Dermatologic surgery
Atypical fibroxanthoma: Systematic review and meta-analysis of treatment with Mohs micrographic surgery or excision

https://doi.org/10.1016/j.jaad.2018.06.048Get rights and content

Background

Atypical fibroxanthoma (AFX) is a fibrohistiocytic tumor with relatively high local recurrence rates but low metastatic potential. Wide local excision (WLE) and Mohs micrographic surgery (MMS) are common treatments, although no consensus exists regarding optimal therapy.

Objective

To systematically review evidence of AFX recurrence and metastatic rates after different surgical modalities.

Methods

A comprehensive search was performed for articles published from 1946 or database inception to March 20, 2017. Studies selected included those that had 5 or more patients with atypical fibroxanthoma treated surgically. Two reviewers independently abstracted the data. Risk of bias was assessed with the Newcastle-Ottawa scale. Main outcomes and measures included recurrence and metastasis.

Results

In total, 23 studies were selected (907 patients and 914 tumors); 175 patients were treated with MMS (recurrence rate 2.0%, 95% confidence interval [CI] 0%-4.1%; metastatic rate 1.9%, 95% CI 0.1%-3.8%), and 732 were treated with WLE (recurrence rate 8.7%, 95% CI 5%-12.3%; metastasis rate 1%, 95% CI 0.2%-1.9%). Among immunocompromised patients, no recurrence or metastases developed in the MMS subgroup, although 4 of 10 recurred and 1 of 10 metastasized in the WLE subgroup.

Limitations

Low quality of the studies published.

Conclusion

MMS for atypical fibroxanthoma is associated with a lower recurrence rate than WLE.

Section snippets

Methods

This study was deemed exempt from review by the Mayo Clinic Institutional Review Board, and no patient consent was required. This review was conducted and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.9, 10

Studies in meta-analysis

Initial screening of 335 abstracts resulted in a full review of 28 articles (Fig 1). Five articles failed to meet our inclusion criteria and were excluded. No randomized controlled studies were available. Two of the 23 studies were comparative, and 21 were noncomparative (Supplemental Table III; available at http://www.jaad.org).1, 4, 5, 6, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38 One study contained duplicate data from a previous publication4 and was used only

Discussion

In the present systematic review of a pooled group of 907 patients with 914 tumors, the impression gleaned from the literature is that of a lower recurrence rate with MMS than WLE (2.0% vs 8.7%) (Fig 3).1, 4, 5, 6, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38 Careful and complete margin control through MMS most likely contributes to the better outcomes of these AFX patients. In particular, immunocompromised patients appear to have increased risk for recurrence and

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      Citation Excerpt :

      A systematic review of a pooled group of 907 patients with 914 tumors, demonstrated a lower recurrence rate with MMS than WLE (2.0% vs. 8.7%). Although the gap of the recurrence rate between MMS and WLE is narrow, we have to consider that 80% of AFX starts on the head and neck, hence, MMS emerges as the most suitable technique to ensure microscopically controlled excision while optimizing tissue sparing on anatomically sensitive areas.76 Almost all types of cutaneous malignancies have been treated through MMS over the decades, even the rare non-melanoma skin cancers, with superior results to WLE (Table 1).82,85

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    Funding sources: None.

    Conflicts of interest: None disclosed.

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