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The following is a summary of “Mohs surgery for female genital Paget’s disease: a prospective observational trial,” published in the DECEMBER 2023 issue of Obstetrics and Gynecology by Bruce, et al.

For a study, researchers sought to compare the surgical and oncologic outcomes of margin-controlled surgery versus traditional surgical excision in female genital Paget’s disease.

Conducted as a prospective observational trial from 2018 to 2022, the study enrolled patients with vulvar or perianal Paget’s disease undergoing surgical excision guided by Mohs micrographic surgery. The protocol involved scouting biopsies, modified Mohs surgery, and surgical excision under general anesthesia. Outcomes were compared with a retrospective cohort undergoing traditional excision. Peripheral margin clearance was assessed using a moat technique with cytokeratin 7 staining, while medial margin assessment for structures like the clitoris, urethra, vagina, and anus utilized a hybrid of Mohs surgery and intraoperative frozen sections.

Three-year recurrence-free survival was significantly higher for Mohs-guided excision (93.3%; 95% CI: 81.5%–100.0%) compared to traditional excision (65.9%; 95% CI: 54.2%–80.0%) (P=.04). The median diameter of the excisional specimen was similar between groups (11.3 cm vs 9.5 cm; P=.17). Complex reconstructive procedures were more common with Mohs-guided surgery (66.7% vs 30.2%; P<.01). While peripheral margin clearance was universal, positive medial margins were noted in 9 patients. Among the reasons for positive medial margins were intentional organ sparing and suboptimal performance of intraoperative hematoxylin and eosin frozen sections without cytokeratin 7. Notably, grade 3 or higher postoperative complications were infrequent, with a rate of 0.0% for Mohs-guided excision compared to 2.4% for traditional excision, demonstrating a statistically non-significant difference (P=.99). 

Margin control with modified Mohs surgery significantly improved short-term recurrence-free survival for female genital Paget’s disease. However, challenges persist in achieving margin control for medial anatomic structures. The study suggested that Mohs-guided surgical excision, requiring specialized, collaborative care, maybe optimally performed at designated referral centers.

Source: ajog.org/article/S0002-9378(23)00588-4/fulltext