Indication guidelines for Mohs micrographic surgery in skin tumors

Abstract: Mohs micrographic surgery is a technique used to excise skin tumors based on comprehensive surgical mapping, in which the surgeon removes the tumor, followed by a complete histological evaluation of the tumor's margins. The correlation of the presence of a tumor in histological examinations and its precise location on the surgical map result in a complete removal of the tumor with maximum normal tissue preservation. The present article seeks to provide general practitioners and healthcare specialists with guidelines regarding recommendations for Mohs micrographic surgery to treat skin tumors, based on the most reliable evidence available in medical literature on the subject. This bibliographic review of scientific articles in this line of research was conducted based on data collected from MEDLINE/PubMed. The search strategy used in this study was based on structured questions in the Patient, Intervention, Control, and Outcome (PICO) format. MeSH terms were used as descriptors. The indications of this technique are related to recurrence, histology, size, definition of tumor margins, and location of tumors. These guidelines attempt to establish the indications of Mohs surgery for different types of skin tumors.

Treatment of cutaneous tumors with topical 5 percent imiquimod cream

INTRODUCTION: There are various approaches to the treatment of cutaneous tumors; one of them is treatment with imiquimod, a synthetic toll-like receptor agonist with a low molecular weight that offers a topical, noninvasive, and non-surgical therapeutic option. The main objective of our study was to provide data on 89 patients who used a 5 percent imiquimod cream for the treatment of cutaneous tumors at the Cutaneous Oncology Group of the Dermatology Department of Hospital das Clinicas from 2003 to 2008. MATERIALS AND METHODS: Here, we present our experience in the treatment of 123 cutaneous tumors of various types, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), Bowen's disease, erythroplasia of Queyrat, Paget's disease, and trichoepithelioma, with 5 percent imiquimod cream from 2003 to 2008 in the Cutaneous Oncology Group of the Dermatology Department of Hospital das Clinicas. Patients were divided into two separate groups according to their diagnosis and comorbidities; these comorbidities included epidermodysplasia verruciformis, xeroderma pigmentosum, albinism, basal cell nevus syndrome, Brooke-Spiegler syndrome, HIV, chronic lymphocytic leukemia, B-cell lymphoma, and kidney transplantation. Treatment duration, response to imiquimod, follow-up, recurrence, and local and systemic reactions associated with use of the drug were analyzed. Epidemiological data were obtained and cure rates were calculated. RESULTS: The ratio of women to men was 1.28:1, and the mean age was 63.1 years. Tumors were located mainly on the face, back, trunk, and legs. For patients with comorbidities, the overall cure rate was 38 percent. These specific patients demonstrated cure rates of 83.5 percent for superficial BCC and 50 percent for Bowen's disease. Aggressive BCC and superficial and nodular BCC did not present a good response to treatment. Trichoepitheliomas and nodular BCC showed a partial response, and erythroplasia of Queyrat showed ...

Fatores preditivos do maior número de estádios na cirurgia micrográfica de Mohs para o tratamento do carcinoma espinocelular da cabeça / Predictors of higher number of stages in Mohs micrographic surgery for the treatment of squamous cell carcinoma of the head

FUNDAMENTOS: Os carcinomas espinocelulares da pele da cabeça têm como opção terapêutica mais segura a cirurgia micrográfica de Mohs, que apresenta os menores índices de recidiva e a máxima preservação tecidual. Características dos carcinomas espinocelulares podem estar relacionadas a maior número de estádios cirúrgicos. OBJETIVO: Definir características dos carcinomas espinocelulares que sejam preditoras de maior número de estádios na cirurgia de Mohs. MÉTODOS: Análise retrospectiva de 51 carcinomas espinocelulares da cabeça tratados pela cirurgia de Mohs para determinar fatores de risco de maior número de estádios. Foram analisados limites clínicos, morfologia, recidiva, histologia e tamanho, relacionando-os ao número de estádios cirúrgicos. A análise estatística foi realizada pelo teste exato de Fisher e regressão logística multivariada. RESULTADOS: Os carcinomas recidivados tiveram tendência a maior número de estádios (p=0,081). Os tumores com limites imprecisos apresentaram três vezes mais possibilidades de maior número de fases na análise da razão de chances. Esse achado foi compatível com dados da literatura, apesar de não ter sido estatisticamente significante. CONCLUSÃO: Características pré-operatórias dos carcinomas espinocelulares, como recidiva e limites imprecisos, apesar de não preditivas, indicaram tendência a maior número de estádios na cirurgia micrográfica de Mohs.

BACKGROUND: Squamous cell carcinomas of the skin of the head are better treated with Mohs micrographic surgery which has the lowest recurrence rates and allows spare normal tissue. There are some characteristics of squamous cell carcinoma that can be related to a higher number of surgical stages. OBJECTIVE: To study characteristic of head squamous cell carcinoma that predicts a higher number of Mohs surgical stages. METHODS: A retrospective analysis of 51 squamous cell carcinomas of the head treated with Mohs surgery was performed to determine risk factors for a higher number of surgical stages. The characteristics analyzed were clinical limits, morphology, recurrence, histological differentiation and size and compared to the number of surgical stages. The analysis was performed by Fisher’s exact test and multivariate logistic regression. RESULTS: The recurrent squamous cell carcinomas showed a tendency for a higher number of stages (p=0,081). The Odds Ratio for a higher number of Mohs stages was three for inaccurate limits; although not statistically significant,it corroborates clinical and previous publication. CONCLUSION: Clinical characteristics of squamous cell carcinoma as recurrence and inaccurate limits would not predict, but could indicate tendency of a higher number of Mohs micrographic surgery stages.

Risco de complicações durante a cirurgia dermatológica: protocolo das exéreses em fuso / Risk of complications during dermatologic surgery: protocol for excisional surgery

FUNDAMENTOS: A cirurgia dermatológica é prática comum no dia-a-dia do dermatologista, havendo portanto necessidade de estudos que demonstrem a segurança do procedimento. OBJETIVO: Criação de protocolo que avaliasse o risco de complicações durante e imediatamente após a cirurgia dermatológica, sobretudo em pacientes com co-morbidades clínicas. MÉTODOS: Foram realizadas 860 exéreses em fuso no período de janeiro de 2001 a novembro de 2003, sendo todas protocoladas segundo algumas variáveis - como idade e sexo do paciente, tipo de lesão excisada, doenças associadas e uso de medicações, tamanho do fuso, tempo de cirurgia, tipo e quantidade de anestésico utilizado e aferição da pressão arterial -, correlacionando-as ao risco de complicações. RESULTADOS: Dos 860 pacientes operados, 64,6 por cento não apresentaram nenhuma complicação; 34,6 por cento apresentaram elevação da pressão arterial sem repercussão clínica; 0,5 por cento apresentaram sangramento importante que pôde ser controlado; dois pacientes apresentaram hipotensão arterial. CONCLUSÃO: A cirurgia dermatológica é muito segura, podendo ser realizada em consultórios ou ambulatorialmente, consistindo, na maioria dos casos, em procedimento pequeno e rápido, sendo o risco de complicações muito baixo.