Achieving Adherence With NCCN Guidelines for Nonmelanoma Skin Cancer Regarding Peripheral and Deep En Face Margin Assessment (PDEMA)

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Yaohui G. Xu Department of Dermatology, University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI

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Young Lim Department of Dermatology, Havard Medical School, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA

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Jeremy S. Bordeaux Department of Dermatology, Case Comprehensive Cancer Center/University Hospitals Cleveland Medical Center, Cleveland, OH

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Sumaira Z. Aasi Department of Dermatology, Stanford Cancer Institute, Stanford, CA

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Murad Alam Department of Dermatology and Otolaryngology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL

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Pei-Ling Chen Department of Pathology, Moffitt Cancer Center, Tampa, FL

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Carlo M. Contreras Department of Surgical Oncology, The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute, Columbus, OH

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Dominick DiMaio Department of Pathology, Fred & Pamela Buffett Cancer Center, Omaha, NE

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Jessica M. Donigan Department of Dermatology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT

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Jeffrey M. Farma Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA

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Roy C. Grekin Department of Dermatology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA

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Lawrence Mark Department of Dermatology, Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN

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Kishwer S. Nehal Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY

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Paul Nghiem Department of Dermatology, Fred Hutchinson Cancer Center/University of Washington, Seattle, WA

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Kelly Olino Department of Surgical Oncology, Yale Cancer Center/Smilow Cancer Hospital, New Haven, CT

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Tejesh Patel Department of Dermatology and Pathology, University of Tennessee Health Science Center, Memphis, TN

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Jeffrey Scott Department of Dermatology, Clinical Skin Center, Fairfax, VA

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Ashok R. Shaha Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY

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Divya Srivastava UT Southwestern Simmons Comprehensive Cancer Center, Dallas, TX

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Chrysalyne D. Schmults Department of Dermatology, Havard Medical School, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA

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Peripheral and deep en face margin assessment (PDEMA), formerly termed by NCCN as complete circumferential peripheral and deep margin assessment (CCPDMA), has the advantages of histologic visualization of the entire marginal surface, highly accurate resection of involved tissue, and sparing of uninvolved tissue. Owing to its highest reported cure rates, PDEMA is the NCCN-preferred treatment for dermatofibrosarcoma protuberans, high-risk basal cell carcinoma, and very-high-risk cutaneous squamous cell carcinoma. In the United States, Mohs micrographic surgery (Mohs) is the most common method of PDEMA. In Germany and some other countries, non-Mohs methods of PDEMA referred to as the Tubingen torte and muffin techniques are more widely used. The Tubingen methods of PDEMA require close communication between surgeon and pathologist. This article describes the background of both Mohs and Tubingen PDEMA, reviews what constitutes PDEMA, and provides a protocol for Tubingen PDEMA detailing critical components in a stepwise fashion using illustrative photos and diagrams. We hope to broaden understanding of the NCCN Guidelines and their rationale, align practice, and optimize patient outcomes.

Submitted October 25, 2023; final revision received January 30, 2024; accepted for publication May 10, 2024.

Disclosures: Dr. Schmults has disclosed serving as a principal investigator and as a consultant for Regeneron Pharmaceuticals, Sanofi, Castle Biosciences, and Merck; and owning stock in Cytiva. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Correspondence: Yaohui G. Xu, MD, PhD, Department of Dermatology, University of Wisconsin School of Medicine and Public Health, 7th Floor, 1 South Park Street, Madison, WI 53715. Email: yxu@dermatology.wisc.edu
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