Table 23.2 Leiomyosarcomas treated by MMS

serial sectioning using a “bread-loafing” technique provides a very limited examination of the surgical margins, and false negative histologic reporting may contribute to the high recurrence rate of LMS with conventional excision. Wide excisional margins may also lead to greater tissue destruction resulting in profound functional, cosmetic, psychological, and social consequences [25]. Mohs micrographic surgery theoretically provides complete peripheral and deep margin evaluation, which prevents both inadequate and excessive tissue removal. While there are only 16 documented cases of LMS treated by Mohs micrographic surgery, only 2 cases have recurred (Table 23.2) [21, 24–29]. The aggregate recurrence rate of 12.5% for Mohs micrographic surgery compares favorably to that reported for wide excision.

MMS also has the advantage of tissue sparing when compared with the wide excision. The large LMS on the shin was excised using MMS. Sparing of the tibial nerve was possible in this particular case using Mohs surgery to assess the deep margins rather than a deep en bloc resection. Limiting the defect size while obtaining clear margins can significantly reduce postoperative morbidity especially on areas of the body such as the leg characterized by delayed wound healing. Although preliminary studies show the benefits of MMS for LMS, additional cases and longer follow-up periods are required to establish its efficacy.

Cryotherapy may be an alternative for patients unable to undergo surgery. Montes et al. described two elderly patients that were treated with cryosurgery for LMS of the scalp [30]. Treatments were done with tissue temperature 40–50°C for a period of 5 min and repeated treatment every 2 weeks for a total of three to six treatments. Neither patient showed evidence of recurrence 2 years after treatment. Adjuvant radiation or chemotherapy has no proven benefit for superficial LMS [31–33].

Patients diagnosed with subcutaneous LMS should receive a chest radiograph because of the potential for lung metastasis. Close clinical follow-up for a minimum of 5 years is recommended, as tumors usually recur within 1–5 years of initial surgery [10, 32].

Summary: Conclusion

•The overall cure rate of leiomyosarcoma treated by Mohs micrographic surgery is 87% which compares favorably to wide excision and offers the advantage of tissue sparing. Immunosuppression may promote aggressive tumor behavior. Deeply invasive tumors may result in cutaneous or distant metastases regardless of the method of excision.

23.5 Conclusion

LMS is a rare spindle cell tumor of smooth muscle derivation that may originate in the skin or deeper soft tissue. Because of the locally aggressive nature and propensity for recurrence, Mohs micrographic surgery may result in superior local control of superficial LMS.

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