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Resumen Antecedentes El registro Regesmohs es un registro de ambito nacional, de pacientes evaluados y sometidos a una cirugia de Mohs, en 17 centros espanoles, desde julio de 2013. Como la cirugia de Mohs es el tratamiento que mejores resultados da para el manejo del carcinoma de celulas basales (CCB) de alto riesgo y otros tumores de la piel, queriamos describir los motivos por los que algunos pacientes fueron considerados no aptos para ser sometidos a este tratamiento y que tratamientos alternativos recibieron. Estos datos pueden ser utiles para evitar excluir a pacientes aptos para ser sometidos a una cirugia de Mohs, para calcular la demanda que estos pacientes generan a nivel sanitario, asi como la demanda que hay de tratamientos de inhibidores de la via de Hedgehog en dicho grupo de pacientes. Objetivo Describir a aquellos pacientes que fueron considerados no aptos para ser sometidos a una cirugia de Mohs tras valoracion prequirurgica y los tratamientos que recibieron. Metodos Regesmohs incluye a todos los pacientes consecutivos para ser sometidos a una cirugia de Mohs en los centros participantes, recogiendo datos sobre las caracteristicas de los pacientes, las intervenciones y los resultados a corto y largo plazo. Se hizo una descripcion de los pacientes considerados no aptos para ser sometidos a una cirugia de Mohs tras valoracion prequirurgica. Resultados Tres mil once pacientes fueron incluidos en el registro Regesmohs entre julio de 2013 y octubre de 2016. En 85 pacientes no se realizo cirugia de Mohs porque se consideraron candidatos inadecuados. Sesenta y siete pacientes presentaban CCB. Las razones para ser considerado paciente no apto fueron: contraindicaciones medicas (27,1%, n = 23), tumores de bajo riesgo (18,8%, n = 16) y tumores gigantes e invasion osea (15,3%, n = 13). Solo un paciente (1,2%) revelo compromiso de ganglios linfaticos y ningun paciente metastasis visceral. De los 85 pacientes considerados no aptos 29 (34,1%) fueron sometidos a cirugia convencional, 24 (28,3%) a radioterapia, 4 (4,7%) a inhibidores de la via de Hedgehog (solo indicado para el CCB) y 2 (2,4%) a tratamiento paliativo. No hubo datos de seguimiento de 14 pacientes (16,5%). Conclusion Las comorbilidades medicas fueron la razon mas habitual para retener la cirugia de Mohs. Retener un tratamiento en funcion de una propagacion a lugares distantes no es algo habitual. La mayoria de los pacientes considerados no aptos recibieron tratamientos mas sencillos: cirugia convencional o radioterapia, siendo los inhibidores de la via de Hedgehog una opcion novedosa.

Introduction The Spanish Mohs Surgery Registry is used to collect data on the use and outcomes of Mohs micrographic surgery (MMS) in Spain. The aim of this study was to describe perioperative and intraoperative data recorded for MMS procedures performed between July 2013 (when the registry started) and January 2016. Material and methods Prospective cohort study of data from 18 hospitals. The data collected included type of anesthesia, surgical technique, hospital admission, number of Mohs stages, management of preoperative risk factors, additional treatments, previous treatments, type of tumor, operating time, and complications. Results Data were available for 1796 operations. The most common tumor treated by MMS was basal cell carcinoma (85.96%), followed by squamous cell carcinoma (6.18%), lentigo maligna (2.81%), and dermatofibrosarcoma protuberans (1.97%). Primary tumors accounted for 66.9% of all tumors operated on; 19.2% of tumors were recurrent and 13.9% were persistent. The most common previous treatment was surgical. MMS was mostly performed under local anesthesia (86.7% of cases) and as an outpatient procedure (71.8%). The frozen section technique was used in 89.5% of cases. One stage was needed to achieve tumor-free margins in 56.45% of patients; 2 stages were required in 32.1% of patients, 3 in 7.1%%, 4 in 2.7%, and 5 or more in 1.8%. The defect was reconstructed by the dermatologist in 98% of patients and the most common technique was flap closure (47.2%). Intraoperative complications were recorded for just 1.62% of patients and the median (interquartile range) duration of surgery was 75 (60-100) minutes. Conclusion The characteristics of the patients and tumors treated by MMS are similar to those reported for similar studies in other geographic areas. Lentigo maligna and dermatofibrosarcoma protuberans accounted for a higher proportion of cases in our series, and repair of the surgical defect by a dermatologist was also more common. Operating times in MMS are not much longer than those reported for other procedures and the rate of intraoperative complications is very low.

Background Regesmohs registry is a nationwide registry including patients evaluated for Mohs surgery in 17 Spanish centres since July 2013. Given that Mohs surgery is the therapy with best results for high risk basal cell carcinoma (BCC) and other skin tumours, we wanted to describe the reasons that lead to some patients being excluded from this therapy and the alternative treatments that they received. These data may be useful to avoid excluding patients for Mohs surgery use, to estimate the healthcare demand of these patients and the demand for Hedgehog inhibitors therapy in this group. Objective To describe patients excluded for Mohs surgery after pre-surgical assessment, and the treatments that they received. Methods Regesmohs includes all consecutive patients assessed for Mohs surgery in the participating centres, collecting data on patient characteristics, intervention, and short and long-term results. Patients excluded for Mohs surgery after pre-surgical evaluation were described. Results 3011 patients were included in Regesmohs from July 2013 to October 2016. In 85, Mohs surgery was not performed as they were considered inadequate candidates. 67 had BCC. Reasons for exclusion were: medical contraindication (27.1%, n = 23) low-risk tumour in (18.8%, n = 16) and giant tumour and bone invasion (15.3%, n = 13). Only 1 patient (1.2%) showed lymph node involvement and no patients had visceral metastases. Of the 85 excluded patients, 29 (34.1%) were treated with conventional surgery, 24 (28.3%) with radiotherapy, 4 (4.7%) with inhibitors of the Hedgehog pathway (only indicated for BCC), and 2 (2.4%) received palliative care. We had no follow-up data on 14 patients (16.5%). Conclusion Medical comorbidities were the most common reason for withholding Mohs surgery. Withholding therapy on the basis of distant extension is uncommon. Most excluded patients received simpler therapies: conventional surgery or radiotherapy, with hedgehog inhibitors being a new option.

Background The elderly population is increasing and more patients in this group undergo Mohs micrographic surgery. The few publications investigating MMS in elderly people conclude that it is a safe procedure; however, these are single centre studies without a comparison group. Objective To compare the characteristics of patients, tumours, MMS, and one-year follow-up in patients younger than 80 years, with patients older than 80 years at the time of surgery. Methods Data was analysed from REGESMOHS, a prospective cohort study of patients treated with MMS. The participating centres were 19 Spanish hospitals where at least one MMS is performed per week. Data on characteristics of the patient, tumour, and surgery were recorded. Follow-up data was collected from two visits; the first within one month post-surgery and the second within the first year. Results From July 2013 to October 2016, 2575 patients that underwent MMS were included in the registry. Of them, 1942 (75,4%) were aged < 80 years and 633 (24,6%) were ≥80 years-old. In the elderly, the tumour size was significantly higher with a higher proportion of squamous cell carcinoma. Regarding surgery, elderly more commonly had tumours with deeper invasion and required a higher number of Mohs surgery stages, leaving larger defects, and requiring more time in the operating room. Despite this, the incidence of post-operative complications was the same in both groups (7%) and there were no significant differences in proportion of relapses in the first-year follow-up. Conclusion The risk of short term complications and relapses were similar in elderly and younger groups. MMS is a safe procedure in the elderly. This article is protected by copyright. All rights reserved.

We have read with interest the article by Dr Sanchez-Castellanos, Dr Sandoval-Tress, and Dr HenandezTorres entitled, “Persistence of the Omphalomesenteric Duct. Childhood Differential Diagnosis of Umbilical Granuloma”1 and would like to make a few comments. Although there have been reports of clinical differences between the various neonatal umbilical nodules (umbilical granuloma, persistence of omphalomesenteric duct, urachus remnants, etc) in the past,1 these were not based on confirmed diagnoses, but rather on the response or lack thereof to a destructive treatment. Making a diagnosis on whether or not the lesion is destroyed by chemical cauterization with silver nitrate is not a very scientific approach. We agree with the authors’ conclusion that any newborn with an umbilical neoplasm should undergo a study of the lesion to confirm the diagnosis, thus making appropriate treatment possible to avoid potential complications.1 A greater understanding of umbilical nodules in childhood and their complications would require clinical and epidemiological studies based on histopathological diagnoses. In 2005 we described a simple method for diagnosis by anatomical pathology from biopsies taken by presutured pursestring suture of neonatal umbilical nodules.2 The painless application of a purse-string suture at the base of the umbilical nodule, a knot to ensure that the lesion was exsanguinated, and immediate removal by cutting with scissors above the suture line allowed histological study of 75% to 90% of the lesion. The presuturing technique with immediate excision for biopsy is minimally traumatic and takes less than a minute. The cosmetic outcome is excellent and we believe the technique is of interest in dermatological surgery.