Systematic Review Comparing Wide Local Excision and Mohs Micrographic Surgery for Pleomorphic Dermal Sarcoma

BACKGROUND: Pleomorphic dermal sarcoma (PDS) is a rare cutaneous sarcoma with locally aggressive behaviour and metastatic potential. Optimal surgical management remains uncertain, with both wide local excision (WLE) and Mohs micrographic surgery (MMS) used in clinical practice. This systematic review aimed to compare oncological outcomes following WLE and MMS for PDS. METHODS: A systematic literature search was conducted in multiple databases from inception to December 2025. Studies reporting histologically confirmed PDS treated with WLE and/or MMS and including recurrence and/or survival outcomes were eligible. Methodological quality was assessed using Joanna Briggs Institute critical appraisal tools. RESULTS: Thirteen retrospective studies comprising 543 patients were included. PDS predominantly affected elderly patients and mostly involved the head and neck, particularly the scalp. WLE was the primary surgical modality, while MMS was reported in two studies. Local recurrence rates following WLE ranged from 4.2% to 69%, with higher rates observed in cohorts including incomplete excision, satellite metastases, or recurrent disease. Median time to recurrence was typically within the first year. MMS series reported recurrence rates between 12.5% and 20.9%, though interpretation was limited by small sample sizes, heterogeneous baseline disease, and confounding by indication. Metastatic rates ranged from 0% to 19%, and disease-specific mortality was uncommon but occurred predominantly following distant metastases. CONCLUSION: Complete surgical excision with clear margins remains the cornerstone of PDS management. While MMS may be considered in selected cases, particularly in anatomically constrained sites, current evidence is insufficient to support its routine use over WLE. Further multicentre studies are required to better define optimal surgical strategies.