To Mohs or not to Mohs
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)
- et al.
Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans. Results of a multiinstitutional series with an analysis of the extent of microscopic spread
J Am Acad Dermatol
(1997 Oct) - et al.
Dermatofibrosarcoma protuberans: wide local excision vs. Mohs micrographic surgery
Cancer Treat Rev
(2008 Dec) - et al.
Reducing surgical margins in dermatofibrosarcoma protuberans using the pathological analysis technique 'vertical modified technique': a 5-year experience
J Plast Reconstr Aesthet Surg
(May 2013) - et al.
Outcomes of surgery for dermatofibrosarcoma protuberans
Eur J Surg Oncol
(2004) - et al.
Is Mohs micrographic surgery more effective than wide local excision for treatment of dermatofibrosarcoma protuberans in reducing risk of local recurrence? A critically appraised Topic
BJD
(2012)
Cited by (16)
Long-term outcomes of surgical treatment for dermatofibrosarcoma protuberans according to width of gross resection margin
2016, Journal of Plastic, Reconstructive and Aesthetic SurgeryCitation Excerpt :In addition, a specially trained surgeon and dermatopathologist are necessary for Mohs surgery.17 It is unclear whether Mohs surgery is superior to wide local excision.10,28 The choice between wide local excision and Mohs surgery should be based on tumor characteristics and institutional expertise in these modalities.28
Malignant cutaneous adnexal tumours of the head and neck: An update on management
2015, British Journal of Oral and Maxillofacial SurgeryCitation Excerpt :Margins of 2–4 cm are needed if wide excision is done, and deep margins should extend to the underlying investing fascia (Fig. 2). Kokkinos et al. showed that wide excision has the advantage of achieving clear margins in a single procedure.29 Meguerditchian et al. found higher rates of recurrence after wide excision than after MMS, but the difference was not significant because the numbers were too low.30
True Mohs or not true Mohs, that is really the question
2014, Journal of Plastic, Reconstructive and Aesthetic SurgeryDermatofibrosarcoma protuberans in children and adolescents: Clinical presentation, histology, treatment, and review of the literature
2014, Journal of Plastic, Reconstructive and Aesthetic SurgeryTo mislead or not to mislead?: Letter of response to Article: Kokkinos C, Sorkin T, Powell B. to Mohs or not to Mohs. J Plast Reconstr Aesthetic Surg (2014) 67: 23-26.
2014, Journal of Plastic, Reconstructive and Aesthetic Surgery