Journal of Clinical and Aesthetic Dermatology

APR 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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42 JCAD journal of clinical and aesthetic dermatology April 2017 • Volume 10 • Number 4 Network. For the management of DFSP, the NCCN guidelines advocate that MMS, modified Mohs surgery, or traditional WLE are all appropriate methods to achieve clear histological margins. However, tumor size, location, and cosmesis are important variables to consider when deciding on the best-suited surgical therapy for the patient. 22 The NCCN cites two systemic reviews and a retrospective study comparing MMS with WLE. The former two cited systemic reviews identified lower recurrence rates following use of MMS compared to WLE. The latter retrospective study concluded that positive margins more frequently occurred following WLE compared to MMS, though the recurrence rates were statistically similar. 22,26,29,30 The NCCN recommendation for the management of DFSP is MMS or its variants to ensure complete removal with clear margins and minimize tissue loss where possible. Alternatively, WLE can also be used, with 2 to 4cm peripheral margins and deep margins extending to the investing fascia of the muscle or pericranium where appropriate. In consideration of the eccentric projections seen with DFSP, a complete histologic assessment of all surgical margins should be completed prior to attempting reconstruction of the defect to avoid tumor seeding and subsequent spreading. 22,31,32 European Dermatology Forum. The latest EDF guidelines on the management of DFSP were established by a collaboration of the EDF, the European Association of Dermato-Oncology, and the European Organization of Research and Treatment of Cancer. For DFSP, the EDF favors MMS over WLE. Should WLE be pursued, the EDF recommends 1 to 1.3cm peripheral margins based on findings using micrographic techniques and deep margins extending to the deep fascia. For DFSP with fibrosarcomatous change, WLE or MMS can be r E v i E W Table 3. Cutaneous squamous cell carcinoma global guideline comparison of surgical margins 12,13,15,16,18 orGANizATioN PEriPHErAL MArGiNS DEEP MArGiNS Low-riSk LESioNS HiGH-riSk LESioNS Low- AND HiGH-riSk LESioNS NCCN Preferred: SE -4–6mm Preferred: SE ->6mm Not specified EDF Preferred: SE -5mm Preferred: SE (or MMS) -6–10mm Level of hypodermis, sparing the aponeuroses, perichondrium, and periosteum if they are una6ected by tumor extension BAD Preferred: SE -4mm Preferred: SE (or MMS) -≥6mm Not specified CCA/ACN Preferred: SE -4mm Preferred: SE -≤10mm Through normal subcutaneous fat Sweden Preferred: SE -4mm Preferred: SE (or MMS) -≥6mm Not specified British Association of Dermatology (BAD), Cancer Council Australia and Australian Cancer Network (CCA/ACN), European Dermatology Forum (EDF), National Cancer Care Network (NCCN), Mohs micrographic surgery (MMS), standard excision (SE)

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