Postoperative permanent section evaluation of Mohs micrographic surgery debulk specimens does not result in upstaging of cutaneous squamous cell carcinoma compared to stage at the completion of surgery: A retrospective case series

Background

Mohs micrographic surgery (MMS) is used for the treatment of high-risk cutaneous squamous cell carcinoma (cSCC). MMS examines the surgical margins in real time and does not commonly examine the central component of the tumor.

Objective

To determine if debulk specimens provide additional details relevant to tumor staging not gained from routine MMS.

Methods

A retrospective chart review of debulk specimens taken during MMS for cSCC was performed. Dermatopathology reports were analyzed and tumors were staged using Brigham and Women's Hospital and American Joint Committee on Cancer's 8th edition staging systems.

Results

Permanent section evaluation of debulk specimens did not result in clinically meaningful information for staging that could not be gained from MMS layers or initial biopsy analysis.

Limitations

A single institution, and a small sample size of 39 tumors.

Conclusions

Evaluation of debulk specimens during MMS may not always be an effective use of time or health care resources.

Identifying critical quality metrics in Mohs Surgery: A national expert consensus process

BACKGROUND

Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care.

OBJECTIVE

The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS.

METHODS

Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives.

RESULTS

Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback.

LIMITATIONS

Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes.

CONCLUSION

With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.

Patient-Reported Nasal Function and Appearance After Interpolation Flap Repair Following Skin Cancer Resection: A Multicenter Prospective Cohort Study

Objective: Among patients undergoing two-stage interpolated flap repair of nasal defects, nasal function, and appearance before surgery and at 16 weeks after flap takedown were compared using the Nasal Appearance and Function Evaluation Questionnaire (NAFEQ). Design: Multicenter prospective cohort study. Methods: Adult patients with a nasal skin cancer anticipated to require two-stage interpolation flap repair completed the NAFEQ before surgery, at 1 week after flap placement, 4 weeks after flap takedown, and 16 weeks after flap takedown. Results: One hundred sixty-nine patients were enrolled, with 138 patients completing both presurgical and 16-week post-takedown NAFEQs. Overall NAFEQ score increased by 1.09 points (1.91% improvement, confidence interval [95% CI -0.34 to 2.53]). NAFEQ functional subscale increased by 0.72 points (2.58% increase; 95% CI [0.10-1.35]) and appearance subscale increased by 0.37 points (1.28% improvement, 95% CI [-0.65 to 1.39]). Conclusion: At 16 weeks after flap takedown, patients' perceptions of their nasal function and appearance are similar to or slightly improved when compared with their presurgical assessments.

Evidence-Based Clinical Practice Guidelines for Extramammary Paget Disease

IMPORTANCE

Extramammary Paget disease (EMPD) is a frequently recurring malignant neoplasm with metastatic potential that presents in older adults on the genital, perianal, and axillary skin. Extramammary Paget disease can precede or occur along with internal malignant neoplasms.

OBJECTIVE

To develop recommendations for the care of adults with EMPD.

EVIDENCE REVIEW

A systematic review of the literature on EMPD from January 1990 to September 18, 2019, was conducted using MEDLINE, Embase, Web of Science Core Collection, and Cochrane Libraries. Analysis included 483 studies. A multidisciplinary expert panel evaluation of the findings led to the development of clinical care recommendations for EMPD.

FINDINGS

The key findings were as follows: (1) Multiple skin biopsies, including those of any nodular areas, are critical for diagnosis. (2) Malignant neoplasm screening appropriate for age and anatomical site should be performed at baseline to distinguish between primary and secondary EMPD. (3) Routine use of sentinel lymph node biopsy or lymph node dissection is not recommended. (4) For intraepidermal EMPD, surgical and nonsurgical treatments may be used depending on patient and tumor characteristics, although cure rates may be superior with surgical approaches. For invasive EMPD, surgical resection with curative intent is preferred. (5) Patients with unresectable intraepidermal EMPD or patients who are medically unable to undergo surgery may receive nonsurgical treatments, including radiotherapy, imiquimod, photodynamic therapy, carbon dioxide laser therapy, or other modalities. (6) Distant metastatic disease may be treated with chemotherapy or individualized targeted approaches. (7) Close follow-up to monitor for recurrence is recommended for at least the first 5 years.

CONCLUSIONS AND RELEVANCE

Clinical practice guidelines for EMPD provide guidance regarding recommended diagnostic approaches, differentiation between invasive and noninvasive disease, and use of surgical vs nonsurgical treatments. Prospective registries may further improve our understanding of the natural history of the disease in primary vs secondary EMPD, clarify features of high-risk tumors, and identify superior management approaches.

Systematic Review of Technical Variations for Mohs Micrographic Surgery for Melanoma

BACKGROUND

Mohs micrographic surgery (MMS) for cutaneous melanoma is becoming more prevalent, but surgical technique varies.

OBJECTIVE

To define variations in published techniques for MMS for melanoma.

METHODS AND MATERIALS

A systematic review was performed of PubMed, EMBASE, and Scopus databases to identify all articles describing surgical techniques for MMS for melanoma. Technical details were recorded for the preoperative, intraoperative, and postoperative phases of MMS.

RESULTS

Twenty-four articles were included. Mohs surgeons vary in how they assess clinical margins, how wide a margin they excise on the first MMS layer, and how they process tissue to determine tumor stage and margin clearance during MMS for melanoma.

CONCLUSION

Mohs micrographic surgery for melanoma is performed with varied surgical techniques. To establish best practices, additional research is necessary to determine how different techniques affect outcomes.

Patient Quality of Life After Interpolated Flap Repair of Nasal Mohs Surgery Defects: A Multicenter Prospective Cohort Study

Importance

Single-center studies have shown that patients report better skin cancer-specific quality of life (QOL) after Mohs micrographic surgery (MMS), but it is unclear whether this improved QOL applies to patients after MMS and complex reconstruction in cosmetically sensitive areas.

Objective

To evaluate patient QOL after MMS and interpolation flap reconstruction for patients with nasal skin cancers.

Design, Setting and Participants

This multicenter prospective survey study used the Skin Cancer Index (SCI), a validated, 15-question QOL questionnaire administered at 4 time points: before MMS, 1 week after flap placement, 4 weeks after flap takedown, and 16 weeks after flap takedown. Patients age 18 years or older with a nasal skin cancer who presented for MMS and were anticipated to undergo 2-stage interpolated flap repair by a Mohs surgeon were recruited from August 9, 2018, to February 2, 2020, at 8 outpatient MMS locations across the United States, including both academic centers and private practices.

Main Outcomes and Measures

Mean difference in overall SCI score before MMS vs 16 weeks after flap takedown.

Results

A total of 169 patients (92 men [54.4%]; mean [SD] age, 67.7 [11.4] years) were enrolled, with 147 patients (75 men [51.0%]; mean [SD] age, 67.8 [11.7] years) completing SCI surveys both before MMS and 16 weeks after flap takedown. Total SCI scores improved significantly 16 weeks after flap takedown compared with pre-MMS scores, increasing by a mean of 13% (increase of 7.11 points; 95% CI, 5.48-8.76; P < .001). All 3 SCI subscale scores (emotion, appearance, and social) improved significantly (emotion subscale, increase of 3.27 points; 95% CI, 2.35-4.18; P < .001; appearance subscale, increase of 1.65 points; 95% CI, 1.12-2.18; P < .001; and social subscale, increase of 2.10 points; 95% CI, 1.55-2.84; P < .001) 16 weeks after flap takedown compared with pre-MMS.

Conclusions and Relevance

Removal of a nasal skin cancer and repair of the resulting defect can be distressing for patients. However, this cohort study suggests that physicians referring patients for MMS can be reassured that their patient's QOL will improve on average after surgery, even when a complex reconstruction is required.

Preferences for Prophylactic Oral Antibiotic Use in Dermatologic Surgery: A Multicenter Discrete Choice Experiment

BACKGROUND

Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood.

OBJECTIVE

To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions.

MATERIALS AND METHODS

Multi-center, prospective discrete choice experiment (DCE).

RESULTS

Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics.

CONCLUSION

Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience.

Opioid Prescribing Recommendations After Mohs Micrographic Surgery and Reconstruction: A Delphi Consensus

BACKGROUND

Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence.

OBJECTIVE

To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction.

METHODS

This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at ≥80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval.

RESULTS

Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid.

CONCLUSION

Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommendations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic.

Preoperative Considerations for the Prevention of Surgical Site Infection in Superficial Cutaneous Surgeries: A Systematic Review

Background: Surgical site infections (SSIs) pose challenges to the outcome of superficial cutaneous procedures. Objective: The objective of this study was to summarize published data regarding appropriate perioperative considerations to decrease SSI, including antiseptic use, topical decolonization, antibiotic prophylaxis, and clean versus sterile technique in superficial cutaneous procedures. A literature search was performed via PubMed and Cochrane Library by using relevant keywords. A total of 37 articles met the inclusion criteria. Strength of data was assessed according to the Oxford Centre criteria and a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: Chlorhexidine is the antiseptic of choice in clean or outpatient superficial cutaneous procedures. Decolonization of carriers of Staphylococcus aureus with mupirocin is warranted for all superficial cutaneous procedures. Minor procedure rooms may be considered for superficial cutaneous procedures that possess an inherently low risk of SSI. Surgeons may consider nonsterile gloves instead of sterile gloves for clean or outpatient superficial cutaneous procedures. Postoperative use of topical antibiotics may be discontinued, as there are risks of adverse effects and increasing bacterial resistance without a significant reduction in SSI. Conclusion and Relevance: This systematic review provides new and updated evidence for the prevention of SSI in superficial cutaneous procedures through antiseptic use, antibiotic use, topical agents, and the surgical environment. The overall quality of evidence is good, with most articles being original research or systematic reviews. However, there is a need for dermatologic- and plastic surgery-specific studies regarding the prevention of SSI.

Evidence-Based Clinical Practice Guidelines for Microcystic Adnexal Carcinoma: Informed by a Systematic Review

Importance

Microcystic adnexal carcinoma (MAC) occurs primarily in older adults of white race/ethnicity on sun-exposed skin of the head and neck. There are no formal guiding principles based on expert review of the evidence to assist clinicians in providing the highest-quality care for patients.

Objective

To develop recommendations for the care of adults with MAC.

Evidence Review

A systematic review of the literature (1990 to June 2018) was performed using MEDLINE, Embase, Web of Science, and the Cochrane Library. The keywords searched were microcystic adnexal carcinoma, sclerosing sweat gland carcinoma, sclerosing sweat duct carcinoma, syringomatous carcinoma, malignant syringoma, sweat gland carcinoma with syringomatous features, locally aggressive adnexal carcinoma, and combined adnexal tumor. A multidisciplinary expert committee critically evaluated the literature to create recommendations for clinical practice. Statistical analysis was used to estimate optimal surgical margins.

Findings

In total, 55 studies met our inclusion criteria. The mean age of 1968 patients across the studies was 61.8 years; 54.1% were women. Recommendations were generated for diagnosis, treatment, and follow-up of MAC. There are 5 key findings of the expert committee based on the available evidence: (1) A suspect skin lesion requires a deep biopsy that includes subcutis. (2) MAC confined to the skin is best treated by surgery that examines the surrounding and deep edges of the tissue removed (Mohs micrographic surgery or complete circumferential peripheral and deep margin assessment). (3) Radiotherapy can be considered as an adjuvant for MAC at high risk for recurrence, surgically unresectable tumors, or patients who cannot have surgery for medical reasons. (4) Patients should be seen by a physician familiar with MAC every 6 to 12 months for the first 5 years after treatment. Patient education on photoprotection, periodic skin self-examination, postoperative healing, and the possible normal changes in local sensation (eg, initial hyperalgesia) should be considered. (5) There is limited evidence to guide the treatment of metastasis in MAC due to its rarity. Limitations of our findings are that the medical literature on MAC comprises only retrospective reviews and descriptions of individual patients and there are no controlled studies to guide management.

Conclusions and Relevance

The presented clinical practice guidelines provide an outline for the diagnosis and management of MAC. Future efforts using multi-institutional registries may improve our understanding of the natural history of the disease in patients with lymph node or nerve involvement, the role of radiotherapy, and the treatment of metastatic MAC with drug therapy.

Intraoperative electrosurgical smoke during outpatient surgery: a survey of dermatologic surgeon and staff preferences

Electrosurgery generates smoke that may be harmful. We created a survey to evaluate perceptions of electrosurgical smoke and how information on the harm it potentially causes changes these perceptions. We distributed the survey to the membership of the American College of Mohs Surgery and the American Society for Dermatologic Surgery and received 437 useable responses. Results indicated that many dermatologic surgeons were aware of and bothered by surgical smoke, and these reactions were more prevalent after being educated on the potential hazards of electrosurgical smoke.

Setting our sights on the right target: how addressing physician burnout may be a solution for improved patient experience

Physician burnout is an important issue that can have serious implications for both physicians and patients. Many of the techniques used by larger medical groups attempt to compel improvements in patient satisfaction scores at the potential cost of increased physician burnout. Because burnout has been associated with poorer patient care and experience, medical groups large and small should work aggressively to reduce the causes of burnout as a way to also improve patient experience. In this contribution, the patient experience measure and the electronic medical record are reviewed in the context of the regulatory and bureaucratic pressures they place on physicians to examine how they may contribute to burnout and, therefore, worsen patient experience.

Analysis of the patient experience measure

Assessing the patient experience has been a component of national health care policy for years in various forms, and it is now incorporated into many areas affecting physician practice. This review will focus on the origin and importance of this measure and address its critiques. The evolution of the measure as it progressed from patient satisfaction to patient experience and the rationale behind this shift will be detailed, the thought process behind the measure as an indicator of a culture of patient-centeredness and quality rather than as strictly a score will be reviewed, and the various motivators for physicians to improve patient experience will be divided into extrinsic and intrinsic and discussed.

Combined closures in reconstructive surgery

It is common for dermatology surgery patients to present on the day of surgery with more than one skin cancer needing Mohs micrographic surgery. When these carcinomas are located near one another, it may be more practical to treat both at the same time as the reconstruction for one defect may involve or otherwise affect the treatment or reconstruction for the other carcinoma. Treating both cancers on the same day creates an opportunity for efficient repairs where a creative single reconstruction may minimize the amount of tissue wasted during reconstruction,and minimize morbidity for the patient. Further,combining multiple defects into one closure may reduce cost as it has been shown that reconstructive choice affects the cost-effectiveness of Mohs surgery relative to a traditional excision and Mohs surgeons more commonly select less costly options for wound management. We present a case series of two-in-one closures - repairing two defects with one closure.

Ultrasonic modulation of tissue optical properties in ex vivo porcine skin to improve transmitted transdermal laser intensity

BACKGROUND AND OBJECTIVE

Applications of light-based energy devices involving optical targets within the dermis frequently experience negative side-effects resultant from surface scattering and excess optical absorption by epidermal melanin. As a broadband optical absorber, melanin decreases the efficacy of light-based treatments throughout the ultraviolet, visible, and near-infrared spectra while also generating additional heat within the surface tissue that can lead to inflammation or tissue damage. Consequently, procedures may be performed using greater energy densities to ensure that the target receives a clinically relevant dose of light; however, such practices are limited, as doing so tends to exacerbate the detrimental complications resulting from melanin absorption of treatment light. The technique presented herein represents an alternative method of operation aimed at increasing epidermal energy fluence while mitigating excess absorption by unintended chromophores. The approach involves the application of continuously pulsed ultrasound to modulate the tissue's optical properties and thereby improve light transmission through the epidermis.

MATERIALS AND METHODS

To demonstrate the change in optical properties, pulsed light at a wavelength of 532 nm from a Q-switched Nd:YAG laser was transmitted into 4 mm thick samples of porcine skin, comprised of both epidermal and dermal tissue. The light was transmitted using an optical waveguide, which allowed for an ultrasonic transducer to be incorporated for simultaneous paraxial pulsation in parallel with laser operation. Light transmitted through the tissue was measured by a photodiode attached to an integrating sphere.

RESULTS

Increasing the driving voltage of ultrasonic pulsation resulted in an increase in mean transmitted optical power of up to a factor of 1.742 ± 0.0526 times the control, wherein no ultrasound was applied, after which the optical power increase plateaued to an average amplification factor of 1.733 ± 0.549 times the control.

CONCLUSIONS

The increase implies a reduction in light either back-scattered or absorbed within the tissue, which would allow for a greater proportion of incident energy to be delivered to the clinical target, thereby improving procedural efficacy and potentially reducing the severity of detrimental side-effects. Apparatus Lasers Surg. Med. 49:666-674, 2017. © 2017 Wiley Periodicals, Inc.

Cutaneous Carcinoma: Beyond Mohs Surgery

Program Description:

This miniseminar is intended to be a discussion of how best to manage patients with cutaneous carcinomas with aggressive growth features, with local invasion and metastasis that may not be controlled with either traditional extirpative surgery or Mohs micrographic resection. This presentation will be primarily focused on issues related to aggressive growth situations with basal cell and squamous cell carcinomas, particularly those with perineural invasion. How far to go with extirpative surgery versus considerations for other treatments will be discussed.

Educational Objectives:

1) Recognize cutaneous carcinomas with aggressive growth features, including best tumor mapping and staging. 2) Interpret available treatment strategies when confronted with cutaneous carcinomas that are not likely to be controlled with surgical extirpation alone. 3) Define current concepts with use of targeted medical therapies in the treatment of advanced and metastatic cutaneous carcinomas.

Rebound of psoriasis during treatment with efalizumab

Recently, the biologics have emerged as a new class of drugs for systemic therapy of psoriasis with efalizumab (Raptiva) being one of the most recently FDA-approved agents. We report a case of a 34-year-old Caucasian male who experienced psoriasis rebound during a 7-week lapse in treatment with subcutaneous efalizumab 0.8 mg/kg/week, which he had been using for 4 weeks up to that point. The patient then restarted efalizumab, but his psoriasis continued to worsen causing him to be admitted for Goeckerman day care. He rebounded again 4 weeks following his ultimate discontinuation of efaluzimab despite intensive therapy with the Goeckerman regimen. This case is reported to highlight the recent findings that psoriasis rebound, defined as psoriasis area and severity index (PASI) of 125% or greater or morphology change, has been associated with both the use and the discontinuation of efalizumab.