10.5826/dpc.1204a176
Introduction: Several studies investigated the use of dermoscopy in the delineation of Basal cell carcinoma (BCC) for Mohs micrographic surgery (MMS) with conflicting results
Objective: The purpose of this systematic review with meta-analysis was to evaluate the effectiveness of the use of dermoscopy-guided MMS in the treatment of BCC.
Methods: We included all comparative studies including more than twenty-five cases. Cases of BCC treated using dermoscopy-guided MMS (or slow MMS) were compared to those treated with curettage-guided MMS or “standard” MMS. 
Results: A total of 6 studies including 508 BCCs were reviewed. There was no statistically significant difference in the proportion of total margin clearance on the ﬁrst MMS stage between BCCs removed using dermoscopy-guided MMS and those that had curettage or visual inspection. However, lateral margin involvement was significantly lower in BCCs that had dermoscopy-guided MMS.
Limitations: Scarcity of research on this subject
Conclusions: Dermoscopy allows visualization of structures up to 1mm into the dermis, and therefore it is rational to use it for lateral margin evaluation. Currently, there are two comparative studies showing the efficacy of dermoscopy for lateral margin evaluation during MMS. Future studies are required to develop an evidence-based recommendation regarding the utility of dermoscopy in MMS.
text/xml
2160-9381
2191
en
Faten Zeglaoui
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
3D histology
The Use of Dermoscopy in the Delineation of Basal Cell Carcinoma for Mohs Micrographic Surgery: A Systematic Review with Meta-Analysis
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2022-10-31
2021-11-21
2022-10-31
2022-12-01
e2022176
Dermatol Pract Concept
Introduction: Several studies investigated the use of dermoscopy in the delineation of Basal cell carcinoma (BCC) for Mohs micrographic surgery (MMS) with conflicting results
Objective: The purpose of this systematic review with meta-analysis was to evaluate the effectiveness of the use of dermoscopy-guided MMS in the treatment of BCC.
Methods: We included all comparative studies including more than twenty-five cases. Cases of BCC treated using dermoscopy-guided MMS (or slow MMS) were compared to those treated with curettage-guided MMS or “standard” MMS. 
Results: A total of 6 studies including 508 BCCs were reviewed. There was no statistically significant difference in the proportion of total margin clearance on the ﬁrst MMS stage between BCCs removed using dermoscopy-guided MMS and those that had curettage or visual inspection. However, lateral margin involvement was significantly lower in BCCs that had dermoscopy-guided MMS.
Limitations: Scarcity of research on this subject
Conclusions: Dermoscopy allows visualization of structures up to 1mm into the dermis, and therefore it is rational to use it for lateral margin evaluation. Currently, there are two comparative studies showing the efficacy of dermoscopy for lateral margin evaluation during MMS. Future studies are required to develop an evidence-based recommendation regarding the utility of dermoscopy in MMS.
Faten Zeglaoui
2022/10/31
10.5826/dpc.1204a176
e2022176
Department of dermatology, Charles Nicolle Hospital, Tunis, Tunisia; University of Tunis El Manar, Faculté de Médecine de Tunis
2160-9381
3D histology
en
e2022176
Lupu M, Voiculescu VM, Caruntu A, Tebeica T, Caruntu C. Preoperative Evaluation through Dermoscopy and Reflectance Confocal Microscopy of the Lateral Excision Margins for Primary Basal Cell Carcinoma. Diagnostics. 2021;11(1):120. doi:10.3390/diagnostics11010120
The Use of Dermoscopy in the Delineation of Basal Cell Carcinoma for Mohs Micrographic Surgery: A Systematic Review with Meta-Analysis
https://dpcj.org/index.php/dpc/article/download/2191/1808
 The Use of Dermoscopy in the Delineation of Basal
   Cell Carcinoma for Mohs Micrographic Surgery:
      a Systematic Review With Meta-Analysis
                         Noureddine Litaiem1,2, Faten Hayder1,2, Imene Benlagha1,2,
                            Manel Karray1,2, Chadli Dziri2,3, Faten Zeglaoui1,2


1 Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
2 University of Tunis El Manar, Faculté de Médecine de Tunis, Tunis, Tunisia; 3 Director of Honoris Medical Simulation Center, Tunisia



Key words: Mohs micrographic surgery, Slow Mohs, dermoscopy, dermatoscopy, basal cell carcinoma
Citation: Litaiem N, Hayder F, Benlagha I, Karray M, Dziri C, Zeglaoui F. The Use of Dermoscopy in the Delineation of Basal Cell
Carcinoma for Mohs Micrographic Surgery: A Systematic Review with Meta-Analysis. Dermatol Pract Concept. 2022;12(4):e2022176.
DOI: https://doi.org/10.5826/dpc.1204a176
Accepted: February 18, 2022; Published: October 2022
Copyright: ©2022 Litaiem N et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Noureddine Litaiem, Department of dermatology, Charles Nicolle Hospital, Tunis, Tunisia.
E-mail: Noureddine.litaiem@gmail.com




  ABSTRACT             Introduction: Several studies investigated the use of dermoscopy in the delineation of basal cell carci-
                       noma (BCC) for Mohs micrographic surgery (MMS) with conflicting results.
                       Objectives: The purpose of this systematic review with meta-analysis was to evaluate the effectiveness
                       of the use of dermoscopy-guided MMS in the treatment of BCC.
                       Methods: We included all comparative studies. Cases of BCC treated using dermoscopy-guided MMS
                       (or slow MMS) were compared to those treated with curettage-guided MMS or “standard” MMS.
                       Results: A total of 6 studies including 508 BCCs were reviewed. There was no statistically significant
                       difference in the proportion of total margin clearance on the ﬁrst MMS stage between BCCs removed
                       using dermoscopy-guided MMS and those that had curettage or visual inspection. However, lateral
                       margin involvement was significantly lower in BCCs that had dermoscopy-guided MMS.
                       Conclusions: Dermoscopy allows visualization of structures up to 1mm into the dermis. Therefore, it
                       is rational to use it for lateral margin evaluation. Currently, there are two comparative studies showing
                       the efficacy of dermoscopy for lateral margin evaluation during MMS. Future studies are required to
                       develop an evidence-based recommendation regarding the utility of dermoscopy in MMS.




Review | Dermatol Pract Concept. 2022;12(4):e2022176                                                                                     1
Introduction                                                          Methods
Basal cell carcinoma (BCC) is the most prevalent skin cancer          Search Strategy
worldwide [1]. The overall incidence has been steadily rising         This systematic review with meta-analysis was performed
in the last decade throughout the world due to a burgeoning           according to the Preferred Reporting Items for Systematic
aging population and increased surveillance and diagnosis [2].        Reviews and Meta-Analyses (PRISMA) guidelines [13]. We
    The biological behavior of BCC depends on the tumor               searched the PubMed and Scopus databases from inception up
subtype [1,2]. Undiagnosed and untreated BCC could lead               to January 26, 2022 to identify eligible studies. We aimed to
to extensive local destruction and increase both functional           identify all relevant studies published in English language. We
and cosmetic morbidity making the treatment and repair ap-            used the following search algorithm: (“Basal cell carcinoma”)
proach challenging for the physician.                                 AND (“Mohs surgery” or “Slow Mohs” or “micrographic
    The National Comprehensive Cancer Network (NCCN)                  surgery” or ”3‐D histology” or “microscopically controlled
has established guidelines of care for BCCs [3]. High-risk BCCs       surgery”) AND (“dermoscopy” or “dermatoscopy” or “epi-
include recurrent BCC, tumors with ill-defined borders, located       luminescence microscopy”). The PubMed and Scopus search
on high-risk mask area of the face, arising on sites of prior radi-   strategies are available as supplementary material.
ation therapy or harboring aggressive histological features [3].
There are multiple treatment options for BCC such as ablative
                                                                      Inclusion and Exclusion Criteria of Studies
laser, photodynamic therapy, curettage, cryosurgery, imiquimod,
                                                                      Two review authors (NL and FH) independently screened
and sonic hedgehog pathway inhibitors [12,2]. However, sur-
                                                                      titles and abstracts for eligible studies. Eligible articles were
gical excision remains the gold standard for treatment of most
                                                                      identified on the basis of the following inclusion criteria:
BCCs [1]. Standard excision is performed with a predefined
                                                                      (i) comparative studies having at least a group of BCCs treated
clinical margin in order to achieve low recurrence rates. Mohs
                                                                      with dermoscopy-guided MMS, (ii) studies that used a control
micrographic surgery (MMS) is a specialized surgical technique
                                                                      group of BCCs treated with visual inspection and/or curet-
that combines surgery with pathology. MMS uses horizontal
                                                                      tage-guided MMS, (iii) articles published in English language.
frozen sections to obtain complete margin control resulting in
                                                                      For eligible studies, full articles were retrieved in full and ana-
minimal tissue removal with low recurrence rates [1]. MMS
                                                                      lyzed by two independent authors (NL and FH). Any discrep-
proved to be superior to standard excision for high-risk BCC
                                                                      ancy between the two investigators was resolved by consensus.
[1]. Slow Mohs is a variant of MMS using formalin-fixed par-
affin-embedded sections with similar outcome [4].
    Dermoscopy, also known as dermatoscopy or epilumi-                PICO(S): Populations, Interventions, Comparison,
nescence microscopy, is a non-invasive imaging technique              Outcome Measures, Types of Studies
widely employed for the diagnosis of skin cancers. Some               We included all comparative observational as well as ran-
specific dermoscopic patterns are helpful in the diagnosis            domized clinical trials (RCT). Participants with BCC regard-
of BCC [5]. The use of dermoscopy in the demarcation of               less of the clinical and histological subtype of the tumor were
surgical margins is another scope of its application. For in-         eligible for inclusion.
stance, the use of dermoscopy in MMS might help reduce the                Cases of BCC treated using dermoscopy-guided MMS
number of Mohs stages and achieve surgical margin control             (or slow MMS) were compared to those treated with
within the 1st Mohs stage [4,6-11].                                   curettage-guided MMS or “standard” MMS. The latter uses
    Many studies investigated the effectiveness of dermos-            visual inspection alone to delineate the tumors. All types of
copy in tumor delineation for MMS but with varying out-               dermoscopy techniques were eligible, regardless of the po-
comes [4,6-11]. While some suggested that dermoscopy                  larization mode (polarized vs. nonpolarized mode) and the
could help reduce the number of Mohs stages and there-                device type (hand-held dermoscopy or video dermoscopy).
fore shorten operative time and cost [4,9,11], others argued              The main outcome measure was the proportion of to-
against the usefulness of this approach [6,12]. The ambiguity         tal margin clearance on the ﬁrst MMS stage. The secondary
of these findings is further hampered by the lack of random-          outcome measures included the: (i) number of Mohs stages
ized studies and systematic reviews.                                  required to achieve complete margin control, (ii) the lateral
                                                                      margin involvement rate, and (iii) the recurrence rate.

Objectives                                                                If one or more outcome measures were missing, we con-
                                                                      tacted the corresponding author at least twice (with at least
The purpose of this systematic review with meta-analysis was          one-week interval) to ask whether full data were available. If
to evaluate the effectiveness of the use of dermoscopy-guided         the contact was unsuccessful, the corresponding article was
MMS in the treatment of BCC.                                          excluded from the analysis.



2                                                                                 Review | Dermatol Pract Concept. 2022;12(4):e2022176
Assessment of the risk of bias                                      meta-analysis and subgroup analyses. We performed all calcu-
Two review authors (NL and FH) independently assessed the           lations using Comprehensive meta-analysis 3.0 package.
quality of consistency and the risk of bias in the eligible stud-      We investigated heterogeneity using Cochran Q test.
ies. Any disagreement was resolved by discussion or by con-         Evaluation of the percentage of variation between the sam-
sensus with a third author (CD). MINORS score was used              ple estimates was performed using the Higgins I2 statistic.
for observational studies [14]. RCT were evaluated using the
Jadad score [15] .                                                  Results
Data Synthesis and Statistical Analysis                             Results of the Search
Results were reported as Odds ratio (OR) with 95% confi-            The literature search identified 289 articles (Figure 1). After
dence intervals (CIs) for dichotomous data (proportion of to-       removing duplicates, 69 articles were screened for eligibil-
tal margin clearance on the ﬁrst MMS stage, lateral margin          ity. Fifty-five records were excluded, including not relevant
involvement, and recurrence rates) and standardized mean dif-       articles (N = 30), papers not published in English (N = 3),
ference with standard error of the mean for continuous data         editorials and commentary (N = 11), review articles (N = 10)
(number of Mohs stages). A random-effects model was used.           and book chapters (N = 2). Fourteen full-text articles were
Forest plots summarized the data. Funnel plot was used to           assessed for eligibility. Among these, 4 were excluded (case
investigate the existence of publication bias. Strategies for ad-   reports and noncomparative studies) [16-19]. Three research
dressing heterogeneity included performing a random-effects         letters were excluded [11,20,21]. Among these research




 Figure 1. Flow diagram.



Review | Dermatol Pract Concept. 2022;12(4):e2022176                                                                              3
letters, two compared dermoscopy to naked eye examination            The mean number of Mohs stages in each study group
in BCC margin evaluation but the number of Mohs stages            was specified in 5 articles [4,6-9]. However, related standard
in each study group expressed in mean with standard de-           deviations were only available in 3 articles [4,6,7]. Contact
viation was not available [11,20]; and one article included       with the corresponding authors of these studies was unsuc-
only BCC evaluated using dermoscopy prior to MMS [21].            cessful. Therefore, we did not have the required data to carry
A randomized open-label study comparing visual inspection,        out the up-mentioned analysis for these articles [4,6,7].
curettage, and dermoscopy in tumor delineation for MMS               Only two studies reported the number of positive lateral
was excluded because no outcome measure was available             margins after the first Mohs stage [4,10].
for each study group [12]. Contact with the corresponding            Relapse rates were described in 2 articles [4,9], ranging
authors of this study was unsuccessful. Six articles were ulti-   between no relapse and 4%, after a follow-up period of 10 ±
mately included in the present systematic review. Of these, 2     5 and more than 62.5 months respectively.
studies were from Asia-Pacific region, 1 from North Amer-
ica, 1 from South America, 1 from Europe, and 1 from Africa       Assessment of Risk of Bias in Included Studies
(Table 1) [4,6-10].                                               For RCT [6,7], the Jadad scale was 1 and 2. Overall, the
                                                                  methodological quality was poor. There was no disagree-
Description of Included Studies                                   ment between the review authors (NL and FH) about the
Of the 6 included studies, 2 were RCTs [6,7], and four were       studies quality.
observational studies [4,8-10]. There was no randomized              For non-randomized studies [4,8-10], the MINORS in-
controlled study available for the present systematic review.     dex ranged between 14 and 16.
All included studies were conducted in university‐setting cen-
ters [4,6-10]. These studies had no funding support and cor-      Effects of Interventions
responding authors declared no conflicts of interest [4,6-10].    When comparing dermoscopy-guided vs. standard MMS for
    The number of BCCs evaluated ranged from 40 to 197            BCC treatment, there was no statistically significant differ-
BCCs per study. The total number of evaluated BCCs was            ence in the proportion of total margin clearance on the ﬁrst
508. Suzuki et al included both BCC (N = 40) and squamous         MMS stage (OR 0.86, 95% CI 0.41 to 1.15; five studies
cell carcinomas (N = 6). The latter were excluded from the        [4,7-10]) (Figure 2).
analysis. Three studies specified BCC subtypes [6,7,9]. Asil-        There was no statistically significant difference in the
ian and Momeni included only nodular BCC [6], and Gur-            number of Mohs stages when comparing dermoscopy-guided
gen and Gatti only infiltrative BCC [7]. Dika et al included      and standard MMS (The standardized mean difference -0.17,
various BCC subtypes including nodular (N = 40) and mor-          95% CI -0.51 to 0.17; three studies [4,6,7]) (Figure 3). For
pheiform BCCs (N = 40) [9].                                       this outcome measure, we found heterogeneity (Tau2 = 0220
    Recurrent BCCs were excluded in three studies [4,6,7].        et I2 = 70.334%). Subgroup analysis was performed based
One study included only recurrent BCC following ablative          on the technique used for Mohs surgery (frozen sections
laser treatment [10]. Two studies enrolled both primary and       versus formalin-fixed paraffin-embedded sections). After
recurrent BCC (Table 1) [8,9].                                    subgroup analysis, including studies using MMS [6,7], there
    Four studies compared 2 interventions for MMS: tumor          was no heterogeneity (Tau2 = 0.000), the pooled standard
delineation using naked eye examination versus dermosco-          difference in means showed no statistically significant differ-
py-guided margin assessment [4,7,8,10]. One of the studies        ence. Only one study reported the number of Mohs stages in
compared dermoscopy-guided MMS to curettage-guided                patients treated using Slow Mohs [4]. Since iterative Mohs
MMS [9]. Asilian and Momeni compared 3 groups: tumor              sessions rely on histopathological examination of excised tis-
demarcation using naked eye examination (N = 20), dermos-         sue, it is possible that the type of tissue processing technique
copy (N = 20) and curettage (N = 20) [6].                         (frozen sections in MMS vs formalin-fixed paraffin-embed-
    For the primary outcome “total margin clearance on the        ded sections in slow Mohs) is responsible for heterogeneity
ﬁrst MMS stage”, we assumed that BCCs that underwent              regarding the outcome measure (number of Mohs stages).
more than one Mohs stage showed at least one positive                A significantly lower proportion of positive lateral mar-
margin. Thereby, the number of BCCs showing total margin          gins was obtained with dermoscopy-guided MMS compared
clearance on the ﬁrst MMS stage was extracted from 5 arti-        with standard MMS based on visual inspection (OR 0.16,
cles [4,7-10].                                                    95% CI 0.06 to 0.83; 2 studies [4,10]) (Figure 4).
    The secondary outcomes included the mean number of               With regards to recurrence rates, available data was
Mohs stages, the recurrence rate, and the number of positive      insufficient for meta-analysis. Two studies reported the
lateral margins after the first Mohs stage.                       number of recurrences after MMS [4-9]. One of these




4                                                                            Review | Dermatol Pract Concept. 2022;12(4):e2022176
                                                              Table 1. Summary of included studies.
                                                                                                                          Recurrent BCC     Cases included
                                                                      Coverage    Intervention       BCC subtypes in       before Mohs          in the         Follow-up
  Author      Year   Country    Study objective        Study design    period        groups            each group            surgery        meta-analysis       (months)
Asilian and   2012   Iran      To compare three        RCT            2011-      3 groups:          nodular BCC in all    not included in        40           ND
Momeni [6]                     ways (naked eye                        2012       tumor              included cases        the study
                               examination,                                      demarcation
                               dermoscopy, and                                   using naked eye
                               curettage) for                                    examination
                               determining tumor                                 (N = 20),
                               extension before                                  dermoscopy
                               initiation of MMS,                                (N = 20) and
                                                                                 curettage
                                                                                 (N = 20)
Gurgen and    2012   United    To compare the          RCT            ND         2 groups:          infiltrative BCC in   not included in        40           ND
Gatti [7]            States    final number                                      - dermoscopy      all cases             the study
                               of MMS stages                                       group (N = 20)
                               performed using                                   - visual
                               dermoscopy and                                      inspection
                               visual inspection                                   group (N = 20)
                               of infiltrative basal
                               cell carcinoma
Suzuki        2014   Brazil    To assess the        observational     2009-2011 2 groups:           ND                    Group 1: 3/21          44           ND
et al [8]                      impact of            study                       - Group1: Mohs                           Group 2: 4/23
                               dermoscopy on                                      surgery
                               the demarcation of                                 (N = 21)
                               surgical margins for                             - Group 2: Mohs
                               MMS and ascertain                                  surgery with
                               whether the use of                                 dermoscopy-
                               this method can                                    guided margins
                               shorten operative                                  (N = 23)
                               time

                                                                                                                                                             Table 1 continues
6
                                                                                                            Table 1. Summary of included studies. (continued)
                                                                                                                                                                                Recurrent BCC      Cases included
                                                                                                                           Coverage      Intervention      BCC subtypes in       before Mohs           in the       Follow-up
                                                         Author     Year   Country    Study objective      Study design     period          groups           each group            surgery         meta-analysis     (months)
                                                       Dika et al   2017   Italy     to evaluate the       observational   2005-2010 2 groups:            Group 1:              Group 1                 197         Group 1
                                                       [9]                           role of video-        study                     - Group 1:          - nodular BCCs       (31/102)                            (82.6)
                                                                                     dermoscopy                                        Patients treated     (N = 21)            Group 2                             Group 2
                                                                                     and curettage in                                  with video         - pigmented BCCs     (26/95)                             (62.5)
                                                                                     MS for a better                                   dermoscopy           (N = 28)
                                                                                     margin evaluation                                 guided Mohs        - morpheiform
                                                                                     intraoperatively                                  surgery              BCCs (N = 20)
                                                                                                                                       (N = 102)          Group 2:
                                                                                                                                     - Group 2:          - nodular BCCs
                                                                                                                                       Patients treated     (N = 19)
                                                                                                                                       with curettage-    - pigmented BCCs
                                                                                                                                       guided Mohs          (N = 28)
                                                                                                                                       surgery (N =       - morpheiform
                                                                                                                                       95)                  BCCs (N = 20)
                                                                                                                                                          Subtypes of primary
                                                                                                                                                          tumors (nodular,
                                                                                                                                                          pigmented, or
                                                                                                                                                          morpheiform
                                                                                                                                                          BCCs) were equally
                                                                                                                                                          distributed in the
                                                                                                                                                          2 groups (primary
                                                                                                                                                          BCC in Group A 71
                                                                                                                                                          Group B 69)
                                                       Shin et al   2020   Korea     To evaluate the       observational   2009-       2 groups:            ND                  All cases were          133         ND
                                                       [10]                          usefulness of         study           2016        - Clinical surgical                     recurrent BCC
                                                                                     dermoscopy in                                       margin                                 (previously
                                                                                     determining MMS                                     (N = 69)                               treated by
                                                                                     surgical margins                                  - Dermoscopic                           ablative laser).
                                                                                     of BCCs with a                                      surgical margin                        Recurrent
                                                                                     history of ablative                                 (N = 64)                               cases after
                                                                                     laser treatment.                                                                           radiotherapy
                                                                                                                                                                                or surgical
                                                                                                                                                                                resection were
                                                                                                                                                                                excluded.




Review | Dermatol Pract Concept. 2022;12(4):e2022176
                                                                                                                                                                                         Recurrent BCC     Cases included
                                                                                                                                          Coverage    Intervention     BCC subtypes in    before Mohs          in the        Follow-up
                                                          Author          Year      Country       Study objective        Study design      period        groups          each group         surgery        meta-analysis      (months)
                                                        Litaiem           2020      Tunisia     To evaluate the use      observational    2016-      2 groups:         ND                not included in        54          10 ± 5
                                                        et al [4]                               of dermoscopy in         study            2019       G1: tumor                           the study
                                                                                                the demarcation of                                   demarcation
                                                                                                surgical margins in                                  using naked eye
                                                                                                slow Mohs surgery.                                   examination
                                                                                                                                                     (N = 28)
                                                                                                                                                     G2: tumor
                                                                                                                                                     demarcation
                                                                                                                                                     using naked eye
                                                                                                                                                     examination +
                                                                                                                                                     dermoscopy
                                                                                                                                                     (N = 26)




Review | Dermatol Pract Concept. 2022;12(4):e2022176
                                                       BCC = basal cell carcinoma; ND = not described; RCT = randomized clinical trial.




7
 STUDY NAME                         STATISTICS FOR EACH STUDY                             ODDS RATIO AND 95% CI

                                 ODDS    LOWER    UPPER
                                 RATIO    LIMIT   LIMIT P-VALUE

GURGEN AND GATTI, 2012 1,238             0,343    4,464       0,744
SUZUKI ET AL., 2014              1,222   0,372    4,018       0,741
DIKA ET AL., 2017                0,521   0,295    0,921       0,025
SHIN ET AL, 2020                 0,958   0,463    1,983       0,909
LITAIEM ET AL, 2020              0,247   0,079    0,769       0,016
                                 0,686   0,409    1,150       0,153
                                                                         0,01           0,1             1             10           100
                                                                                Dermoscopy-guided MMS       Standard and curettage-guided MMS



META ANALYSIS (OUTCOME: POSITIVE MARGINS)                                       (Q TEST) P=0,164 - I2: 38,4%


                                              FUNNEL PLOT OF STANDARD ERROR BY LOG ODDS RATIO
                        0,0



                        0,2
       STANDARD ERROR




                        0,4



                        0,6



                        0,8

                          -2,0   -1,5      -1,0      -0,5        0,0             0,5          1,0            1,5           2,0

                                                            LOG ODDS RATIO

Figure 2. Comparison of the proportion of positive margins after the first Mohs stage using dermoscopy-guided vs. standard or curettage
guided MMS for BCC treatment




studies reported a recurrence rate of 3% in BCCs treated               Three studies excluded recurrent BCC [4,6,7], while one
with dermoscopy-guided MMS and of 5.2% in those treated                study included only recurrent BCC following ablative laser
with curettage-guided MMS (P = 0.48; Fisher exact test) af-            [10]. Of the included studies, pooling of the data was fea-
ter a follow-up period of 82.6 and 62.5 months respectively            sible for 3 evaluated outcomes. There was no statistically
[9]. In the second study, both study groups showed no recur-           significant difference in the proportion of total margin clear-
rence after a mean follow-up period of 10 ± 5 months [4].              ance on the ﬁrst MMS stage between BCCs removed using
                                                                       dermoscopy-guided MMS and those that had curettage or vi-

Conclusions                                                            sual inspection. However, lateral margin involvement was sig-
                                                                       nificantly lower in BCCs that had dermoscopy-guided MMS.
In the present study, we aimed to assess the effectiveness of             To the best of our knowledge, no systematic review ad-
dermoscopy as an ancillary tool for MMS. Six studies were              dressed the question of whether dermoscopy is useful for
included: 2 RCTs [6,7], and 4 observational studies [4,8-              delineating BCC margins for MMS. Que published a com-
10]. The total number of evaluated BCCs was 508. Three                 prehensive narrative review on noninvasive imaging tech-
studies specified the subtypes of evaluated BCCs [6,7,9].              nologies used for the delineation of BCC in the setting of



8                                                                                   Review | Dermatol Pract Concept. 2022;12(4):e2022176
STUDY NAME                                  STATISTICS FOR EACH STUDY                                             STD DIFF IN MEANS AND 95% CI
                                STD DIFF STANDARD LOWER UPPER
                               IN MEANS ERROR      LIMIT LIMIT P-VALUE
ASILIAN MOMENI 2012                0,200        0,317 -0,421   0,821         0,317
GURGEN GATTI 2012                  0,191        0,317 -0,430   0,812         0,317
LITAIEM 2020                       -0,739       0,281 -1,290 -0,187          0,281
                                   -0,130       0,323 -0,764 -0,503          0,323

                                                                                            -2,00               -1,00             0,00             1,00              2,00

                                                                                                DERMOSCOPY-GUIDED MMS               STANDARD OR CURETTAGE-GUIDED MMS




META ANALYSIS (OUTCOME: NUMBER OF MOHS SESSIONS)                                                                        (Q TEST) P=0,034 -I2: 70,3%


                                                FUNNEL PLOT OF STANDARD ERROR BY STD DIFF IN MEANS
                         0,0



                         0,1
        STANDARD ERROR




                         0,2



                         0,3



                         0,4

                           -2,0        -1,5         -1,0           -0,5         0,0                 0,5                 1,0          1,5             2,0

                                                                          STD DIFF IN MEANS


Figure 3. Comparison of the number of Mohs stages using dermoscopy-guided vs. standard or curettage MMS for BCC treatment




 STUDY NAME                            STATISTICS FOR EACH STUDY                                                ODDS RATIO AND 95% CI

                               ODDS      LOWER       UPPER
                               RATIO      LIMIT      LIMIT     P-VALUE

 SHIN 2020                     0,120        0,034     0,429          0,001

 LITAIEM 2020                  0,206        0,061     0,703          0,012

                               0,159        0,066     0,385          0,000

                                                                                     0,01                 0,1                 1             10             100

                                                                                      DERMOSCOPY-GUIDED MMS                   STANDARD AND CURETTAGE-GUIDED MMS



                                                                                                                                                             2
 META ANALYSIS (OUTCOME: POSITIVE LATERAL MARGINS AFTER THE FIRST MOHS SESSIONS)                                                         (Q TEST) P=0,550 - I : 0%


Figure 4. Comparison of the proportion of positive lateral margins after the first Mohs stage using dermoscopy-guided vs. standard or
curettage guided MMS for BCC treatment



Review | Dermatol Pract Concept. 2022;12(4):e2022176                                                                                                                        9
MMS [22]. Three technologies were discussed: dermoscopy,          not indicated in all included studies. This may hinder the
confocal microscopy, and optical coherence tomography.            interpretation of findings and undermine their accuracy. Fi-
Only the number of Mohs stages was evaluated as an out-           nally, both dermoscopy and MMS are operator-dependent
come measure in relation to dermoscopy. Que stated that           procedures [4]. Thus, controlled, consistent and reproducible
dermoscopy did not prove to decrease the number of Mohs           results are not readily attainable.
stages. In our systematic review, there was no statistically            Despite these limitations, this systematic review is a com-
significant difference in the number of Mohs stages between       prehensive summary on the reported use of dermoscopy for
the use of dermoscopy or visual inspection for MMS (the           BCC delineation in MMS to date. Overall, our data suggest
standardized mean difference -0.17, 95% CI -0.51 to 0.17;         that dermoscopy could improve lateral margin assessment
three studies [4,6,7]). A hypothesis to explain this finding      within the first Mohs stage. Future randomized clinical trials
is that dermoscopy utility is limited to the first Mohs stage.    are required to develop an evidence-based recommendation
Subsequent stages would only rely on the surgeon’s skills and     regarding the utility of dermoscopy in MMS.
experience.
     In the present systematic review, there was no significant
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Review | Dermatol Pract Concept. 2022;12(4):e2022176                                                                                     11
12   Review | Dermatol Pract Concept. 2022;12(4):e2022176
