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.

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.

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.

Differences of Mohs micrographic surgery in basal cell carcinoma versus squamous cell carcinoma.

BACKGROUND: The two main tumors treated with Mohs micrographic surgery (MMS) are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). There are no studies analyzing whether MMS is different when treating these two types of tumors. OBJECTIVE: We aim to compare the characteristics of the patients, the tumors, and MMS, and first-year follow-up of MMS in BCC and SCC. METHODS: REGESMOHS is a prospective cohort study of patients treated with MMS. The participating centers are 19 Spanish hospitals where at least one MMS is performed per week. Data on characteristics of the patients, tumors, and surgery were recorded. The follow-up was done with two visits: the first visit within 1 month after surgery and the second one within the first year. RESULTS: From July 2013 to April 2017, a total of 2,669 patients who underwent MMS were included in the registry. Of them, 2,448 (93%) were diagnosed with BCC, and 181 (7%) were diagnosed with SCC. Patients with SCC were older than those with BCC (median age 73 years vs. 68 years) and presented immunosuppression more frequently. The tumor size was significantly larger in the SCC group. Regarding surgery, deeper invasion was more frequent in SCC, resulting in larger defects. Despite this, SCC did not require more stages to get clear margins or more time in the operating room. Incomplete Mohs was more frequent in the SCC group (6%) than in the BCC group (2%). The incidence of perioperative complications was higher when treating SCC. There were more relapses in the first-year follow-up in the SCC group. CONCLUSION: There are significant differences when comparing MMS in BCC and SCC. Knowledge of these differences can help to prepare the patient and plan the surgery, optimizing results.

Síndrome de Muir-Torre / Muir-Torre's Syndrome

El síndrome de Muir-Torre es una genodermatosis caracterizada por la asociación de tumores cutáneos derivados de las glándulas sebáceas y neoplasias viscerales, destacando su carácter familiar, multiplicidad, lenta evolución y buen pronóstico vital. Presentamos el caso de un varón de 65 años diagnosticado de adenocarcinoma de colon y adenocarcinoma gástrico que desarrolló dos sebaceomas, un adenoma sebáceo y tres hiperplasias sebáceas. En la familia existe, además, una marcada incidencia de neoplasias viscerales, por lo que el cuadro puede encuadrarse como un síndrome de Muir-Torre en el contexto de un síndrome de cáncer familiar. Realizamos una revisión de la literatura, destacando las características clinicopatológicas más importantes de esta entidad (AU)

Reconstrucción de la región ciliar mediante colgajo de deslizamiento en V-T / V-T Advancement flap for eyebrown reconstruction

La región ciliar y supraciliar son áreas de frecuente asiento de lesiones tumorales cuya corrección quirúrgica puede ser problemática. La reconstrucción tras la excisión del tumor debe realizarse sin distorsión anatómica, intentando evitar la elevación de la ceja, la asimetría respecto a la región frontal contralateral y, en lo posible, la pérdida de folículos pilosos. Presentamos el caso de una mujer de 72 años con un carcinoma epidermoide de mediano tamaño, localizado en ceja y región supraciliar izquierda. Tras la excisión se empleó un colgajo de deslizamiento en V-T para la corrección del defecto resultante, con un resultado funcional y estético satisfactorio. En este trabajo realizamos la descripción de esta técnica y revisamos las diferentes posibilidades reconstructivas tras cirugía oncológica en la región ciliar. (AU)

Los tres grandes. Primera parte: Robert Willan (1757-1812) / The three big masters. First part: Robert Willan (1757-1812)

Robert Willan es considerado el fundador de la Dermatología británica. De familia cuáquera, se graduó en Edimburgo, ejerciendo como médico general en el Dispensario de Carey Street en Londres. Su clasificación de las enfermedades cutáneas utiliza la misma metodología aplicada por la botánica. Su discípulo Thomas Beteman fue el encargado de darla a conocer. (AU)

Nevo de Reed: un simulador clínico y dermatoscópico de melanoma / Reed nevus: a clinic and dermatoscopic simulator of melanoma

La dermatoscopia o microscopía de epiluminiscencia es una técnica complementaria de la exploración clínica, rápida y no invasiva que aumenta la precisión diagnóstica de los tumores cutáneos pigmentados. El conocimiento de los diferentes patrones dermatoscópicos permite, en ocasiones, diferenciar el melanoma de un grupo de lesiones que clínica y/o evolutivamente se comportan como simuladores de melanoma. Presentamos el caso de un varón de 32 años que desarrolló una lesión pigmentada de escaso tiempo de evolución, de crecimiento progresivo, cuya imagen dermatoscópica mostraba múltiples extensiones periféricas digitiformes, adoptando un patrón 'en llamarada' sugestivo de nevo de Reed, aunque con algún dato atípico que obligó a descartar un melanoma incipiente mediante el estudio histológico. Comentamos la utilidad de la dermatoscopia en el diagnóstico de este grupo de lesiones y los diferentes patrones dermatoscópicos que puede presentar el nevo de Reed (AU)

Candidiasis hiperplásica oral pseudotumoral / Pseudotumoral hyperplastic form of oral candidiasis

La Candidiasis oral es una de las infecciones más frecuentes producidas por el género Candida, cuya aparición está determinada por una conjunción de factores favorecedores locales o sistémicos. Clásicamente se han establecido cuatro formas clínico-evolutivas bien diferenciadas: pseudomembranosa, atrófica aguda, atrófica crónica e hiperplásica crónica. La Candidiasis hiperplásica crónica es un cuadro poco frecuente, con mala respuesta al tratamiento antifúngico convencional. Presentamos el caso de un varón de 70 años, fumador, que desarrolló una Candidiasis hiperplásica oral cuya forma de presentación clínica fue poco habitual, simulando una lesión tumoral. La ausencia de respuesta al tratamiento antimicótico prolongado y la posibilidad de degeneración neoplásica determinaron la excisión quirúrgica. Comentamos los principales aspectos etiopatogénicos, clínicos, diagnósticos y terapéuticos de esta entidad (AU)

Empleo del colgajo axial frontonasal en cirugía reconstructiva de punta nasal / The use of axial fronto-nasal flap in reconstructive surgery of the nasal tip

La corrección de defectos de gran tamaño localizados en el dorso y la punta nasales tras la extirpación de lesiones tumorales debe realizarse mediante colgajos locales o a distancia. Éstos aportan un tejido de gran similitud en textura, color y grosor superior al proporcionado por los injertos de piel. El colgajo frontonasal descrito por Marchac es una variante del colgajo pannasal de Rieger que incorpora una excelente vascularización axial a través de la arteria angular. Esta modificación aumenta la movilidad, permitiendo un amplio descenso y rotación para la cobertura de defectos en la punta nasal. Aportamos el caso de una mujer de 80 años que presentaba un carcinoma basocelular de gran tamaño localizado en tercio distal del dorso y la punta nasales. Tras la extirpación se empleó un colgajo axial frontonasal para la corrección del defecto resultante, obteniéndose un excelente resultado cosmético. Describimos la técnica y comentamos las ventajas que aporta en cirugía reconstructiva nasal (AU)