To Mohs or not to Mohs

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Summary

Background

The preferred method of treatment of Dermatofibrosarcoma Protuberance (DFSP) is surgery. Clear margins are achieved by wide local excision (WLE) or by Mohs micrographic surgery. Mohs surgery and reconstruction always requires two or more procedures. This study aims to assess the ability of WLE to accomplish clear histopathological margins and low recurrence rate with a single procedure. We present our results from ten years experience of wide local excision.

Methods

This is a retrospective analysis of data of all cases of DFSP treated with WLE by a single operator in our department between 2002 and 2012.

Results

Twenty patients were identified. The surgical excision and reconstruction were performed on the same day in all cases. The mean histological peripheral margin was 17 mm and the deep 9 mm.

There was no incomplete excision and no recurrence recorded. There were no postoperative complications or tumour recurrences reported for an average period of 5.6 years follow-up.

Conclusion

Mohs surgery offers clear histological margins but requires multiple patient visits to achieve complete excision and later reconstruction. We show that WLE can achieve these in one procedure, the excision margins making little difference when planning the eventual reconstruction.

Introduction

Dermatofibrosarcoma protuberans (DFSP) is a rare neoplasm of the dermis. It is locally aggressive but rarely metastasises. It affects usually adults but has been described in the elderly. DFSP is a slow growing tumour that often presents on the torso.

The preferred method of treatment of DFSP is surgery with adequate margins. Clearance is achieved by wide local excision (WLE) or by Mohs micrographic surgery. The aim of Mohs surgery is to minimise the amount of skin and subcutaneous tissue resected. Mohs surgery has been suggested as standard of care for management of DFSP. This is “slow Mohs” which means large excisions are undertaken under local anaesthetic. As the pathology of DFSP is difficult, this means patients have to return for further “slow Mohs” until clearance has been achieved. Standard time between sessions is 2 days.

We recommend that clear histopathological margins and low recurrence rate can be achieved in a single procedure and show that the excision margins make little difference when planning the eventual reconstruction. We present our results from ten years experience of wide local excision.

Section snippets

Patients and methods

All patients who underwent WLE of DFSP by a single operator (BP) for the last 10 years (September 2002–September 2012) were identified and a retrospective data collection and analysis was undertaken. Patients were referred to the department of Plastic Surgery from other hospitals or General Practitioners after histopathological confirmation of DFSP with excisional, incisional or punch biopsy. All patients were offered WLE. The surgical excision margin was either 20 or 30 mm depending on a

Results

Twenty cases in nineteen patients were identified for the ten-year period; one patient (JC) had two synchronous lesions (Table 1). Of the 20 patients 11 were male and nine female. The patient age range was 19–79 (mean 45). All operations were performed under a general anaesthetic. The surgical excision and reconstruction were performed on the same day in all cases.

The DFSP was on extremities in four cases, on the trunk in 15 and on the scalp in one case (Table 2). The surgical excision margin

Discussion

There have been many studies reporting on the outcome of Mohs surgery1, 2 and comparing Mohs surgery with wide local excision of DFSP.3, 4

Mohs micrographic surgery has the advantage of providing a clear surgical margin confirmed by immediate histological examination of the specimen. However if the defect requires a reconstruction, this will be done at a second stage while in the mean time the patient has to cope with open wounds and dressings. WLE provides the advantage of single stage

Conflict of interest

None.

Funding

None.

References (10)

There are more references available in the full text version of this article.

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