Mohs micrographic surgery
Mohs micrographic surgery is a specialized technique used to achieve the narrowest margins necessary to avoid tumor recurrence, while maximally preserving cosmesis. In case series, it has been associated with a lower local recurrence rate than the other local modalities, but there are no randomized trials allowing direct comparison. This surgery is best suited to the management of tumors in cosmetically sensitive areas or for tumors that have recurred after initial excision (e.g., eyelid periorbital area, nasolabial fold, nose-cheek angle, posterior cheek sulcus, pinna, ear canal, forehead, scalp, fingers, and genitalia).[7,8]
Mohs micrographic surgery is also often used to treat high-risk tumors with poorly defined clinical borders or with perineural invasion. The method requires special training. The tumor is microscopically delineated, with serial radial resection, until it is completely removed as assessed with real-time frozen sections. Nevertheless, since the technique removes tumor growing in contiguity and may miss noncontiguous in-transit cutaneous micrometastases, some practitioners remove an additional margin of skin in high-risk lesions even after the Mohs surgical procedure confirms uninvolved margins.[Level of evidence: 3iiiDiv]
Radiation therapy is a logical treatment choice, particularly for patients with primary lesions requiring difficult or extensive surgery (e.g., nose, lip, or ears).[4,9] Radiation therapy eliminates the need for skin grafting when surgery would result in an extensive defect. Cosmetic results are generally good, with a small amount of hypopigmentation or telangiectasia in the treatment port. Radiation therapy can also be used for lesions that recur after a primary surgical approach. Radiation therapy is avoided in patients with conditions that predispose them to radiation-induced cancers, such as xeroderma pigmentosum or basal cell nevus syndrome.
Although radiation therapy, with or without excision of the primary tumor, is used for histologically proven clinical lymph node metastases and has been associated with favorable disease-free survival rates, the retrospective nature of these case series makes it difficult to know the impact of nodal radiation on survival.[11,12][Level of evidence 3iiiDii]
Curettage and electrodesiccation