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Integrating contrast-enhanced ultrasound to optimize margin delineation in Mohs micrographic surgery for primary
Bin Tu1, Min-Hong Zou2, Yan-Ying Ji3
1Department of Dermatology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
Introduction:
Dermatofibrosarcoma protuberans (DFSP) is characterized by infiltrative "tentacle-like" extensions, making accurate preoperative margin delineation challenging. While high-frequency ultrasound (HFUS) visualizes subclinical spread, its ability to fully capture tumor extent remains limited. Contrast-enhanced ultrasound (CEUS), by depicting microvascular perfusion, may improve delineation, but its clinical impact on Mohs micrographic surgery (MMS) remains unclear.
Methods:
This retrospective cohort study included 220 primary DFSP patients treated with MMS. Preoperative margin delineation utilized HFUS-only or HFUS+CEUS. The primary outcome was extra peripheral Mohs stages. Secondary outcomes included extra deep and total stages, margin positivity, and other surgical characteristics. Multivariable Poisson regression with LASSO-based variable selection was used, alongside cohort-restriction, covariate-specification, and propensity score-matched (PSM) analyses. Risk-stratified and subgroup analyses explored effect heterogeneity.
Results:
HFUS+CEUS was associated with fewer extra peripheral Mohs stages than HFUS-only (adjusted incidence rate ratio [aIRR], 0.310; P = 0.049). Peripheral margin positivity was reduced from 17.4% to 5.1% (P = 0.020). These findings were consistent across sensitivity analyses and in the PSM cohort (aIRR, 0.309; P = 0.033). The relative effect was most pronounced in the high-risk stratum (IRR, 0.124; P = 0.041), although interaction testing was not statistically significant (P = 0.077). No significant differences were observed in deep or total stages, likely due to ultrasound depth limitations.
Conclusions:
Integrating CEUS with HFUS enhances the precision of preoperative margin delineation for DFSP, reducing extra peripheral Mohs stages. This multimodal imaging strategy represents a valuable, tissue-sparing refinement to the preoperative workflow of MMS, particularly for patients with higher baseline risk.
