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Tariq S, Saeed A, Ismaeel H, Ullah S, Hamid MA. Rise in the Number of Complex Skin Cancers Necessitates Establishing Mohs Micrographic Surgery Fellowships in Pakistan. Cureus 2023; 15:e43183. [PMID: 37692578 PMCID: PMC10485791 DOI: 10.7759/cureus.43183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
As more and more patients seek treatment for increasingly complicated and cosmetically challenging skin cancers, Mohs Micrographic Surgery (MMS) is now exceedingly in demand. Training in MMS could help dermatologists improve patient outcomes allowing them to handle complex lesions safely and efficiently and hence, provide the best possible care. As a result, there is an urgent need to train additional dermatologists in Mohs Surgery in order to meet the huge demand for dermatologists with imperative expertise, specifically in this field.
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Affiliation(s)
- Shahan Tariq
- Dermatology, National University of Medical Sciences, Rawalpindi, PAK
| | - Afshan Saeed
- Dermatology, Pak-Emirates Military Hospital, Rawalpindi, PAK
- Dermatology, District Headquarters (DHQ) Hospital Haripur, Haripur, PAK
| | - Hamza Ismaeel
- Pediatrics, Rawalpindi Medical University, Rawalpindi, PAK
| | | | - Muhammad Ammar Hamid
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, USA
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2
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Hope RH, Dowdle TS, Hope L, Pruneda C. Mohs micrographic surgery for keratinocyte carcinomas: clinicopathological predictors of the number of stages. Proc AMIA Symp 2023; 36:608-615. [PMID: 37614851 PMCID: PMC10444016 DOI: 10.1080/08998280.2023.2236478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 08/25/2023] Open
Abstract
Background The number of Mohs stages needed to remove a keratinocyte carcinoma affects resource use, expenses, and repair complexity. This study aimed to identify clinicopathological predictors associated with increased or decreased stages and areas for further research. Methods A retrospective review was conducted from a single private practice with two Mohs surgeons of 2788 consecutive Mohs cases between January 2017 and December 2021, analyzing the average number of stages taken versus national norms (P = 0.21) and subgroups using unpaired t tests (*<0.05). Results Several tumor features were significantly associated with fewer stages: squamous cell carcinomas, Mohs appropriate use criteria score of 7 or 8, preoperative size <0.25 cm2, tumors on the lips and extremities (including hands/fingers), and smoking. Clinicopathological features significantly associated with more stages included Mohs appropriate use criteria score of 9, recurrent skin cancers, basal cell carcinomas, tumor size of 2.25-3.99 cm2, cancers on ears, solid organ transplant patients, treatment delays >180 days, and patients ≥90 years old. Conclusions Significant predictors exist for both increased and decreased numbers of Mohs micrographic surgery stages required to eradicate a tumor, which may help Mohs surgeons facilitate, plan, and allocate resources more effectively. Areas for further research in Mohs micrographic surgery are identified.
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Affiliation(s)
- Richard H. Hope
- Lubbock Dermatology and Skin Cancer Center, Lubbock, Texas, USA
- Department of Dermatology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Travis S. Dowdle
- Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Landon Hope
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Corley Pruneda
- Department of Dermatology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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Massey PR, Gupta S, Rothstein BE, Konnikov N, Mahalingam M, Ruiz ES, Schmults CD, Waldman A. Total Margin-Controlled Excision is Superior to Standard Excision for Keratinocyte Carcinoma on the Nose: A Veterans Affairs Nested Cohort Study. Ann Surg Oncol 2021; 28:3656-3663. [PMID: 33742233 DOI: 10.1245/s10434-021-09604-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 12/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Keratinocyte carcinoma (KC), including basal and squamous cell carcinoma, is the most common human malignancy. Limited real-world data have compared surgical outcome or cost between total margin-controlled excision (TMCE) and standard excision (SE), the two most common treatments for invasive KC. We compared reconstruction, margin status, and cost between TMCE and SE for KC on the nose at a Veterans Affairs (VA) healthcare system. METHODS Randomly selected primary KCs on the nose ≤3 cm that were confined to soft tissue, without nerve or lymphovascular invasion, and treated with SE or TMCE between 2000 and 2010, were assessed. Utilization of flap or graft reconstruction and margin status following all surgical attempts were recorded. Costs were based on Current Procedural Terminology codes standardized to 2019 Medicare payments. RESULTS Overall, 148 cases were included in each treatment group. Baseline characteristics were similar between groups, although SE tumor median diameter was 1 mm larger. SE was associated with increased utilization of flap or graft reconstruction (odds ratio 2.05, 95% confidence interval 1.16-3.59, p = 0.01). Positive margins were present in 24% of SEs initially and remained positive after the final recorded excision in 9% of cases. No positive final margins were noted in TMCE cases. SE cost per tumor was significantly higher than TMCE ($429.03 ± 143.55; p = 0.003). CONCLUSIONS Surgical management of KC with SE is associated with increased reconstruction complexity, a significant risk of positive margins, and higher cost compared with TMCE. The 23% risk of positive margins supports National Comprehensive Cancer Network guidelines for the treatment of high-risk KC with TMCE, unless delayed reconstruction is employed.
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Affiliation(s)
- Paul R Massey
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sameer Gupta
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Nellie Konnikov
- Department of Dermatology, Veterans Affairs, Boston Healthcare System, Boston, MA, USA
| | - Meera Mahalingam
- Dermatopathology Section, Department of Pathology and Laboratory Medicine, Veterans Affairs, Boston Healthcare System, Boston, MA, USA
| | - Emily S Ruiz
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Dermatology, Veterans Affairs, Boston Healthcare System, Boston, MA, USA
| | - Chrysalyne D Schmults
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Abigail Waldman
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Dermatology, Veterans Affairs, Boston Healthcare System, Boston, MA, USA.
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Correa J, Pastor M, Céspedes E, Magliano J, Bazzano C. Tissue-Sparing Outcome of Mohs Micrographic Surgery in Squamous Cell Carcinomas. ACTAS DERMO-SIFILIOGRAFICAS 2020. [DOI: 10.1016/j.adengl.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Correa J, Pastor M, Céspedes E, Magliano J, Bazzano C. Tissue-Sparing Outcome of Mohs Micrographic Surgery in Squamous Cell Carcinomas. ACTAS DERMO-SIFILIOGRAFICAS 2020; 111:847-851. [PMID: 32717186 DOI: 10.1016/j.ad.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 07/04/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Micrographic Mohs Surgery (MMS) offers the highest cure rates and healthy skin tissue sparing effect compared with standard excision. OBJECTIVE To quantify the tissue-sparing properties of MMS in squamous cell carcinoma (SCC) in comparison with standard excision (SE). METHODS A bidirectional, descriptive study, including 94 cases of SCC, was performed, on patients with histologic diagnosis of SCC (in situ, well differentiated, moderately differentiated, and undifferentiated), that where operated with MMS between 2013 and 2018 at Hospital de Clínicas Dr. Manuel Quintela in Montevideo, Uruguay. Tumor size and defect area after MMS were measured in 2 perpendicular directions. The suspected defect area was calculated with standard excision using a 4-mm margin for low risk lesions and a 10-mm margin for high risk lesions. The primary outcome of this study was the size of the defect area post MMS compared with the calculated defect area with standard excision. RESULTS The median tumor size was 1,41mm2, and the median defect size after MMS was 4,12mm2. The median defect size calculated for standard surgical excision was 8,36mm2. LIMITATIONS We do not use all National Comprehensive Cancer Network (NCCN) criteria. We define low and high risk lesions just taking into account anatomical location, size, histopathology and whether it was a primary or recurrent tumor. CONCLUSION Our results show that MMS has a tissue-sparing effect of at least 52% compared to SE.
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Affiliation(s)
- J Correa
- Unidad de Cirugía Dermatológica, Hospital Dr. Manuel Quintela, Universidad de la República, Montevideo, Uruguay.
| | - M Pastor
- Unidad de Cirugía Dermatológica, Hospital Dr. Manuel Quintela, Universidad de la República, Montevideo, Uruguay
| | - E Céspedes
- Unidad de Cirugía Dermatológica, Hospital Dr. Manuel Quintela, Universidad de la República, Montevideo, Uruguay
| | - J Magliano
- Unidad de Cirugía Dermatológica, Hospital Dr. Manuel Quintela, Universidad de la República, Montevideo, Uruguay
| | - C Bazzano
- Unidad de Cirugía Dermatológica, Hospital Dr. Manuel Quintela, Universidad de la República, Montevideo, Uruguay
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Lee CT, Lehrer EJ, Aphale A, Lango M, Galloway TJ, Zaorsky NG. Surgical excision, Mohs micrographic surgery, external‐beam radiotherapy, or brachytherapy for indolent skin cancer: An international meta‐analysis of 58 studies with 21,000 patients. Cancer 2019; 125:3582-3594. [DOI: 10.1002/cncr.32371] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/25/2019] [Accepted: 06/06/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Charles T. Lee
- Department of Radiation Oncology Fox Chase Cancer Center Philadelphia Pennsylvania
| | - Eric J. Lehrer
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | - Abhishek Aphale
- Department of Dermatology Fox Chase Cancer Center Philadelphia Pennsylvania
| | - Miriam Lango
- Department of Surgery Fox Chase Cancer Center Philadelphia Pennsylvania
| | - Thomas J. Galloway
- Department of Radiation Oncology Fox Chase Cancer Center Philadelphia Pennsylvania
| | - Nicholas G. Zaorsky
- Department of Radiation Oncology Fox Chase Cancer Center Philadelphia Pennsylvania
- Department of Radiation Oncology Penn State Cancer Institute Hershey Pennsylvania
- Department of Public Health Sciences Penn State College of Medicine Hershey Pennsylvania
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Mohs Micrographic Surgery Volume and Payment Patterns Among Dermatologists in the Medicare Population, 2013. Am J Clin Oncol 2019; 41:1199-1203. [PMID: 29672366 DOI: 10.1097/coc.0000000000000448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Mohs micrographic surgery (MMS) has expanded markedly in recent years but there is limited information on volume, practice patterns or reimbursement. This study characterizes MMS utilization in the Medicare population. MATERIALS AND METHODS We analyzed the Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File Calendar Year 2013 data set for provider service volume and reimbursement for dermatologists who did and did not perform MMS procedures. RESULTS Total Medicare-funded MMS procedures increased 25% from 2009 (558,447) to 2013 (700,262). Dermatologists who performed MMS had significantly more average services per provider (5419.4 vs. 3627.1, r=0.16, P<0.0001), were reimbursed significantly more in average total procedure-related compensation ($475,883.64 vs. $144,564.74, r=0.49, P<0.0001) than dermatologists who did not perform MMS, and made up 71.3% of the top decile of dermatologists ranked by total reimbursement received from Medicare. Total MMS service volume and reimbursement was concentrated among a subset of providers. Among MMS providers, a higher volume of MMS procedures was correlated with a greater likelihood of performing procedures on lesions located on the trunk, arms or legs (r=0.27, P<0.001). CONCLUSIONS In 2013 reimbursement for MMS comprised almost 19% of the amount reimbursed by Medicare Part B Fee For Service to dermatologists and greater than half a percent of the total amount reimbursed to all physicians participating in the program. Further studies incorporating clinical and outcomes data are needed to evaluate appropriate utilization of this procedure.
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Murray C, Sivajohanathan D, Hanna TP, Bradshaw S, Solish N, Moran B, Hekkenberg R, Wei AC, Petrella T. Patient Indications for Mohs Micrographic Surgery: A Systematic Review. J Cutan Med Surg 2018; 23:75-90. [PMID: 30033747 DOI: 10.1177/1203475418786208] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The purpose of the present review was to describe evidence-based indications for Mohs micrographic surgery (MMS) in patients with a diagnosis of skin cancer. Relevant studies were identified from a systematic MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews search of studies published from 1970 to 2017. Randomized controlled trials (RCTs), prospective and retrospective comparative studies with greater than 30 patients, and single-arm retrospective studies with multivariate analyses were included. A total of 2 RCTs, 3 prospective studies, and 16 retrospective studies (14 comparative and 2 single-arm) were included. Data on recurrence rate, cure rate, complications, cosmesis, and quality of life were extracted. Surgery (with postoperative or intraoperative marginal assessment) or radiation for those who are ineligible for surgery should remain the standard of care for patients with skin cancer given the lack of high-quality, comparative evidence. MMS is recommended for those with histologically confirmed recurrent basal cell carcinoma (BCC) of the face and is appropriate for primary BCCs of the face that are >1 cm, have aggressive histology, or are located on the H zone of the face. The available evidence is difficult to generalize to all patients with skin cancer because the evidence did not adequately cover non-BCC skin cancers; however, those skin cancers can be considered on a case-by-case basis for MMS. MMS should be performed by physicians who have completed a degree in medicine or equivalent, including a Royal College of Physicians and Surgeons of Canada Specialist Certificate or equivalent, and have received advanced training in MMS.
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Affiliation(s)
- Christian Murray
- 1 Division of Dermatology, Women's College Hospital & University of Toronto, Toronto, ON, Canada
| | - Duvaraga Sivajohanathan
- 2 Department of Oncology, McMaster University & Program in Evidence-Based Care, Cancer Care Ontario, Hamilton, ON, Canada
| | - Timothy P Hanna
- 3 Department of Radiation Oncology, Cancer Centre of Southeastern Ontario, Kingston, ON, Canada
| | | | - Nowell Solish
- 1 Division of Dermatology, Women's College Hospital & University of Toronto, Toronto, ON, Canada
| | - Benvon Moran
- 5 Division of Dermatology, Queen's University, Kingston, ON, Canada
| | - Robert Hekkenberg
- 6 Department of Surgery, Royal Victoria Regional Health Centre & Surgical Oncology Program, Cancer Care Ontario, Barrie, ON, Canada
| | - Alice C Wei
- 7 Quality and Knowledge Transfer, Surgical Oncology Program, Cancer Care Ontario, Toronto, ON, Canada
| | - Teresa Petrella
- 8 Department of Medical Oncology, Odette Cancer Centre, Toronto, ON, Canada
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