Histopathologic Evaluation of Atypical Fibroxanthoma or Pleomorphic Dermal Sarcoma Debulk Specimen from Mohs Surgery: A Requirement for Their Proper Distinction

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The relation between FXA and PDS has provoked a lot of debate and misundestending in the literature in the recent years. Advanced age and sun  exposed area are common and Immunohistochemistry is useful only to differentiate from SCC invasive and melanoma. As synonym of PDS why superficial MFH? Is the regression important for the outcome as in melanoma?

Author Response

Comment 1: "The relation between AFX and PDS has provoked a lot of debate and misunderstanding in the literature in the recent years. Advanced age and sun-exposed area are common and Immunohistochemistry is useful only to differentiate from SCC invasive and melanoma. As synonym of PDS why superficial MFH? Is the regression important for the outcome as in melanoma?"

Response 1: Thank you for your comments. The term superficial MFH has been used as a synonym for AFX and PDS in the past (see Table 1). Also, regression can rarely occur in these tumors (see Table 1, histopathology section). The link or association between regression in AFX with clinical outcome is not well-established yet. As these points are already touched upon in the manuscript, no further changes are made.

Reviewer 2 Report

Comments and Suggestions for Authors

This opinion piece emphasizes a need for debulk specimens on AFX/PDS, similar to what is routinely done for melanoma cases treated with Mohs. Comments and questions are below:

-Page 1, section 2:  For the statement "When viewed under a microscope, they are usually characterized as circumscribed dermal tumors", I would eliminate the circumscribed as AFX are frequently poorly circumscribed. 

-Page 2: For the statement "PDS can spread to the skin (including satellite metastasis), lymph nodes, and lungs (metastatic rate range of 10-20%)", this implies that AFX does not. There is a low risk with AFX (see reference). I would change this to "PDS has a greater risk of ..."

Reference: Ørholt M, et al. Atypical fibroxanthoma and pleomorphic dermal sarcoma: Local recurrence and metastasis in a nationwide population-based cohort of 1118 patients. J Am Acad Dermatol. 2023 Dec;89(6):1177-1184. 

The remainder of the paper including the table should also reflect that AFX has a low risk (1%) of metastasis. 

Author Response

Comment 1: "Page 1, section 2:  For the statement "When viewed under a microscope, they are usually characterized as circumscribed dermal tumors", I would eliminate the circumscribed as AFX are frequently poorly circumscribed."

Response 1: The word "circumscribed" is removed.

Comment 2: "Page 2: For the statement "PDS can spread to the skin (including satellite metastasis), lymph nodes, and lungs (metastatic rate range of 10-20%)", this implies that AFX does not. There is a low risk with AFX (see reference). I would change this to "PDS has a greater risk of ..."

Response 2: Changes are made on Page 2 and Table 1 (clinical behavior section) to address this comment. The changes are in red font.

Thank you for the comments!

Reviewer 3 Report

Comments and Suggestions for Authors

Well written and well-referenced article with a good review of the currently literature with clinically relevant points.

 

Line 38-40:  I recommend modification of the sentence, as the histologic differential diagnosis can also include other sarcomas as stated at the end of the sentence.  Example:  would change "mainly comprised of keratinocytic and melanocytic markers" to "including, but not limited to keratinocytic and melanocytic markers".

Please modify/improve the color balance of the H&E photos (a, b, g, and h) to resemble the high resolution and well-balanced images (c and d). 

Author Response

Comment 1: "Well-written and well-referenced article with a good review of the current literature with clinically relevant points".

Response 1: Thank you!

Comment 2: "Line 38-40:  I recommend modification of the sentence, as the histologic differential diagnosis can also include other sarcomas as stated at the end of the sentence.  Example:  would change "mainly comprised of keratinocytic and melanocytic markers" to "including, but not limited to keratinocytic and melanocytic markers".

Response 2:  The changes are made to address this suggestion. The changes are in red font.

Comment 3: "Please modify/improve the color balance of the H&E photos (a, b, g, and h) to resemble the high resolution and well-balanced images (c and d)."

Response 3: The color balance (of figures a, b, g, and h) is improved.

Thank you for the comments!