Prognostic Analysis of Patients With Extramammary Paget Disease Treated With Conservative Excision

BACKGROUND

Extramammary Paget disease (EMPD) is a malignant skin tumor with a relatively good prognosis. The standard treatment is wide local resection or Mohs micrographic surgery. However, conservative excision may be a better option when radical wide local excision is difficult to perform due to the patients' mental or physical condition. There have been no studies on the prognosis of patients with EMPD who underwent conservative excision.

OBJECTIVE

To compare the prognosis of conservative excision cases to wide excision cases of EMPD.

MATERIALS AND METHODS

The authors retrospectively analyzed the clinical data of 69 cases of EMPD without metastases to lymph nodes or organs (11 cases treated with conservative excision, 58 cases treated with wide local excision) who underwent resection of the primary tumor from 2002 to 2022 in the Department of Dermatology at Hokkaido University Hospital.

RESULTS

The log-rank test showed no significant differences in overall survival or metastasis-free survival between the wide excision group and the conservative excision group, although conservative surgery was often chosen in elderly patients or patients with lower performance status.

CONCLUSION

This study suggests that conservative surgery should be considered as a treatment option for EMPD.

Morbidity and Mortality of Melanoma on the Trunk and Extremities Treated With Mohs Surgery Versus Wide Excision: A Systematic Review

BACKGROUND

Recommendations for the approved use of Mohs surgery for cutaneous melanoma on the trunk and extremities remain uncertain.

OBJECTIVE

To compare survival and recurrence between patients treated with Mohs surgery versus wide excision for melanoma on the trunk and extremities.

METHODS

The databases Medline, Embase, Web of Science, CENTRAL, and EMCare were searched from inception on January 11, 2021. Contemporary comparisons were included exclusively. Meta-analysis was conducted using generic inverse variance and a fixed effects model.

RESULTS

Four studies were eligible for inclusion. The study population (n = 279,556) was 52.1% men and 97.2% White. There were no observed differences in 5-year overall survival (hazard ratio 0.98, 95% confidence interval 0.90-1.07, I2 = 0%), disease-free survival (HR 0.89, 95% CI 0.12-6.47, I2 = 0), or local recurrence among patients treated with Mohs surgery relative to wide excision. Quality of the evidence was very low.

CONCLUSION

This systematic review found survival and local recurrence were comparable among patients treated with Mohs surgery or wide excision for melanoma on the trunk and extremities. Future prospective contemporary studies with more diverse representation that report surgical complications and costs may facilitate more definitive recommendations.

Characteristics of Superficial Basal Cell Carcinomas Containing More Aggressive Subtypes on Final Histopathologic Diagnosis

BACKGROUND

The prognosis and treatment of basal cell carcinoma (BCC) are largely dependent on tumor subtype, which is typically determined by punch or shave biopsy. Data regarding concordance between BCC subtype on initial biopsy and final histopathology for Mohs micrographic surgery (MMS) or excision with frozen sections (EFS) are limited.

OBJECTIVES

To determine the concordance between initial biopsy and final MMS or EFS subtyping of BCC. We aim to investigate the incidence and clinical characteristics of lesions initially diagnosed as superficial BCC (sBCC) that are later found to have a nodular, micronodular, or infiltrative component.

METHODS

We conducted a retrospective review of all MMS or EFS cases performed at a single academic center from August 1, 2015 to August 31, 2017. Inclusion criteria were a biopsy-proven diagnosis of sBCC and presence of residual tumor following stage I of MMS or EFS. Fisher’s exact test was used to evaluate significance of clinical characteristics and outcomes associated with the presence of a nodular, micronodular, or infiltrative BCC component.

RESULTS

A total of 164 MMS or EFS cases had an initial biopsy showing sBCC. Of these, 117 had residual BCC on stage I, and 43 (37%) were found to have a nodular, micronodular, or infiltrative component. Significant predictors of reclassified BCC subtype included age over 60 years (P=0.006) and location on the head or neck (P=0.043). Reclassified lesions required significantly more stages of MMS to clear (P=0.036). Shave biopsy was used to diagnose 114 (98%) of the included cases.

CONCLUSIONS

Over one third of shave biopsies that initially diagnosed sBCC failed to detect a nodular, micronodular, or infiltrative component. Management of biopsy-proven sBCC should take into account the possible presence of an undiagnosed deeper tumor component with appropriate margin-assessment treatment modalities when clinically indicated. J Drugs Dermatol. 2021;20(3):283-288. doi:10.36849/JDD.5383.

Employment and Migration Patterns of Recent Micrographic Surgery and Dermatologic Oncology Fellowship Graduates

BACKGROUND

There is currently an uneven distribution of the Mohs surgery workforce, with a dearth in nonurban areas. The relationship between training and employment locations of Mohs surgeons has not been studied.

OBJECTIVE

To analyze the employment location of recent micrographic surgery and dermatologic oncology (MSDO) graduates in reference to residency and fellowship locations.

MATERIALS AND METHODS

Data collection of training and practice locations of 421 MSDO fellowship graduates from 2012 to 2017.

RESULTS

Thirty-two percent (n = 136) and 53% (n = 225) of MSDO fellowship graduates' first employment locations were located within 10 and 100 miles of either their residency or fellowship locations. Ninety-six percent of graduates were employed in a metropolitan location. Female graduates worked closer to training sites than male graduates, with 62% (n = 124) versus 46% (n = 102) working within 100 miles of either training site. Analysis by fellowship census region showed that graduates clustered around training sites in all regions, with 45% to 60% of graduates working within 100 miles of either training site.

CONCLUSION

The majority of graduates chose to work in a metropolitan area. Training location strongly predicts employment location. More than 45% of graduates in any region worked within 100 miles of their residency or fellowship site, and a sizeable portion worked within 10 miles.

Evaluation of Public Interest in Mohs Surgery and Other Elective Surgical Procedures During the COVID-19 Pandemic

BACKGROUND

The reallocation of health care resources to focus on the acute care needs of COVID-19 patients leads to a delay and deferral of outpatient surgical procedures such as Mohs surgery.

OBJECTIVE

Planning for the resumption of regular outpatient surgical care and preparing for future surges in COVID-19 cases requires identifying surrogate markers of health care demand.

MATERIALS AND METHODS

United States national and state-based Google search data for "Mohs surgery" and other common elective surgical and cosmetic procedures were evaluated. These were compared with national and state-wide COVID-19 case number and death data from the Johns Hopkins University. Pearson correlation coefficients were generated to assess the association between COVID-19 cases and deaths with Google search trends.

RESULTS

Search volume for "Mohs surgery" and other elective surgical and cosmetic procedures significantly decreased as the number of new deaths from COVID-19 increased. Statistically significant inverse correlation was noted between "Mohs surgery" search volume and new COVID-19 deaths on a national and state-based level.

CONCLUSION

Search metric analysis may be used as part of a big data model to help predict health care demand during the reopening phase of the COVID-19 pandemic.

Malignant Cutaneous Adnexal Tumors and Role of SLNB

BACKGROUND

Malignant cutaneous adnexal tumors (MCATs) are rare and their natural history is poorly understood. Available literature indicates aggressive behavior with a significant risk of metastasis.

STUDY DESIGN

Retrospective review of our institutional surgical oncology databases was performed for patients diagnosed with MCATs (2001-2020). We hypothesized that most patients have a low risk of lymph node involvement, recurrence, and death. Kaplan-Meier statistical analysis was used to assess risk of recurrence and 5-year survival.

RESULTS

We identified 41 patients diagnosed with MCATs (median age 59 years, 68% were men). Most patients had long-standing cutaneous lesions (median 24 months) and no palpable adenopathy. Most patients had stage I or II disease (98%). Primary tumors were treated with wide local excision (n = 28 [68%]), Mohs surgery (n = 5 [12%]), or amputation (n = 8 [19%]). Of 25 patients who underwent SLNB (61%), 1 had lymphatic metastasis. These include apocrine carcinoma (1 of 3), digital papillary adenocarcinoma (0 of 8), porocarcinoma (0 of 4), and additional MCAT sub-types (0 of 10). Three patients (7%) had disease recurrence at a median interval of 3.6 years (interquartile range 1.5 to 4.4 years). Five patients (12%) died at a median interval of 7 years (interquartile range 6.7 to 9.2 years), but only 1 patient was known to have succumbed to MCAT. Overall 5-year survival rate was 96% (95% CI, 75% to 99%).

CONCLUSIONS

Despite the historical impression that MCATs have a high metastatic potential, most patients have low recurrence rates and excellent 5-year survival rates. Lymphatic disease identified after SLNB in early-stage tumors is rare and the value of this staging procedure in MCAT remains unclear.

Use of Skin Cancer Procedures, Medicare Reimbursement, and Overall Expenditures, 2012-2017

This cohort study describes recent trends in use and payment rates and in overall expenditure for skin cancer procedures in the Medicare Part B population in the United States.

Upstaging of basal cell and squamous cell carcinomas during definitive surgery: a review of predictive preoperative clinical and histologic features

The incidence of nonmelanoma skin cancer (NMSC) in the United States is increasing with approximately 3.6 million cases diagnosed per year. The staging and treatment of NMSC is guided by histologic subtype based on skin biopsy, along with other tumor-specific factors. However, a biopsy only represents a portion of the tumor, so there is a risk of upstaging at the time of definitive surgery. We conducted a review of the literature and found that a significant proportion of NMSC were upstaged during surgery. The rate of upstaging of basal cell carcinoma (BCC) was 7-31% and that of squamous cell carcinoma in situ (SCCIS) to squamous cell carcinoma (SCC) was 3-39%. Biopsy sampling error and variability in interpreting and reporting by dermatopathologists contribute to these discrepancies. It is pertinent to consider more comprehensive treatment modalities for tumors at high risk for upstaging. Diligence to identify tumors at higher risk for upstaging will allow clinicians to optimize management.

Antibiotic Practices in Mohs Micrographic Surgery

BACKGROUND

Mohs micrographic surgery is a safe procedure with low rates of infection.

OBJECTIVE

To establish current antibiotic prescribing practices amongst Mohs surgeons.

METHODS AND MATERIALS

16-question survey sent to American College of Mohs Surgery members.

RESULTS

305 respondents with collectively 7,634+ years of experience. The majority performed outpatient surgery (95.0%) and avoided oral or topical antibiotics for routine cases (67.7% and 62.8%, respectively). Prophylactic antibiotics were routinely prescribed for artificial cardiac valves (69.4%), anogenital surgery (53.0%), wedge excision (42.2%), artificial joints (41.0%), extensive inflammatory skin disease (40.1%), immunosuppression (38.9%), skin grafts (36.4%), leg surgery (34.2%), and nasal flaps (30.1%). A minority consistently swabbed the nares to check for staphylococcus aureus carriage (26.7%) and decolonized carriers prior to surgery (28.0%).

CONCLUSION

Disparity exists in antibiotic prescribing practices amongst Mohs surgeons. There may be under-prescription of antibiotics for high risk factors like nasal flaps, wedge excisions, skin grafts, anogenital/lower extremity site, and extensive inflammatory disease. Conversely, there may be over-prescription for prosthetic joints or cardiac valves. Increased guideline awareness may reduce post-operative infections and costs/side effects from antibiotic over-prescription. J Drugs Dermatol. 2020;19(5): doi:10.36849/JDD.2020.4695.

Topical Fluorouracil Therapy for Residual Superficial Basal Cell Carcinoma Following Mohs Micrographic Surgery

When treating invasive basal cell carcinoma (BCC) with Mohs micrographic surgery (MMS), including infiltrative and nodular subtypes, the goal is complete surgical removal of the tumor. In some cases, after several stages of MMS, residual foci of superficial BCC are noted with no dermal invasive components apparent. Some patients and surgeons have opted for halting surgery and treating residual superficial BCC with adjuvant topical fluorouracil. In this retrospective study, this treatment method is shown to be effective with a recurrence rate of BCC of 3.7% over a mean follow up of 28 months. This treatment method reduces the number of stages of MMS as the surgery is stopped was invasive BCC is removed. This can be beneficial when considering the morbidity of prolonged surgical procedures in frail, elderly patients experiencing surgical fatigue, the cost of additional stages, and the cost of advanced repairs due to enlarging defect size. J Drugs Dermatol. 2020;19(5): doi:10.36849/JDD.2020.4811.

Upstaging of melanoma in situ and lentigo maligna treated with Mohs micrographic surgery rarely results in additional surgical management

As Mohs micrographic surgery (MMS) is more widely utilized for melanoma in situ (MIS) and lentigo maligna (LM), there is increasing concern over whether the procedure can negatively affect the treatment of upstaged tumors. Previous studies have shown that about 1-2% of MIS/LM treated with MMS require sentinel lymph node biopsy, but little is still known regarding surgical outcomes. We performed a retrospective chart review of 117 MIS/LM lesions treated with MMS at Brigham and Women's Hospital. We found a low rate of tumor upstaging (8.5% or 10/117), and only 1.7% (2/117) required wide local excision and sentinel lymph node biopsy. In both patients, there was successful location of the sentinel nodes by surgical oncologists. This study highlights the low risk of MIS/LM upstaging, with the majority changing to T1a, and the low need for further surgical management after MMS. Collaboration with other surgical specialties ensures appropriate management of patients with upstaged tumors.

Quantity and characteristics of flap or graft repairs for skin cancer on the nose or ears: a comparison between Mohs micrographic surgery and plastic surgery

One benefit of Mohs micrographic surgery (MMS) is maximal tissue sparing compared to standard excisional surgery techniques. It also has the highest statistical cure rate for appropriately selected nonmelanoma skin cancers (NMSCs) in cosmetically sensitive areas, making it a preferred choice for many self-referred patients or their referring physicians. Patients and nondermatologist physicians may be unaware of how frequently Mohs surgeons perform complex surgical repairs compared to other specialists. Our objective was to compare the quantity and characteristics of flap or graft repairs on the nose or ears following skin cancer extirpation performed by either a fellowship-trained Mohs surgeon or plastic surgeons at 1 academic institution. A retrospective chart review of all skin cancer surgeries was performed to collect data on all flap or graft repairs on the nose or ears at Baylor Scott and White Health (Temple, Texas) from October 1, 2016, to October 1, 2017. We collected secondary data on final defect size prior to the repair, skin tumor type, referring specialty for the procedure, and patient demographics. We found that Mohs surgeons performed a larger number of complex repairs on cosmetically sensitive areas compared to plastic surgeons following skin cancer removal, which may be unrecognized in several specialties that refer patients for management of skin cancers, creating a possible practice gap. More data may aid referring providers in optimally advising and managing patients with cutaneous malignancies.

Tracking Mohs micrographic surgery referrals at the VA

Large dermatology centers such as the Veterans Affairs health care system carry the challenge of providing adequate care for patients within an appropriate timeline. Herein we begin a discussion about the tracking systems in place at busy hospitals, such as the VA, where numerous biopsies are referred to outside providers for further treatment. The complex psychosocial aspect of providing care specifically to veterans is also addressed. Finally, we describe our system, which monitors malignant skin biopsies that are referred to outside clinics for Mohs Micrographic Surgery (MMS).

Understanding Mohs Micrographic Surgery: A Review and Practical Guide for the Nondermatologist

The incidence and diagnosis of cutaneous malignancies are steadily rising. In addition, with the aging population and increasing use of organ transplant and immunosuppressive medications, subsets of patients are now more susceptible to skin cancer. Mohs micrographic surgery (MMS) has become the standard of care for the treatment of high-risk nonmelanoma skin cancers and is increasingly used to treat melanoma. Mohs micrographic surgery has the highest cure rates, spares the maximal amount of normal tissue, and is cost-effective for the treatment of cutaneous malignancies. As in other medical fields, appropriate use criteria were developed for MMS and have become an evolving guideline for determining which patients and tumors are appropriate for referral to MMS. Patients with cutaneous malignancies often require multidisciplinary care. With the changing landscape of medicine and the rapidly increasing incidence of skin cancer, primary care providers and specialists who do not commonly manage cutaneous malignancies will need to have an understanding of MMS and its role in patient care. This review better familiarizes the medical community with the practice of MMS, its utilization and capabilities, differences from wide excision and vertical section pathology, and cost-effectiveness, and it guides practitioners in the process of appropriately evaluating and determining when patients with skin cancer might be appropriate candidates for MMS.

Outlier Practice Patterns in Mohs Micrographic Surgery: Defining the Problem and a Proposed Solution

Importance

Outlier physician practices in health care can represent a significant burden to patients and the health system.

Objective

To study outlier physician practices in Mohs micrographic surgery (MMS) and the associated factors.

Design, Setting, and Participants

This retrospective analysis of publicly available Medicare Part B claims data from January 2012 to December 2014 includes all physicians who received Medicare payments for MMS from any practice performing MMS on the head and neck, genitalia, hands, and feet region of Medicare Part B patients.

Main Outcomes and Measures

Characteristics of outlier physicians, defined as those whose mean number of stages for MMS was 2 standard deviations greater than the mean number for all physicians billing MMS. Logistic regression was used to study the physician characteristics associated with outlier status.

Results

Our analysis included 2305 individual billing physicians performing MMS. The mean number of stages per MMS case for all physicians practicing from January 2012 to December 2014 was 1.74, the median was 1.69, and the range was 1.09 to 4.11. Overall, 137 physicians who perform Mohs surgery were greater than 2 standard deviations above the mean (2 standard deviations above the mean = 2.41 stages per case) in at least 1 of the 3 examined years, and 49 physicians (35.8%) were persistent high outliers in all 3 years. Persistent high outlier status was associated with performing Mohs surgery in a solo practice (odds ratio, 2.35; 95% CI, 1.25-4.35). Volume of cases per year, practice experience, and geographic location were not associated with persistent high outlier status.

Conclusions and Relevance

Marked variation exists in the number of stages per case for MMS for head and neck, genitalia, hands, and feet skin cancers, which may represent an additional financial burden and unnecessary surgery on individual patients. Providing feedback to physicians may reduce unwarranted variation on this metric of quality.

Favourable results of Mohs micrographic surgery for basal cell carcinoma

INTRODUCTION

Basal cell carcinoma (BCC) is the most common malignant neoplasm with an annual incidence approaching 200/100,000 person-years. Mohs micrographic surgery (MMS) is widely used in North America and in Europe for treatment of BCC. This technique ensures radical tumour removal, sparing of the surrounding healthy skin, and it also offers higher cure rates than standard tumour excision with a predefined margin of healthy skin. The superiority of MMS relies on the fact that the entire (100%) margin of the excised tissue is examined microscopically for residual tumour in contrast to the traditional histopathological examination, in which 2% of the margin is examined.

METHODS

In Denmark, MMS was first introduced by us in 2012. In the present study, we retrospectively included all patients who underwent MMS from May 2012 to June 2015.

RESULTS

A total of 231 patients with 263 BCC were included. The mean age was 66.1 years. The most common localisations were the forehead (31.3%), the nose (31.0%) and the cheek (14.7%). Primary BCC comprised 54.0%; the remaining cases were relapses, most frequently after curettage (36.9%), radiotherapy (18.9%) and photodynamic therapy (11.7%). MMS leads to 40% smaller skin defects than standard excisions with 4 or 6 mm margins. Closure of skin defects was achieved by side-to-side closure in 49% and by local flaps in 40%. There were no relapses during the observation time. The safety, cosmetic and functional outcome were excellent.

CONCLUSIONS

We recommend that MMS be included in the Danish BCC treatment guidelines, especially for high-risk BCC in the face, in line with standard practice in Europe and the United States.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

National utilization patterns of Mohs micrographic surgery for invasive melanoma and melanoma in situ

BACKGROUND

Although wide local excision continues to be commonly used for melanoma treatment, Mohs micrographic surgery (MMS) for the treatment of melanomas remains controversial.

OBJECTIVE

We sought to determine national utilization patterns for MMS in the treatment of invasive melanoma and melanoma in situ.

METHODS

A retrospective analysis of patients receiving surgical excision (MMS or wide local excision) for the treatment of invasive melanoma and melanoma in situ was performed using data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program.

RESULTS

A total of 195,768 melanomas were diagnosed from 2003 through 2009 from the 17 SEER registries. Utilization of MMS for invasive melanoma and melanoma in situ increased by 60% from 2003 to 2008. Of all SEER-captured lesions treated by surgical excision in this time period, 3.5% (6872) were excised by MMS.

LIMITATIONS

Patient insurance status, physician reimbursement practices, and health care provider type were not addressed in this article.

CONCLUSION

Use of MMS for melanoma appears to be increasing. Future studies should explore whether this is associated with better outcomes.

Mohs micrographic surgery histopathology concordance

BACKGROUND

The low recurrence rate and tissue-sparing benefit associated with Mohs micrographic surgery (MMS) requires accurate interpretation of frozen sections by the MMS surgeon.

OBJECTIVE

We sought to assess concordance between dermatopathologists and MMS surgeons when reporting cutaneous malignancy in the MMS setting.

METHODS

This study is a retrospective analysis of 1156 slides submitted during 10 years as part of a pre-existing randomized, blinded, quality assurance protocol. Slides were read by one of 5 dermatopathologists and represent cases from 3 MMS surgeons and 5 MMS fellows. Agreement or disagreement was recorded.

RESULTS

Of the 1156 slides, 32 slides (2.8%) were disparate. Aside from differences regarding intraepidermal neoplasia, the concordance rate was 99.7%.

LIMITATIONS

This study represents data collected at a single institution in the United States alone.

CONCLUSION

There was statistically significant concordance between MMS surgeons and dermatopathologists in frozen section interpretation in the MMS setting. Discordance was primarily related to the interpretation of in situ malignancy.

A pilot feasibility study of a rare skin tumor database

BACKGROUND

In the United States melanoma is the only individually reported skin cancer. There are no large state or national registries for nonmelanoma skin cancer. Nevertheless, rare, that is, nonmelanoma, nonepithelial, tumors can also be locally aggressive and metastasize.

OBJECTIVES

This study's purpose was to demonstrate that Mohs surgeons can share data to create a rare skin tumor database. This database may serve as a model for a nationwide database.

MATERIALS AND METHODS

We retrospectively reviewed the surgery logs of five Mohs surgery practices in the Houston, Texas, area for rare-nonmelanoma, nonepithelial-skin cancers. A total of 42,279 biopsy-proven cancers of the skin treated with Mohs micrographic surgery were reviewed. Tumor data including type, prevalence, year of treatment, and the treating Mohs surgeon(s) were compiled and analyzed.

RESULTS

Forty-three types of rare tumors were identified. A total of 317 rare tumors were treated. No practice saw more than 28 rare tumor types. Atypical fibroxanthoma was the rare tumor most often treated.

CONCLUSIONS

Colleagues can cooperate to create a database of rare tumors removed by Mohs micrographic surgery. A range of tumors greater than that seen in any single practice is now available for study. This should provide the impetus for a nationwide rare skin tumor database.

Meta-analysis of published data on incompletely excised basal cell carcinomas of the ear and nose with introduction of an innovative treatment strategy

BACKGROUND

Auricular/nasal basal cell carcinomas (BCC) often require more surgical procedures than BCCs at other sites.

METHODS

A meta-analysis of incompletely excised BCCs compares those on the ear and nose to other sites. The combination of photodynamic diagnostics (PDD) and fresh-frozen sections is compared to multi-stage excisions; in each case, the tissue margins were histographically controlled.

RESULTS

The relative risk of an incomplete excision of a BCC on the ear/nose is 2.5 fold higher than on the rest of the body. The combination of PDD and micrographic surgery with fresh-frozen sections reduces the length of stay by 42.86 % from median 14 d to 8 d as well as increasing the revenue per patient per day by 41.9 % from 320.61 euro to 454.95 euro with nearly a comparable rate of recurrences after one year.

CONCLUSIONS

PDD in combination with single-stage surgery is an equivalent therapy with few side effects and conforming to guidelines. It takes into account both quality assurance and patient preferences. Multicenter, randomized trials seem desirable.

The Australian Mohs database: short-term recipient-site complications in full-thickness skin grafts

BACKGROUND

There are only a few reports on the outcome with full-thickness skin grafts (FTSG) in defect reconstruction after Mohs micrographic surgery (MMS).

OBJECTIVES

The objective was to evaluate the complications with FTSG in patients treated with MMS for cutaneous tumors.

METHODS

This study is based on a prospective data collection of all patients in Australia treated with MMS and monitored by the Skin and Cancer Foundation, between 1993 and 2002. Primary outcome measures were FTSG recipient-site complications (partial/complete graft failure, graft infection, acute bleeding/hematoma, graft hypertrophy, and graft contracture).

RESULTS

The study group included 2,673 patients (50.2% men) with a mean age of 64+/-14 years. Most tumors were basal call carcinoma (90.9%) and were located on the nose (63.8%), periocular area (14.8%), or auricular area (8.1%). A total of 11.7% of cases had recipient-site complications (graft hypertrophy, 42.3%; partial graft failure, 27.2%; graft contraction, 15.3%). Only 45.2% of complicated cases required treatment.

CONCLUSION

Short-term recipient-site complications occurred in less than 12% of reconstructions with FTSG. Graft hypertrophy and partial graft failure accounted for most cases of complications. The authors have indicated no significant interest with commercial supporters.

The incidence of major complications from Mohs micrographic surgery performed in office-based and hospital-based settings

BACKGROUND

There has been significant interest in the safety of office-based surgery.

OBJECTIVE

Our purpose was to compare the safety of Mohs micrographic surgery and related surgical repairs performed in office- and hospital-based settings.

METHODS

The study included 3937 consecutive patients undergoing Mohs surgery. Surgery was performed at either an outpatient office or a hospital-based setting.

RESULTS

Mohs surgery was performed on 1540 patients in the hospital and 2397 patients underwent surgery in the office. The mean patient age was 66 years, and 61% were men. Ninety-three percent of lesions were basal cell or squamous cell carcinomas, and 86% were located on the head and neck. The average tumor measured 1.1 x 1.0 cm, required 1.7 stages of Mohs surgery, and resulted in a defect measuring 2.4 x 1.8 cm. Linear closures, flaps, grafts, and second-intention healing were utilized in 69%, 14%, 6%, and 11% of defects, respectively. There were no differences in patient or tumor characteristics or the types of closures used at the two operating facilities. The only serious surgical complication was gastrointestinal hemorrhage due to naproxen prescribed postoperatively for auricular chondritis in one patient.

CONCLUSION

Mohs micrographic surgery and repair of associated defects can be safely performed in either an office- or hospital-based setting.

Treatment of basal cell carcinomas by general practitioners in Australia

BACKGROUND

Basal cell carcinomas (BCCs) are a relatively common form of skin damage in Australians, involving approximately 1 in 200 general practice encounters per year.

AIM

To determine current treatments and the associated healthcare resource costs of BCC therapy in Australia.

METHODS

A retrospective survey was undertaken relating to the treatment of patients presenting to their doctor with previously untreated BCCs. Data were collected from a sample of general practitioners who were asked to randomly select two BCC patients from their medical records and complete a questionnaire. Information about treatment types, number of doctor visits, treatment complications, and specialist referrals was extracted from the patient records.

RESULTS

One hundred and sixty-four patients were recruited into the study (59% male), who were treated for a total of 244 BCCs (average of 1.5 lesions per patient). Twenty-two per cent of patients were referred to a specialist, most being referred to a general surgeon (45%) or plastic surgeon (25%). Excision was the preferred therapy; second choices were cryosurgery or curettage and cautery. Few adverse events were recorded. The typical number of doctor visits varied from 3.2 to 7.4, with a range of total cost per patient of 146.60-496.20 AUS dollars, depending on complexity and the need for referral.

CONCLUSION

With a reported incidence in Australia of approximately 788 per 100,000 persons, BCCs are not inexpensive to treat for such a relatively common condition.

Cosmetic results of histographically controlled excision of non-melanoma skin cancer in the head and neck region

BACKGROUND

Beside the primary goal of complete eradication, the cosmetic result is an important aspect of the treatment of non-melanoma skin tumors especially in the head and neck region.

PATIENTS AND METHODS

From 1990 to 2000, we treated a total of 5,227 large basal cell carcinomas (BBC) and 1,189 squamous cell carcinomas (SCC) in the head and neck region by surgical excision in 4,239 inpatients at the Department of Dermatology, University of Tübingen. The procedure used in all patients was a conservative excision controlled by complete three dimensional histology of all margins (3D-histology) and specifically targeted follow-up surgery where required (histographic surgery). As part of the prospective tumor follow-up, we asked the treating outdoor physician one and four years later to evaluate the results of our surgical procedures.

RESULTS

Of the 5,565 follow-up questionnaires sent back, 4,868 contained answers regarding the cosmetic result. The data from both answers were pooled. In 1,972 (40,5 %) patients the cosmetic result was evaluated as "excellent", in 1,992 (40,9%) as "good", in 662 (13,6%) as "satisfactory", in 191 (3,9%) as "mediocre" and in 51 (< 1,0%) as "poor". In 697 of the responses, the physician did not comment the cosmetic results or the patient was lost for follow up.

CONCLUSION

With respect to both long term safety and cosmetic outcome, tumor surgery with 3D-histology of excisional margins has set very high quality standards in the treatment of non-melanoma skin cancer of the head and neck area.

Microcystic adnexal carcinoma: Treatment with Mohs micrographic surgery

BACKGROUND

Microcystic adnexal carcinoma (MAC) is reported to have a high rate of recurrence with standard wide local excision.

OBJECTIVE

To report a large series of patients with MAC treated with Mohs micrographic surgery (MMS).

METHODS

This prospective, multi-center case series included all patients in Australia treated with MMS for MAC, who were monitored by the Skin and Cancer Foundation between 1993 and 2002.

RESULTS

There were 44 cases; most of them (90.9%) were located in the head and neck area. In 31.8% of cases it was a recurrent tumor. In 32.5% of cases the tumor was initially misdiagnosed as basal cell carcinoma or squamous cell carcinoma. Perineural invasion was recorded in 17.5% of cases; most of them (85.7%) were previously recurrent tumors. There was only one case of recurrence (5%) out of 20 patients who completed a 5 year follow-up period after MMS.

CONCLUSION

The low 5-year recurrence rate of MAC with MMS emphasizes the importance of margin-controlled excision.

Mohs surgery for malignant eccrine neoplasms

BACKGROUND

Eccrine carcinomas (ECs) are rare tumors with potentially aggressive clinical behavior and a high recurrence rate following conventional surgical excision. With the exception of microcystic adnexal carcinoma (MAC), there have been few reports on the use of Mohs micrographic surgery (MMS) as a primary treatment for EC.

OBJECTIVE

To review the use of MMS for EC and compare treatment outcomes with those of conventional surgical excision.

METHODS

We report our use of MMS in 7 cases of EC and review the literature regarding the use of MMS for EC excluding microcystic adnexal carcinoma (MAC), which has been described elsewhere.

RESULTS

A total of 19 case reports describing MMS for non-MAS malignant eccrine neoplasms were reviewed. There were no reported recurrences over an average follow-up period of 29 months, whereas the local recurrence rate following conventional surgical excision of these neoplasms from 10-70%.

CONCLUSIONS

While the clinical experience is limited, the use of MMS appears to decrease recurrence rates when compared to conventional surgical excision. Further experience and longer follow-up intervals will be necessary to demonstrate superior efficacy and recommended surgical margins.

Residual skin cancer after preoperative biopsy: evaluation by Mohs micrographic surgery

BACKGROUND

Some patients are referred for Mohs surgery with no or minimal clinical evidence of skin cancer at the biopsy site.

OBJECTIVE

To determine the incidence of residual skin cancer at biopsy sites during Mohs micrographic surgery.

METHODS

We evaluated all patients that underwent Mohs surgery for basal cell and squamous cell carcinomata in one year. The study was carried out prospectively. Debulking was done using a no. 15 blade at the clinical borders of the tumor or biopsy site. All specimens were sectioned at the middle and cut to the periphery at 20- microm intervals.

RESULTS

Seven hundred and forty-one patients underwent operations. In 390 patients, a biopsy was performed prior to surgery. A total of 351 patients were biopsied as prestaged (chemocheck) during surgery. Ninety-nine (25%) of the preoperatively biopsied patients showed no residual tumor in the debulking specimen or the first layer. Of these 99 patients, 84 had basal cell carcinoma and 15 had superficial or in situ squamous carcinoma.

CONCLUSIONS

In this study, preoperative biopsy for diagnosis of skin cancer of the face was curative in 25% of patients, despite pathologic diagnosis of incompletely excised tumor. However, as the majority of preoperatively biopsied patients showed residual tumor, Mohs micrographic surgery is indicated in all patients with incomplete removal of skin cancer of the head and neck.

Mohs micrographic surgery referral patterns: the University of Missouri experience

BACKGROUND

Mohs micrographic surgery (MMS) provides a higher cure rate for nonmelanoma skin cancer (NMSC) than other forms of therapy. The American Academy of Dermatology has published recommended guidelines for MMS referral. However, factors other than the location, size, and type of NMSC may often affect the referral process.

OBJECTIVE

To tabulate and analyze the rates of referral of NMSC for MMS by the dermatology clinics within the University of Missouri system. Data obtained for every biopsy-proven basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) diagnosed at each of our four dermatology clinics during the 3-year period of October 1993-September 1996 were cross-referenced with our Mohs surgery clinic logbook to identify which patients had been referred for MMS.

RESULTS

During the study period, 19.2% of NMSC patients diagnosed were referred for MMS. However, there was significant disparity in referral rates among our four clinics. When the skewed data from our Veterans Administration Hospital clinic were discounted, the overall referral rate from the other clinics was found to be 30.8%.

CONCLUSION

Our finding of a 30.8% referral rate of NMSC for MMS (27. 4% for SCC and 32.9% for BCC) within our university dermatology system is similar to the rates found in previous studies by the Mayo Clinic and Brooke Army Medical Center. MMS referral patterns are affected by many factors besides whether the NMSC meets MMS criteria, including the preference of each individual referring physician, patient, and involved insurance carrier.

Mohs micrographic surgery for the treatment of difficult skin cancers

Most skin cancers can be managed effectively using standard therapeutic methods. However, specific subsets of skin cancers--including tumors that are recurrent, large, or aggressive, along with tumors located at sites of functional and cosmetic concern--provide a significant therapeutic challenge. Mohs micrographic surgery offers the greatest potential cor cure of difficult tumors, while providing for maximal preservation of healthy tissue. This paper describes the history of Mohs surgery, the technique, and the indications for its use.

How many nonmelanoma skin cancers require Mohs micrographic surgery?

BACKGROUND

Cost containment in health care is currently a subject of much debate. The rapid spread of managed care is an attempt to influence practice trends and contain costs. Although seldom directly stated, it is implied that some physicians may perform high-cost procedures when not necessarily indicated, an example being Mohs micrographic surgery (MMS).

OBJECTIVE

There are little data in the literature indicating what percentage of skin cancers treated by MMS would be appropriate. For such data to be meaningful, a model would have to exist wherein there is no financial incentive or disincentive for performing the procedure. Military medicine provides this unique environment.

METHODS

In a retrospective review, we counted the total number of basal cell carcinomas and squamous cell carcinomas diagnosed at Brooke Army Medical Center (BAMC) over a 5-year period. We then determined the number of MMS cases performed on these cancers.

RESULTS

A total of 5193 nonmelanoma skin cancers (NMSC) were diagnosed at BAMC and 1701 of these were treated by MMS. Overall, the percentage of NMSC treated by MMS was 32.7% for the 5-year period.

CONCLUSION

This information may serve as a framework for physicians and health delivery systems as they negotiate managed care contracts for the management of skin cancer.

Postoperative wound infection rates in dermatologic surgery

BACKGROUND

Multiple factors related to the nature of the surgical procedure can influence the risk of wound infection in dermatologic surgery. Despite that, wound infection rates in dermatologic surgical procedures are believed to be low.

OBJECTIVE

This study was conducted: 1) to determine wound infection rates in Mohs and excisional surgery; and 2) to investigate if factors such as lesion type, anatomic location, postoperative defect size, number of Mohs stages required to achieve a tumor-free plane, and the type of reconstructive procedure influence the rate of surgical wound infections.

RESULTS

Wound infection rate for 530 Mohs procedures and 517 excisions combined was 2.29%, falling within the predicted range for "clean" surgical procedures. In addition, Mohs procedures performed on the ear as well as large postoperative defects were found to have a higher rate of wound infections.

CONCLUSION

Dermatologic surgery can be safely performed in an outpatient setting without a significant risk of infection. Certain anatomic sites, such as the ear, as well as size of postoperative defect, are important factors in predicting the risk of postoperative wound infection.

Basal cell carcinoma treated with Mohs surgery. A comparison of 54 younger patients with 1050 older patients

The average age of patients with basal cell carcinoma (BCC) is over 60 years, and fewer than 5% of patients with this tumor are under 30 years of age. A comparison of younger (15 to 30 years) and older (56 to 70 years) patients with BCC was conducted to identify specific tumor or host features associated with BCC occurring early in life. According to data collected over an 11-year period, 54 of 2728 (2%) BCCs occurred "de novo" in younger patients. In contrast to the predominantly male older group, most of the younger patients were female. An increased use of tanning booths and hair-dyes was associated with the younger patients (P less than .001). More overall sunlight exposure and actinic keratoses were associated with the older patients (P less than .01). Defect and lesion sizes were smaller (P less than .01) in the younger group. Location, histology, and clinical morphology did not differ appreciably between the two groups. De novo BCCs in younger and older patients are similar, although some differences do exist.

The use of Mohs micrographic surgery for determination of residual tumor in incompletely excised basal cell carcinoma

BACKGROUND

The presence of tumor involving surgical margins after excision of basal cell carcinoma (BCC) presents a therapeutic dilemma. Some authors advocate a conservative policy whereas others recommend immediate reexcision.

OBJECTIVE

Our purpose was to evaluate residual tumor utilizing Mohs micrographic surgery (MMS) of those BCCs with margin involvement after primary excision.

METHODS

We retrospectively reviewed 77 patients with 78 tumors who underwent MMS because of margin involvement after primary excision of BCC to detect the presence or absence of residual tumor.

RESULTS

Residual tumor was found in 55% of the cases as defined by the need for two or more stages of MMS to achieve a tumor-free plane.

CONCLUSION

We suggest reexcision of all BCCs that are found to have marginal involvement after primary excision because of the large percentage of cases found to have residual tumor.

Current issues in the performance of Mohs micrographic surgery

Recently, a survey was sent to all members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology concerning their performance of Mohs micrographic surgery. Responses to numerous questions regarding the daily practice of this technique revealed that many useful modifications have evolved over the years that serve to enhance the efficacy and the efficiency of the original Mohs surgical procedure. The results of this survey are presented and discussed.