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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43 JCAD journal of clinical and aesthetic dermatology April 2017 • Volume 10 • Number 4 performed and an extended peripheral margin of 3cm is recommended. 33 British Association of Dermatology. The BAD historically recommended WLE as first-line treatment for DFSP. However, in recent years, the British Society for Dermatological Surgery revised these recommendations, now instead advocating for MMS. The BAD guidelines ration that because of DFSP's subclinical and asymmetrical extension into cutaneous anatomy, MMS is preferred to ensure complete removal. 34 Danish guidelines. For the management of DFSP, Danish guidelines recommend WLE using 2 to 3cm peripheral margins and deep margins to include the deep fascia. Alternatively, MMS can be used as a first-line treatment in appropriate candidates (Table 4). 35 Merkel cell carcinoma. MCC is a rare neuroendocrine tumor historically known for its predominance in immunocompromised individuals. In the past two decades, the incidence has tripled in the general population. The two-year mortality of MCC is approximately 28 percent. 36–38 MCC has been associated with excess UV radiation exposure, with 81 percent of lesions located in sun-exposed areas. 39,40 The Merkel cell polyomavirus, a part of the normal human flora, accounts for approximately 80 percent of MCCs. 41,42 Due to the asymptomatic nature, rapid expansion, and tendency for aggressiveness, clinical presentations of MCC are often delayed, resulting in metastatic disease at first presentation. 38,43 National Comprehensive Cancer Network. According to the NCCN, WLE remains the standard of care for MCC. The current recommendation is 1 to 2cm peripheral margins and deep margins extending to the investing fascial layer of the muscle or pericranium where clinically applicable. 44,45 Sentinel lymph node biopsy (SLNB) is advised, but in lesions involving the head and neck there is decreased utility secondary to the complexity of this regional lymphatic system and tendency for false negatives. Inclusion of local adjuvant radiotherapy can be useful, but is not necessary. 44 European Dermatology Forum. The latest EDF guidelines were established by a collaboration of the EDF, the European Association of Dermato-Oncology, and the European Organization of Research and Treatment of Cancer. Due to the tendency of these tumors to develop microscopic satellite lesions, Table 4. Dermatofibrosarcoma protuberans global guideline comparison of surgical margins 22,33–35 orGANizATioN PEriPHErAL MArGiNS DEEP MArGiNS NCCN Preferred: WLE (or MMS) -2–4cm Level of investing fascial layer EDF Preferred: MMS -1–1.3cm -3cm (DFSP with fibrosarcomatous change) DFSP with fibrosarcomatous change: MMS or WLE -3cm Level of deep fascia BAD Preferred: MMS Not specified Denmark Preferred: WLE (or MMS) -2–3cm Level of deep fascia British Association of Dermatology (BAD), dermatofibrosarcoma protuberans (DFSP), European Dermatology Forum (EDF), National Cancer Care Network (NCCN), Mohs micrographic surgery (MMS), wide local excision (WLE) r E v i E W

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