the field. Noteworthy studies addressing cost, safety, and efficacy have received substantial citations, reflecting their significance within the literature. A trend toward more citation in the first five years after publication over time was identified.

Ethics of Residency Programs and Fellowships that Electively Withdraw from the NRMP Match.

The National Resident Matching Program (NRMP), known as "The Match (TM)," facilitates the placement of medical graduates into residency and fellowship programs in the United States. Programs may opt out of TM for various reasons. The selective and intermittent withdrawal of programs from TM raises ethical concerns surrounding fairness, transparency, beneficence, autonomy, and justice for applicants. We discuss these issues, present the history behind TM, and offer suggestions to promote fairness.

Report of Basal Cell Carcinoma Occurring With a Desmoplastic Trichilemmoma Successfully Treated With Mohs Micrographic Surgery.

Desmoplastic trichilemmoma, an uncommon variant of trichilemmoma, is a benign adnexal neoplasm originating from the outer root sheath of a hair follicle, which has rarely been associated with atypical basaloid proliferations, including basal cell carcinoma. In this patient case, a 67-year-old female presented to our dermatology clinic for a skin check. On physical examination, a pearly, pink papule was noted on the vertex scalp, and a biopsy was obtained to rule out malignancy. Histologic examination of the lesion favored a desmoplastic trichilemmoma; however, a basaloid neoplasm could not be ruled out. Subsequently, the patient underwent Mohs micrographic surgery, and upon examination of the Stage I Mohs slides, superficial basal cell carcinoma was identified within the lesion. This case serves to further strengthen the known association between basal cell carcinoma and desmoplastic trichilemmoma. In addition, it demonstrates that the presence of basal cell carcinoma may not be observed on the initial biopsy of these lesions, underscoring the utility of complete surgical excision.

Shared decision making for perioperative antibiotic use during Mohs micrographic surgery on the lower extremities.

Background: While there is a higher risk of surgical site infection (SSI) on the lower extremities following Mohs micrographic surgery (MMS), antibiotic prophylaxis (AP) is debated. Objective: To determine the role of shared decision making (SDM) in guiding AP usage during MMS on the lower extremities. Materials and methods: A prospective observational study was conducted whereby patients received a standardized SDM discussion or routine counseling. Patient satisfaction quantified by the shared decision-making questionnaire (SDMQ9) survey, rate of SSI, and rate of AP prescription were recorded. Results: In total, 51 patients were included. While there were less antibiotics prescribed in the treatment group (20% versus 50%, P = .025), this did not affect incidence of SSI (8% in treatment group versus 7.7% in control group, P = .668). Patient satisfaction was statistically greater in SDM group (4.73 versus 2.18 in control (P < .001). Conclusion: Patient satisfaction scores were higher among the patients who received SDM. While the usage of AP was lower in the SDM group, this did not affect incidence of SSI. This study allows the opportunity to apply SDM in the setting of MMS, which to our knowledge has not yet been attempted in the field of dermatologic surgery.

Porocarcinoma of the Groin: A Case Report.

Introduction: Porocarcinoma is a rare skin cancer that arises from the intraepidermal ducts of sweat glands. It is classically found in the 60-70-year-old age group, and lesions are most commonly reported on the head and neck or lower extremities. Case Presentation: This case focuses on a 49-year-old man who presented to an outpatient dermatology clinic with a growing, painful nodule in his right groin. A shave biopsy was conducted and resulted in a diagnosis of a porocarcinoma. Conclusion: Porocarcinoma is an extremely rare skin cancer that most commonly occurs on the head, neck, or lower extremities of 60-70-year-olds. This report details the interesting findings of a porocarcinoma in an unexpected location and age group and reviews pertinent literature.

Trichoblastic Carcinoma in the Glabella Treated With Mohs Micrographic Surgery.

Trichoblastic carcinoma (TBC) is a rare adnexal neoplasm of follicular germ cell differentiation with the potential for local invasion and metastasis. Histologic features of trichoblastic carcinoma have significant overlap with trichoblastoma and basal cell carcinoma (BCC), making diagnosis difficult in some cases. Treatment strategies are not well defined and include surgical excision for localized tumors and systemic therapies for metastatic disease. We present a case of trichoblastic carcinoma clinically resembling a benign cyst that was ultimately treated with Mohs micrographic surgery (MMS).

Histopathologic Evaluation of Atypical Fibroxanthoma or Pleomorphic Dermal Sarcoma Debulk Specimen from Mohs Surgery: A Requirement for Their Proper Distinction.

Pleomorphic dermal sarcomas can be clinically aggressive, with a higher tendency to cause local recurrence, metastasis, and death. Atypical fibroxanthoma and pleomorphic dermal sarcoma are histopathologically similar, and their distinction requires a systematic examination of the entire excised tumor. Since Mohs micrographic surgery is commonly utilized to treat atypical fibroxanthoma, a histopathologic evaluation of debulk specimens by permanent pathology is prudent to avoid underdiagnosing pleomorphic dermal sarcoma. This approach can improve risk assessment and treatment decisions, ultimately enhancing patient outcomes. Also, the proper distinction will facilitate the future development of accurate staging criteria and additional treatment modalities.