Mohs Micrographic Surgery

5-Year Follow-Up of a Physician Performance Feedback Report Intervention to Reduce Overuse and Excess Cost: A National Cohort Study

BACKGROUND

Mohs micrographic surgery efficiently treats skin cancer through staged resection, but surgeons' varying resection rates may lead to higher medical costs.

OBJECTIVE

To evaluate the cost savings associated with a quality improvement.

MATERIALS AND METHODS

The authors conducted a retrospective cohort study using 100% Medicare fee-for-service claims data to identify the change of mean stages per case for head/neck (HN) and trunk/extremity (TE) lesions before and after the quality improvement intervention from 2016 to 2021. They evaluated surgeon-level change in mean stages per case between the intervention and control groups, as well as the cost savings to Medicare over the same time period.

RESULTS

A total of 2,014 surgeons performed Mohs procedures on HN lesions. Among outlier surgeons who were notified, 31 surgeons (94%) for HN and 24 surgeons (89%) for TE reduced their mean stages per case with a median reduction of 0.16 and 0.21 stages, respectively. Reductions were also observed among outlier surgeons who were not notified, reducing their mean stages per case by 0.1 and 0.15 stages, respectively. The associated total 5-year savings after the intervention was 92 million USD.

CONCLUSION

The implementation of this physician-led benchmarking model was associated with broad reductions of physician utilization and significant cost savings.

Cutaneous Superficial Basal Cell Carcinoma is a Basal Cell Carcinoma In Situ: Electron Microscopy of a Case Series of Basal Cell Carcinomas

Basal cell carcinoma (BCC) is the most common skin cancer. Skin cancers may present either as a non-invasive tumor or an invasive malignancy. The terminology of carcinoma in situ is used when the tumor is either just limited to epidermis or not present as single cells or nests in the dermis. However, currently the terminology superficial BCC is inappropriately used instead of BCC in situ when the skin cancer is limited to epidermis. In this study we compare the pathologic changes of superficial, nodular, and infiltrative BCCs using electron microscopy to identify the ultrastructural characteristics and validate the previously proposed terminology. Three cases of BCC (superficial BCC, nodular BCC, and infiltrative BCC) diagnosed by dermatopathologists at our institute were selected for review. Paraffin block tissues from these cases were sent for electron microscopy studies which demonstrated disruption of basal lamina in both nodular and infiltrative type of BCC, while it remains intact in BCC superficial type after extensive examination. Therefore, similar to other in situ skin cancers, there is no invasion of the neoplasm in superficial BCC into the dermis. Hence, the older term superficial BCC should be appropriately replaced with the newer terminology BCC in situ.

Second-Intention Healing in Mohs Micrographic Surgery: A Single-Center Academic Experience

OBJECTIVE

To describe the trends in second-intention healing (SIH) use at a single Mohs micrographic surgery (MMS) dermatology clinic and assess outcomes and patient satisfaction.

METHODS

The authors conducted a single-center, retrospective study of patients who underwent MMS from November 2012 through November 2018. Data obtained for each patient included sex, age, tumor characteristics, number of MMS stages, final defect size, and postoperative complications. Patient satisfaction of SIH was retrospectively assessed by telephone survey.

RESULTS

Providers used SIH in 22% of all MMS cases (n = 159/718). It was most commonly used for defects located on the nose, ear, temple, and periocular region. The average defect size and number of MMS stages for tumor clearance were 1.3 cm and 1.5 stages, respectively. Overall, low rates of postoperative complications were observed, and 95% of patients reported optimal or acceptable levels of satisfaction.

CONCLUSIONS

This study supports the idea that SIH is a safe, effective alternative for wound management and may have broader practice indications than those traditionally proposed.

Basal cell carcinoma: Epidemiology; pathophysiology; clinical and histological subtypes; and disease associations

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education article will provide a comprehensive and contemporary review of basal cell carcinoma. The first article in this series describes our current understanding of this disease regarding epidemiology, cost, clinical and histopathologic presentations, carcinogenesis, natural history, and disease associations.

Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma (cSCC) is a malignant neoplasm of the skin characterized by an aberrant proliferation of keratinocytes. Cutaneous SCC is the second most common malignancy globally, and usually arises in the chronically sun-damaged skin of elderly white individuals. From a pathologist's perspective, it is important to differentiate cSCC from the benign and reactive squamoproliferative lesions and identify the high-risk features associated with aggressive tumor behavior. In this article, we provide an up-to-date overview of cSCC along with its precursor lesions and important histologic variants, with a particular emphasis on the histopathologic features and molecular pathogenesis.

The characteristics of Mohs surgery performed by dermatologists who learned the procedure during residency training or through postgraduate courses and observational preceptorships

Little is known about the practice characteristics of Mohs surgery performed by physicians who learned the procedure during their dermatology residency training or through postresidency courses and observational preceptorships. All published reports have investigated Mohs surgeons trained in postresidency fellowships. This report presents the results of a multicenter prospective cohort study evaluating 1834 consecutive Mohs surgery cases performed during the same 6-month period by 9 Mohs surgeons who learned the technique in residency or in postresidency courses and observational preceptorships. One major complication was reported, a hematoma requiring outpatient drainage in an emergency room. There were 54 (2.9%) short-term complications, including 20 (1.1%) infections, 17 (0.9%) wound dehiscences, 9 (0.5%) cases of skin flap necrosis, and 8 (0.4%) hematomas or postoperative bleeding episodes. These complication rates and the data evaluating tumor type, anatomic location, primary vs. recurrent tumor status, tumor size, postoperative wound size, number of Mohs surgery stages, and repair type compare favorably to previously published reports.

Characterization of nonmelanoma skin cancer for light therapy using spatial frequency domain imaging

The dosimetry of light-based therapies critically depends on both optical and vascular parameters. We utilized spatial frequency domain imaging to quantify optical and vascular parameters, as well as estimated light penetration depth from 17 nonmelanoma skin cancer patients. Our data indicates that there exist substantial spatial variations in these parameters. Characterization of these parameters may inform understanding and optimization of the clinical response of light-based therapies.

Association between type of reconstruction after Mohs micrographic surgery and surgeon-, patient-, and tumor-specific features: a cross-sectional study

BACKGROUND

There are few data to indicate whether the type of final wound defect is associated with the type of post-Mohs repair.

OBJECTIVE

To determine the methods of reconstruction that Mohs surgeons typically select and, secondarily, to assess the association between the method and the number of stages, tumor type, anatomic location, and patient and surgeon characteristics.

METHODS

Statistical analysis of procedure logs of 20 representative young to mid-career Mohs surgeons.

RESULTS

The number of stages associated with various repairs were different (analysis of variance, p < .001.). Linear repairs, associated with the fewest stages (1.5), were used most commonly (43-55% of defects). Primary repairs were used for 20.2% to 35.3% of defects of the nose, eyelids, ears, and lips. Local flaps were performed typically after two stages of Mohs surgery (range 1.98-2.06). Referral for repair and skin grafts were associated with cases with more stages (2.16 and 2.17 stages, respectively). Experienced surgeons were nominally more likely perform flaps than grafts. Regression analyses did not indicate any association between patient sex and closure type (p = .99) or practice location and closure type (p = .99).

CONCLUSIONS

Most post-Mohs closures are linear repairs, with more bilayered linear repairs more likely at certain anatomic sites and after a larger number of stages.

Characteristics of squamous cell carcinoma in situ of the ear treated using Mohs micrographic surgery

BACKGROUND

Mohs micrographic surgery (MMS) is used to treat squamous cell carcinoma in situ (SCCIS) for tissue conservation.

OBJECTIVE

To examine characteristics of patients with SCCIS of the external ear treated using MMS.

METHODS

A retrospective review from 2005 to 2011.

RESULTS

We identified 173 cases of SCCIS of the ear. The population was 94% male (p < .01), with a mean age of 71. Eight percent (n = 13) of tumors were recurrent after prior treatment. Recurrent tumors occurred exclusively in men and were associated with larger initial size (p = .05), more layers for clearance p = .059), and larger final defect size (p = .01). Tumors with larger initial area were independently associated with older age (p < .01). Complexity of repair was independently associated with more layers (p < .01), larger initial area (p = .01), and larger final area (p = .02). Sex did not affect repair type.

CONCLUSION

SCCIS of the ear predominantly affects men in our referral base of 85% to 90% private patients and 10% to 15% veterans. Recurrent tumors were associated with larger initial size and subclinical spread of tumor. Primary tumors on average required 1.6 layers, validating the utility of MMS in this population in delineating the subclinical spread of SCCIS of the ear.

Factors predictive of complex Mohs surgery cases

BACKGROUND

Mohs surgery allows excision of skin cancer in a tissue-sparing fashion that minimizes recurrence risk. While the indications for Mohs surgery are well established, factors predictive of complex Mohs cases are less studied.

OBJECTIVE

To determine patient, tumor, and surgeon characteristics associated with complex Mohs cases.

METHODS

A retrospective review was performed for a 3-year period (7/2006-6/2009) to identify Mohs cases requiring ≥4 stages ("complex"), and a control population requiring ≤3 stages ("non-complex"). Surgical logs for four fellowship-trained Mohs surgeons were reviewed.

RESULTS

77 complex cases (51 academic practice vs. 26 private practice) were compared with 154 control cases (102 academic practice vs. 52 private practice). There were no significant differences in patient age, gender, immunosuppression, academic (2.7% complex) versus private practice (3.5% complex), or surgeons' years of experience. Factors associated with complexity included: recurrent tumors (p < 0.001; odds ratio (OR) 6.88; 95% confidence interval (CI) 2.8-17); basal cell carcinoma (BCC) with infiltrative or morpheaform histology (p = 0.0019; OR 3.0; 95% CI 1.5-6.3); tumors of the nose (p = 0.0168; OR 2.05; 95% CI 1.1-3.7), especially nasal tip (p = 0.0103; OR 3.68; 95% CI 1.3-10.6) and ear (p = 0.0178; OR 3.0; 95% CI 1.2-7.9), especially helix (p = 0.00744; OR 5.9; 95% CI 1.5-22.7); tumors with pre-operative size >1 cm (p = 0.018; OR 2.0; 95% CI 1.1-3.6); and tumors involving >1 cosmetic subunit (p = 0.0072; OR 5.0; 95% CI 1.5-16.7). Complex tumors had greater post-operative area (10.6 ± 1.3 vs. 3.6 ± 0.7 cm2; p < 0.0001), and more often required flap/graft repair (p < 0.0001; OR 6.9; 95% CI 3.7-13.1).

LIMITATIONS

A retrospective study representing a single geographic area.

CONCLUSIONS

Mohs cases are similar in complexity whether in academic or private practice. Recurrent/aggressive histology tumors, tumors >1 cm, and tumors on the nose or ear are more likely to prove surgically complex. Advanced knowledge of these factors may be useful pre-operatively as Mohs surgeons plan their scheduled cases.

Micrographic surgery of skin cancer in German hospitals 2005-2006

BACKGROUND/OBJECTIVE

Surgical therapy of skin cancer includes conventional wide excision and micrographic surgery (MS). Little is known about the population-wide spread of MS for the treatment of skin cancer. The aim was to estimate the in-hospital use of MS for the treatment of skin cancer in Germany.

METHODS

We used nationwide DRG data from 2005 through 2006. We identified hospitalizations with a main diagnosis of cutaneous malignant melanoma (CMM) (ICD-10: C43) or non-melanoma skin cancer (NMSC) (ICD-10: C44). MS was identified by OPS procedure codes including 5-895.1, 5-895.3, 5-212.1, 5-181.1, 5-181.4, 5-181.6, 5-182.1, 5-091.1, or 5-091.3.

RESULTS

We identified 52 660 and 98 484 hospitalizations with a primary diagnosis of CMM and NMSC respectively; 54.6% and 36.5% of NMSC and CMM-related admissions with local skin cancer treatment included MS. The relative frequency of MS varied by anatomic subsite of the skin cancer and by region of the hospital. Local infections were the most frequent complications after MS with 3.2-4.0% for NMSC and 2.3-2.9% for CMM followed by haemorrhages. Dehiscence of the operation wound is a rare event with risks ranging between 0.1% and 0.3%.

CONCLUSIONS

Micrographic surgery is frequently used for the local treatment of NMSC and varies considerably across Federal States of Germany. It is difficult to speculate how many MS might be performed in private or ambulatory settings in Germany. As MS requires surgical expertise, technical support and dermatopathology, we speculate that MS is much less frequently undertaken in private practices in Germany.