The efficacy of Mohs micrographic surgery over the traditional wide local excision surgery in the cure of dermatofibrosarcoma protuberans

Abstract

Usually most patients with dermatofibrosarcoma protuberans (DFSP) may present rather late when the tumor is in protuberant phase due to its rarity and indolent onset. It has a high propensity for local recurrence and destructive nature. Management of DFSP requires a biopsychosocial and Multidisplinary approach regardless of the clinical or immunohistochemical variant. Surgery is the Gold standard management of localized disease. DFSP rarely exhibits any lymphatic or hematogenous dissemination. It is because of its high recurrence rate associated with Wide Local Excision (WLE), the introduction of Mohs micrographic surgery (MMS) has really helped in reducing the rates of recurrence of DFSP. Thus, the aim of this meta-analysis and systemic review is to advocate for MMS over WLE for DFSP and other cutaneous malignancies using DFSP as a prototype. The objective of this study were to conduct a meta-analysis on comparative surgical methods used in the cure of DFSP with regards to WLE verses MMS, to evaluate the cure rates with relation to recurrence rates, offer a recommendation on the various treatment modalities based on the location of lesion, and use of adjuvant therapy in different clinical-medical setups. A comprehensive retrospective analysis search in EMBASE, Google Scholar and Medline (PubMed) for studies published from 2008 to 2018 containing the surgical management of DFSP with WLE verses MMS were reviewed. Five studies of moderate-quality evidence (level B) with a pooled patient load of 684 was analyzed and found for recurrence of DFSP after WLE and MMS to be 9.10% and 2.72% respectively after an average follow-up time for both groups of 5.32 years with a female predominance of 1.58. The trunk is the commonest site for the DFSP lesion which was at 52.80% then the upper and lower extremities zones and the head and neck zones at 31.75% and 15.45% respectively. The pooled adjusted odds ratio (OR) analysis indicated that there was a direct relationship with regards the reduced recurrence rate of DFSP in the MMS group compared to the WLE group (OR:0.31;95%; CI :0.17-0.56). Furthermore, there was significant association between the reduced recurrence rate with the MMS in DFSP patients with a statistical P-value of 0.0001 at 95% CI. The expected increased recurrence rate by zones was in WLE head and neck zone at 38.19% then trunk and extremities zone at 13.34%. In the MMS group it was at of 23.4% as compared to 16.0% in the head and neck zone. Mohs Micrographic Surgery (MMS) is more efficacious in the cure rate and recurrence reduction of DFSP and should be advocated for as first line therapy especially in high recurrence prone zones.

An experience of slow‐Mohs micrographic surgery for the treatment of Dermatofibrosarcoma protuberans: A long‐term cohort study

“…Putting the higher rate of recurrence in the face next to the size of margins required to be excised shows the significance of the cosmoses and values of slow-Mohs surgery. 14,31 In our study, 76% of the patients underwent skin closure within 5-7 days after the procedure that is compatible with the other study representing a rate of 83%. 23 Slow-Mohs has seldom been reported as an uncomfortable method for the patients, while it was well-tolerated in our study; besides, to us, the advantages of this technique were more prominent.…”

“…DFSP would not develop concentrically; therefore, wide local excision does not seem to be the best approach for the management of this tumor, as too much healthy tissue would be sacrificed. Nevertheless, it is well‐established that an increase in the margin resection decreases the risk of recurrence, while studies have found no correlation between the required size of excised margins with the size of the tumors …”

“…Recurrence of SFDP on the face is more frequent than other parts that may partially occur due to the hesitation in the extensive margin excision of this part. Putting the higher rate of recurrence in the face next to the size of margins required to be excised shows the significance of the cosmoses and values of slow‐Mohs surgery …”

“…Nevertheless, it is well-established that an increase in the margin resection decreases the risk of recurrence, 14,15 while studies have found no correlation between the required size of excised margins with the size of the tumors. 16 The only choice for a wide excision is MMS that has been raised to as much as possible reduce the excised margins in addition to minimize the risk of local recurrence.…”

Dermatofibrosarcoma Protuberans: Update on the Diagnosis and Treatment

“…Multiple studies have shown that MMS can significantly lower the risk of recurrence of DFSP, compared with WLE [ 88 , 90 , 91 ]. A comprehensive retrospective meta-analysis involving 684 patients of DFSP published on Medline from 2008 to 2018 revealed that the recurrence rates of DFSP treated with WLE and MMS were 9.10% and 2.72%, respectively, with mean follow-ups of 5.32 years for both groups [ 92 ]. Lowe et al reported the Mayo Clinic experience illustrating a 30.8% recurrence rate following WLE and 3.0% with Mohs surgery; primary closure was performed following MMS in 73% of cases, vs. flaps, graft and other closures in 52% of the WLE cases [ 90 ].…”