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.

Integrating the 40-Gene Expression Profile (40-GEP) Test Improves Metastatic Risk-Stratification Within Clinically Relevant Subgroups of High-Risk Cutaneous Squamous Cell Carcinoma (cSCC) Patients

INTRODUCTION

The validated 40-gene expression profile (40-GEP) test independently stratifies risk of regional or distant metastasis for cutaneous squamous cell carcinoma (cSCC) tumors with high-risk clinicopathologic features. This study evaluated the stratification of risk by the 40-GEP test in a large cohort of tumors with one or more high-risk factors and in clinically relevant subgroups, including tumors within National Comprehensive Cancer Network (NCCN) high- and very-high-risk groups, lower-stage BWH T1 and T2a tumors, and patients > 65 years old.

METHODS

This multicenter (n = 58) performance study of the 40-GEP included 897 patients. Kaplan-Meier analyses were performed to assess risk stratification profiles for 40-GEP Class 1 (low), Class 2A (higher) and Class 2B (highest) risk groups, while nested Cox regression models were used to compare risk prediction of clinicopathologic risk classification systems versus risk classification systems in combination with 40-GEP.

RESULTS

Patients classified as 40-GEP Class 1, Class 2A, or Class 2B had significantly different metastatic risk profiles (p < 0.0001). Integrating 40-GEP results into models with individual clinicopathologic risk factors or risk classification systems (Brigham and Women's Hospital, American Joint Committee on Cancer Staging Manual, 8th Edition) and NCCN demonstrated significant improvement in accuracy for prediction of metastatic events (ANOVA for model deviance, p < 0.0001 for all models).

CONCLUSION

The 40-GEP test demonstrates accurate, independent, clinically actionable stratification of metastatic risk and improves predictive accuracy when integrated into risk classification systems. The improved accuracy of risk assessment when including tumor biology via the 40-GEP test ensures more risk-aligned, personalized patient management decisions.

Clinical Characteristics of Marginally Recurrent Melanoma After Primary Excision: A Multisite Retrospective Analysis of 140 Cases Referred for Mohs Surgery

BACKGROUND

Marginally recurrent melanoma (MRM) manifests immediately adjacent to or within a scar and arises from incomplete tumor clearance after primary treatment. Little is known about the progression and treatment of MRM after all forms of excision.

OBJECTIVE

To determine the invasive growth potential, tumor-stage progression, and outcomes of those with MRM.

METHODS

One hundred forty patients with MRM were collected from 5 practice databases. All patients were treated with Mohs micrographic surgery. They were evaluated for Breslow depth and tumor stage change from the time of primary treatment and recurrent treatment.

RESULTS

Of 101 cases initially treated as melanoma in situ, 13 (12.9%) marginally recurred with invasive disease at the time of Mohs micrographic surgery. The median thickness of these recurrent melanomas was 0.58 mm. Of 39 cases initially treated as invasive melanoma, 10 (25.6%) marginally recurred with a greater Breslow depth. The median increase in thickness from initial treatment to recurrence was 1.31 mm.

CONCLUSION

Marginally recurrent melanoma retains its invasive growth potential. This can lead to Breslow depth increase, tumor-stage progression, and a worse prognosis on recurrence. Obtaining tumor-free margins is critical in initial and recurrence treatments.

The Controversy and Value of Mohs Micrographic Surgery for Melanoma and Melanoma in Situ on the Trunk and Extremities

BACKGROUND

The use of Mohs surgery for melanoma on the trunk and extremities is not supported in the guidelines of dermatology, but is widely used in the real world.

OBJECTIVE

The purpose of this article is to expose the value of Mohs surgery for melanoma on the trunk and extremities for consideration of updating the guidelines.

MATERIALS AND METHODS

This was a retrospective review of a prospectively maintained database 7 to identify patients whose melanomas would likely have recurred using standard surgical margins. A prediction model was used to evaluate the value of Mohs surgery.

RESULTS

The model predicted that 2,847 (2%) patients with melanoma on the trunk and extremities would likely recur each year with standard surgical margins even after re-excision when positive margins were identified, compared with 0.1% after Mohs surgery. This likely would result in the upstaging of 27% of melanoma in situ patients and 13% of patients with invasive melanoma. The upstaging would also result in a decrease in melanoma-specific survival and the death of 1% of patients with true local recurrences of melanoma.

CONCLUSION

Mohs surgery has value for melanoma on the trunk and extremities by minimizing local recurrence and death from disease progression.

Outcomes of invasive melanoma of the head and neck treated with Mohs micrographic surgery - A multicenter study

BACKGROUND

There are no randomized controlled trials to guide surgical margins for invasive head and neck (H&N) melanoma using conventional excision. Mohs micrographic surgery (MMS) has shown improved local recurrence rates and survival for invasive H&N melanomas.

OBJECTIVE

Determine local recurrence (LR), nodal recurrence, and distant recurrence rates, and disease specific survival for invasive melanoma of the H&N treated with MMS.

METHODS

A retrospective multicenter study of 785 cases of invasive H&N melanoma treated with MMS using frozen sections with melanoma antigen recognized by T-cells 1 immunohistochemical staining was performed to evaluate long-term outcomes over 12-years.

RESULTS

785 melanomas (thickness: 0.3 mm-8.5 mm) were treated with MMS. LR, nodal recurrence, and distant recurrence rates were 0.51% (4/785), 1.0% (8/785), and 1.1% (9/785) respectively. For T1, T2, T3, and T4 tumors LR was 0.16% (1/636), 1.18% (1/85), 2.22% (1/45), and 5.26% (1/19), respectively. Five and 10-year disease specific survival were 96.8% (95% CI 95.0% to 98.5%) and 93.4% (95% CI 88.5% to 98.3%).

LIMITATIONS

A nonrandomized retrospective study.

CONCLUSION

MMS achieves significant improvements in LR compared to a meta-analysis of historical cohorts of patients treated with conventional excision. MMS should be considered an important surgical option for invasive H&N melanoma.

Clinical outcomes of high-risk cutaneous squamous cell carcinomas treated with Mohs surgery alone: An analysis of local recurrence, regional nodal metastases, progression-free survival, and disease-specific death

BACKGROUND

The incidence of cutaneous squamous cell carcinoma (cSCC) continues to increase, and it is now predicted that the number of deaths from cSCC will surpass that of melanoma within the next 5 years. Although most cSCCs are successfully treated, there exists an important subset of high-risk tumors that have the highest propensity for local recurrence (LR), nodal metastasis (NM), and disease-specific death (DSD).

OBJECTIVE

We investigated the clinical outcomes of high-risk cSCCs treated with Mohs surgery (MS) alone, analyzing LR, NM, distant metastasis, and DSD. In addition, we analyzed progression-free survival and DSD in patients who underwent salvage head/neck dissection for regional NMs.

METHODS

Retrospective review of all high-risk cSCC treated in our clinics between January 1, 2000, and January 1, 2020, with follow-up through April 1, 2020.

SETTING

Two university-affiliated, private-practice MS referral centers.

RESULTS

In total, 581 high-risk primary cSCCs were identified in 527 patients, of which follow-up data were obtained for 579 tumors. The 5-year disease-specific survival was 95.7%, with a mean survival time of 18.6 years. The 5-year LR-free survival was 96.9%, the regional NM-free survival was 93.8%, and the distant metastasis-free survival was 97.3%. The 5- and 10-year progression-free survival rates from metastatic disease were 92.6 and 90.0%, respectively. In patients who experienced regional NMs and underwent salvage head and neck dissection with or without radiation, the 2-year disease-specific survival was 90.5%.

CONCLUSION

Our cohort, which is the largest high-risk cSCC cohort treated with MS to date, experienced lower rates of LR, NM, and DSD than those reported with historical reference controls using both the Brigham and Women's Hospital and American Joint Committee on Cancer, Eighth Edition, staging systems. We demonstrated that MS confers a disease-specific survival advantage over historical wide local excision for high-risk tumors. Moreover, by improving local tumor control, MS appears to reduce the frequency of regional metastatic disease and may confer a survival advantage even for patients who develop regional metastases.

Correlation of basal cell carcinoma subtype with histologically confirmed subclinical extension during Mohs micrographic surgery: A prospective multicenter study

BACKGROUND

Traditionally "aggressive" histologic subtypes (HSs) of basal cell carcinoma (BCC) are more likely to quantitatively exhibit subclinical extension (SCE), requiring more stages during Mohs micrographic surgery (MMS) and, therefore, larger margins upon excision. However, the tendency for SCE has never been compared between HSs of BCC in a prospective manner.

OBJECTIVE

To prospectively correlate the HS of BCC with the likelihood of SCE as defined by the number of MMS stages required to clear the tumor.

METHODS

In a prospective, multicenter study involving 17 Mohs surgeons in 16 different practices across the United States, data regarding 1686 cases of BCC undergoing MMS were collected. Patient demographics, tumor characteristics, number of MMS stages required for tumor clearance, and specific BCC subtypes noted on both index biopsy and the final MMS stage were recorded.

RESULTS

Analysis of the average number of MMS stages for each HS required to clear tumor revealed 2 distinct degrees of SCE (P < .0001): high (higher than average) risk of SCE (1.9 stages, 1.0 SD) and low (lower than average) risk of SCE (1.6 stages, 0.9 SD). Subtypes of BCC within the high category were morpheaform (2.1), infiltrative (1.9), metatypical (1.9), mixed (1.8), and superficial (1.8). The low category included BCC subtypes of basosquamous (1.6), micronodular (1.6), nodular (1.6), and unspecified (1.5). Three hundred twenty-four cases (22.0%) manifested HS drift or a change in subtype from index biopsy to the final MMS stage. Superficial BCC was the only subtype that showed an increase in prevalence from index biopsy to the final MMS stage (from 16.0% to 25.8%; P < .0002).

LIMITATIONS

HSs from index biopsy may not be representative of all HSs present, resulting in sampling bias.

CONCLUSION

SCE of superficial BCC was as likely as SCE of BCC subtypes that are considered "aggressive" and are deemed "appropriate" for MMS by the appropriate use criteria. Our study also found that when HS drift occurs, the most likely subtype to extend subclinically is superficial BCC.

Development and validation of a nomogram incorporating gene expression profiling and clinical factors for accurate prediction of metastasis in patients with cutaneous melanoma following Mohs micrographic surgery

BACKGROUND

There is a need to improve prognostic accuracy for patients with cutaneous melanoma. A 31-gene expression profile (31-GEP) test uses the molecular biology of primary tumors to identify individual patient metastatic risk.

OBJECTIVE

Develop a nomogram incorporating 31-GEP with relevant clinical factors to improve prognostic accuracy.

METHODS

In an IRB-approved study, 1124 patients from 9 Mohs micrographic surgery centers were prospectively enrolled, treated with Mohs micrographic surgery, and underwent 31-GEP testing. Data from 684 of those patients with at least 1-year follow-up or a metastatic event were included in nomogram development to predict metastatic risk.

RESULTS

Logistic regression modeling of 31-GEP results and T stage provided the simplest nomogram with the lowest Bayesian information criteria score. Validation in an archival cohort (n = 901) demonstrated a significant linear correlation between observed and nomogram-predicted risk of metastasis. The resulting nomogram more accurately predicts the risk for cutaneous melanoma metastasis than T stage or 31-GEP alone.

LIMITATIONS

The patient population is representative of Mohs micrographic surgery centers. Sentinel lymph node biopsy was not performed for most patients and could not be used in the nomogram.

CONCLUSIONS

Integration of 31-GEP and T stage can gain clinically useful prognostic information from data obtained noninvasively.

Gene expression profiling for metastatic risk in head and neck cutaneous squamous cell carcinoma

OBJECTIVE

Over 50% of newly diagnosed cutaneous squamous cell carcinoma (cSCC) lesions occur in the head and neck (cSCC-HN), and metastasis to nodal basins in this region further complicates surgical and adjuvant treatment. The current study addressed whether the 40-gene expression profile (40-GEP) test can predict metastatic risk in cSCC-HN with improved accuracy and provide independent prognostic value to complement current risk assessment methods.

STUDY DESIGN

Multicenter, retrospective cohort study.

METHODS

Formalin-fixed paraffin-embedded primary tumor tissue and associated clinical data from patients with cSCC-HN (n = 278) were collected from 33 independent centers. Samples were analyzed via the 40-GEP test. Cases were staged per American Joint Committee on Cancer, Eighth Edition (AJCC8) and Brigham and Women's Hospital (BWH) criteria after comprehensive medical record and pathology report review. Metastasis-free survival (MFS) rates were determined, and risk factors were analyzed via Cox regression.

RESULTS

The 40-GEP test classified the cohort into low (Class 1, n = 126; 45.3%), moderate (Class 2A, n = 134; 48.2%), and high (Class 2B, n = 18; 6.5%) metastatic risk at 3 years postdiagnosis. Regional/distant metastasis occurred in 54 patients (19.4%). MFS rates were 92.1% (Class 1), 76.1% (Class 2A), and 44.4% (Class 2B; p < .0001). Multivariate analysis of 40-GEP results with AJCC8 or BWH tumor stage, or clinicopathologic risk factors, demonstrated independent prognostic value of the 40-GEP test (p < .03). Accuracy of predicting metastatic risk was also improved using 40-GEP classification (p < .02).

CONCLUSIONS

Improved metastatic risk stratification through the 40-GEP test could complement cSCC-HN risk assessment for better-informed decision-making for treatment and surveillance and ultimately improve patient outcomes.

LEVEL OF EVIDENCE

3.

Enhanced metastatic risk assessment in cutaneous squamous cell carcinoma with the 40-gene expression profile test

Aim: To clinically validate the 40-gene expression profile (40-GEP) test for cutaneous squamous cell carcinoma patients and evaluate coupling the test with individual clinicopathologic risk factor-based assessment methods. Patients & methods: In a 33-site study, primary tumors with known patient outcomes were assessed under clinical testing conditions (n = 420). The 40-GEP results were integrated with clinicopathologic risk factors. Kaplan-Meier and Cox regression analyses were performed for metastasis. Results: The 40-GEP test demonstrated significant prognostic value. Risk classification was improved via integration of 40-GEP results with clinicopathologic risk factor-based assessment, with metastasis rates near the general cutaneous squamous cell carcinoma population for Class 1 and ≥50% for Class 2B. Conclusion: Combining molecular profiling with clinicopathologic risk factor assessment enhances stratification of cutaneous squamous cell carcinoma patients and may inform decision-making for risk-appropriate management strategies.

Cost effectiveness of intermediate-risk squamous cell carcinoma treated with Mohs micrographic surgery compared with wide local excision

BACKGROUND

The efficacy of Mohs micrographic surgery (MMS) in treating cutaneous squamous cell carcinoma has been demonstrated. The cost effectiveness of MMS has rarely been studied to support the perceived higher cost.

OBJECTIVE

Perform a cost-effectiveness analysis to determine whether MMS is cost effective over wide local excision (WLE) for Brigham and Women's Hospital tumor stage T2a cutaneous squamous cell carcinoma over a 5-year period.

METHODS

A Markov model with a 5-year time horizon was created using variables from published data. Costs in United States dollars and quality-adjusted life-years (QALY) were calculated.

RESULTS

MMS was $333.83 less expensive ($4365.57 [95% CI, $3664.68-$6901.66] vs $4699.41 [95% CI, $3782.94-$10,019.31]) than WLE. MMS gained 2.22 weeks of perfect health (3.776 QALY [95% CI, 3.774-3.777] for MMS and 3.733 QALY [95% CI, 3.728-3.777]) over 5 years. The incremental cost-effectiveness ratio was -$7,822.19. MMS had a 99.9% probability of being more cost effective than WLE. Annualized savings of choosing MMS over WLE would be $200 million and over 25,000 QALY. MMS could cost 3.1 times its current rate and remain cost effective.

LIMITATIONS

Relied on data from external retrospective sources.

CONCLUSION

MMS is less costly and more effective than WLE and should be strongly considered for stage T2a cSCC, given improvements in costs and QALY.

Mohs surgery for early-stage Merkel cell carcinoma (MCC) achieves local control better than wide local excision ± radiation therapy with no increase in MCC-specific death

BACKGROUND

Merkel cell carcinoma (MCC) of the skin is most commonly treated with wide local excision (WLE) with or without adjuvant radiation therapy (RT). Mohs micrographic surgery (MMS) as monotherapy may offer an alternative treatment modality. The purpose of this study is to describe outcomes of patients with primary Stage I/II MCC treated with MMS alone and no RT.

METHODS

A retrospectively collected sample of 56 MCCs treated with MMS was studied over an 18-year period. Tumor and treatment characteristics were described, and follow-up was assessed.

RESULTS

A total of 56 primary Stage I/II MCCs in 53 patients were treated with MMS as monotherapy from April 2001 through July 2019. Patients were followed for an average of 4.6 years (median 2.7 years, range 0.8 to 16.9 years), of which 19 (33.9%) had follow-up of 5 years or more. There were no local recurrences due to inadequate excision. The 5-year Kaplan-Meier MCC-specific survival for AJCC8 Stage I and AJCC8 Stage IIA were 91.2% and 68.6%, respectively.

CONCLUSION

In comparison to historical controls, Mohs surgery offers a survival that is at least as good as WLE +/- RT, with the added benefits of no need for adjuvant RT or the need for further surgery for treatment of local recurrence.

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.

Long-term outcomes of Mohs micrographic surgery for invasive melanoma of the trunk and proximal portion of the extremities

BACKGROUND

Microscopic evaluation of the entire surgical margin during excision of cutaneous malignancies results in the highest rates of complete excision and lowest rates of true local scar recurrence. Few studies demonstrate the outcomes of Mohs micrographic surgery specifically for invasive melanoma of the trunk and proximal portion of the extremities.

OBJECTIVE

To evaluate the long-term efficacy of Mohs micrographic surgery for invasive melanoma of the trunk and proximal portion of the extremities, including true local scar recurrence rate, distant recurrence-free survival, and disease-specific survival.

METHODS

Prospectively collected study of 1416 cases of invasive melanoma of the trunk and proximal portion of the extremities was performed to evaluate long-term outcomes.

RESULTS

True local scar recurrences occurred in our cohort at a rate of 0.14% (2/1416), after a mean follow-up period of 75 months and were not associated with tumor depth. The rate of satellite/in-transit recurrences and the disease-specific survival stratified by tumor thickness were superior to historical control values.

LIMITATIONS

We used a nonrandomized, single institution, retrospective design.

CONCLUSIONS

Mohs micrographic surgery of primary cutaneous invasive melanoma on the trunk and proximal portion of the extremities resulted in local control of 99.86% of tumors and an overall disease-specific death rate superior to that of wide local excision.

Validation of a 40-gene expression profile test to predict metastatic risk in localized high-risk cutaneous squamous cell carcinoma

BACKGROUND

Current staging systems for cutaneous squamous cell carcinoma (cSCC) have limited positive predictive value for identifying patients who will experience metastasis.

OBJECTIVE

To develop and validate a gene expression profile (GEP) test for predicting risk for metastasis in localized, high-risk cSCC with the goal of improving risk-directed patient management.

METHODS

Archival formalin-fixed paraffin-embedded primary cSCC tissue and clinicopathologic data (n = 586) were collected from 23 independent centers in a prospectively designed study. A GEP signature was developed using a discovery cohort (n = 202) and validated in a separate, nonoverlapping, independent cohort (n = 324).

RESULTS

A prognostic 40-GEP test was developed and validated, stratifying patients with high-risk cSCC into classes based on metastasis risk: class 1 (low risk), class 2A (high risk), and class 2B (highest risk). For the validation cohort, 3-year metastasis-free survival rates were 91.4%, 80.6%, and 44.0%, respectively. A positive predictive value of 60% was achieved for the highest-risk group (class 2B), an improvement over staging systems, and negative predictive value, sensitivity, and specificity were comparable to staging systems.

LIMITATIONS

Potential understaging of cases could affect metastasis rate accuracy.

CONCLUSION

The 40-GEP test is an independent predictor of metastatic risk that can complement current staging systems for patients with high-risk cSCC.

Comparison of surgical margins for lentigo maligna versus melanoma in situ

BACKGROUND

Multiple studies have shown a 5-mm surgical margin to be inadequate for excision of melanoma in situ. Some have suggested that a wider margin is needed only for the lentigo maligna subtype.

OBJECTIVE

To compare subclinical extension of lentigo maligna with that of melanoma in situ. The secondary objective was to investigate the effect of other factors on extent of subclinical extension.

METHODS

A prospectively collected series of noninvasive melanomas was studied. Original pathology reports were used to identify lentigo maligna and compare data for that subtype with data for the remaining melanomas in situ.

RESULTS

A total of 1506 lentigo maligna cases and 829 melanomas in situ were included. To obtain a 97% clearance rate, both lentigo maligna and melanoma in situ required a 12-mm margin on the head and neck and a 9-mm margin on the trunk and extremities. Only 79% of lentigo maligna and 83% of melanoma in situ were successfully excised with a 6-mm margin (P = .12). Local recurrence was identified in 0.26% (5 facial, 1 scalp, and 1 acral), with a mean follow-up time of 5.7 years.

LIMITATIONS

Margins less than 6 mm were not studied. The use of lentigo maligna diagnosis was not used by all dermatopathologists consistently. The degree of surrounding photodamage was not assessed.

CONCLUSION

Subclinical extension of lentigo maligna and melanoma in situ are similar. Standard surgical excision of all melanoma in situ subtypes, including lentigo maligna, should include at least 9 mm of normal-appearing skin, which is similar to the amount recommended for early invasive melanoma. Lesions on the head and neck or those with a diameter greater than 1 cm may require even wider margins and are best treated with Mohs micrographic surgery. The perception that lentigo maligna has wider subclinical extension may be related to its frequent location on the head and neck, where photodamage can camouflage the clinical border.

Extramammary Paget Disease

Extramammary Paget disease is an intraepidermal adenocarcinoma, most often limited to the epidermis, with typical cases affecting genital skin. When limited to the epidermis, primary extramammary Paget disease is not life-threatening, but invasive disease may portend a poor prognosis. Surgical excision remains the mainstay of treatment of extramammary Paget disease, and Mohs micrographic surgery is the surgical treatment of choice. Alternative treatments include topical 5-fluorouracil and imiquimod, photodynamic therapy, laser vaporization, chemotherapy, and radiation therapy but data are limited. Implementation of cytokeratin 7 immunostain has increased the ability to detect extramammary Paget disease on frozen section.

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.

The use of Mohs micrographic surgery (MMS) for melanoma in situ (MIS) of the trunk and proximal extremities

BACKGROUND

Evaluation of the entire surgical margin results in high rates of complete excision, low local recurrence rates, and maximal tissue conservation. Although well recognized for melanoma of the head and neck, few studies have focused exclusively on the trunk and proximal extremities.

OBJECTIVE

We sought to evaluate the efficacy of Mohs micrographic surgery for melanoma in situ (MIS) of the trunk and proximal extremities, and determine adequate excision margins for MIS when total margin evaluation is not used.

METHODS

Long-term outcomes in 882 cases of MIS treated with Mohs micrographic surgery were analyzed and compared with historical controls. Rates of complete excision were determined for increasing surgical margin intervals.

RESULTS

One local recurrence occurred in our cohort (0.1%). Only 83% of MIS were excised with a 6-mm margin. Margins of 9 mm were needed to excise 97% of MIS, statistically equivalent to thin melanomas.

LIMITATIONS

We used a nonrandomized, single-institution, retrospective design.

CONCLUSION

Mohs micrographic surgery may cure the 17% of MIS that exceed traditional excision margins of 5 mm and is a valuable option for these patients. Surgical margins of at least 0.9 cm should be considered for MIS of the trunk and extremities when total margin evaluation is not used.

A prospective evaluation of the clinical, histologic, and therapeutic variables associated with incidental perineural invasion in cutaneous squamous cell carcinoma

BACKGROUND

The prognosis and management of incidental perineural invasion (PNI) in patients with cutaneous squamous cell carcinoma (CSCC) has not been well defined.

OBJECTIVE

We sought to investigate the clinical, histologic, and treatment characteristics associated with incidental PNI, histologic PNI extending beyond the tumor bulk, in patients with CSCC.

METHODS

We conducted a multicenter prospective analysis of patients with CSCC undergoing Mohs micrographic surgery.

RESULTS

The incidence of PNI was 4.6% in 753 CSCC cases. PNI was significantly associated with tumors of the head and neck (P = .039), larger tumor diameter (P < .001), presence of clinically palpable lymphadenopathy (P = .012), and recurrent (P < .001) and painful (P < .001) tumors. Further, PNI was significantly associated with poor tumor differentiation (P < .001), greater tumor thickness (P < .001), a greater number of Mohs stages (P < .001), and larger estimated maximum Mohs margin (P < .001) required to clear the tumor.

LIMITATIONS

The low numbers of patients demonstrating incidental PNI limits this study.

CONCLUSIONS

The association of incidental PNI with clinicopathological indicators of poor prognosis suggests that incidental PNI may serve as a marker to improve the precision in the prognostic assessment of patients with CSCC.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Cost analysis: Mohs micrographic surgery

BACKGROUND

With the continuing increase in the incidence of skin cancer, delivery of cost-efficient skin cancer treatment is a top priority.

OBJECTIVE

To compare costs associated with removal of skin cancers using Mohs micrographic surgery (MMS) with that using standard surgical excision (SSE) with frozen or permanent margin control in the office or an ambulatory surgery center (ASC).

METHODS AND MATERIALS

Costs for actual MMS and calculated costs for all SSE were recorded. The expense of treatment of incomplete excisions with subsequent reexcision and reconstruction and MMS on recurrent tumors were added to the final estimate.

RESULTS

Four hundred six tumors were included in the study. An average tumor was cleared in 1.6 stages. MMS was the least expensive surgical procedure evaluated, at $805 per tumor. SSE with permanent margins ($1,026) was more expensive than MMS but less expensive than SSE with frozen margins ($1,200) and ASC-SSE with frozen margins ($2,507). Adjusted for inflation, the cost of MMS, inclusive of initial examination, biopsy, and 5-year follow-up, in 2009 ($1,376) was lower than in 1998 ($1,635).

CONCLUSIONS

This study confirms MMS as the cornerstone of cost-effective treatment, regardless of place of service or type of margin control pathology.

Surgical margins for melanoma in situ

BACKGROUND

A controversy in the treatment of melanoma in situ is the required width of surgical margin. The currently accepted 5-mm margin is based on a 1992 consensus opinion, despite data since then showing this is inadequate.

OBJECTIVE

We sought to develop guidelines for predetermined surgical margins for excision of melanoma in situ.

METHODS

A prospectively collected series of 1072 patients with 1120 melanoma in situs was studied. All lesions were excised by Mohs micrographic surgery with frozen-section examination of the margin. The minimal surgical margin was 6 mm, and the total margin was calculated by adding an additional 3 mm for each subsequent stage required. The minimum surgical margin that would successfully remove 97% of all tumors was calculated. Local recurrence was also tabulated.

RESULTS

In all, 86% of melanoma in situs were successfully excised with a 6-mm margin; 9 mm removed 98.9% of melanoma in situs. The superiority of 9-mm to 6-mm margins was significant (P < .001). Gender, location, and diameter did not affect results. Recurrence rate for this set of patients treated with Mohs micrographic surgery was 0.3% (n = 3).

LIMITATIONS

Margins less than 6 mm were not studied. This is a referral center for melanoma in situ and 10% of tumors were previously treated before presentation to our clinic.

CONCLUSION

The frequently recommended 5-mm margin for melanoma is inadequate. Standard surgical excision of melanoma in situ should include 9 mm of normal-appearing skin, similar to that recommended for early invasive melanoma.

The invasive growth potential of residual melanoma and melanoma in situ

BACKGROUND

Residual melanoma and melanoma in situ (MIS), also referred to as marginally recurrent melanoma, continues to be a concern for all dermatologic surgeons. Little is known about the potential of these tumors to recur with a deeper invasive histology measured according to Breslow depth.

OBJECTIVE

To identify the clinical features and histologic, invasive potential of marginally recurrent melanoma and MIS. By having a more accurate understanding of marginally recurrent melanoma, we can better appreciate the consequence of inadequate excision and recognize the importance of improving initial treatments.

MATERIALS AND METHODS

An analysis was performed of 108 marginally recurrent melanoma and MIS cases based on prospective data collection. For each case, clinical data, including a comparison of Breslow depth from the time of primary treatment and salvage surgery for marginally recurrent tumor, were tabulated.

RESULTS

Of the 84 lesions initially treated as MIS, 19 (22.6%) recurred marginally with a histologically invasive component and a mean Breslow depth of 0.94 mm. Of the 24 patients diagnosed with invasive melanoma, eight (33.3%) had a deeper Breslow depth at the time of clinical recurrence than at the time of primary treatment. The change in Breslow depth for these eight cases was 1.53 to 2.83 mm.

CONCLUSIONS

Our findings demonstrate the invasive growth potential of MIS and invasive melanoma inadequately excised at the time of primary treatment. This finding illustrates the consequences of marginal recurrence and stresses the importance of accurate and complete removal of melanoma at the time of initial diagnosis and treatment.

Split-thickness skin graft in nonhelical ear reconstruction

Defects of the nonhelical ear after skin cancer extirpation can be challenging. When other reconstructive options are not optimal, split-thickness grafting is an easy and effective technique for successful aesthetic and functional restoration of the ear.

Melanocytes in long-standing sun-exposed skin: quantitative analysis using the MART-1 immunostain

OBJECTIVE

To help distinguish early melanoma from normal sun-damaged skin by quantifying the density, confluence, and depth of follicular penetration of melanocytes in long-standing sun-exposed skin of the face and neck.

DESIGN

Case series.

SETTING

Referral center.

PATIENTS

Random selection of 149 patients undergoing Mohs surgery for basal cell and squamous cell carcinomas of the face and neck.

INTERVENTION

Frozen-section slides were made from long-standing sun-exposed normal skin and stained with MART-1 (melanoma antigen recognized by T cells 1 staining) immunostain.

MAIN OUTCOME MEASURES

The number, confluence, and depth of penetration of melanocytes along the follicular epithelium were quantified per high-power field (original magnification x 400, equivalent to 0.5 mm of skin). Confluence was categorized by the number of adjacent melanocytes (none, 0-1; mild, 2; moderate, 3-6; and severe, >6).

RESULTS

The mean number of melanocytes per high-power field was 15.6 (range, 6-29). Confluence was severe in 1.0% of the specimens, moderate in 34.0%, mild in 54.0%, and absent in 11.0%. Focal areas of increased melanocyte density occurred in 24.2% of the specimens; in these areas, the mean number of melanocytes per high-power field was 20.3 (range, 7-36) and the confluence of melanocytes was severe in 13.0%, moderate in 50.0%, and mild in 37.0%. The mean depth of follicular epithelium penetration by melanocytes was 0.38 mm. Pagetoid spread and nesting of melanocytes were not seen. Nonspecific scattered MART-1-staining dermal cells were in half of the slides.

CONCLUSIONS

Melanocytes in long-standing sun-exposed skin have an increased density and a confluence that is often moderate (3-6 adjacent melanocytes), but they do not exhibit pagetoid spread or nesting. Nonspecific MART-1-staining dermal cells should not be interpreted as invasive melanoma.

Cutaneous head and neck melanoma treated with Mohs micrographic surgery

BACKGROUND

Previous studies show that Mohs micrographic surgery is a viable treatment option for cutaneous melanoma. The head and neck region represents an anatomic location of historically high recurrence/metastasis rates and poor survival rates.

OBJECTIVE

Our purpose was to determine the safety and efficacy of Mohs micrographic surgery for the treatment of primary cutaneous melanoma of the head and neck.

METHODS

A consecutive sample of 625 patients referred for treatment of primary cutaneous melanoma of the head and neck comprised the study group. Mean follow-up for the group was 58.0 months. All melanomas were excised using Mohs micrographic surgery and surgical margin examination was performed using frozen section tissue in all cases. After stratification using updated American Joint Commission for Cancer (AJCC) Breslow thickness criteria, the Kaplan-Meier method was used to calculate 5-year local recurrence rates, metastasis rates, and disease specific survival rates. Tumors were then re-stratified by earlier Breslow thickness criteria for comparison to historical controls for local recurrence rates, metastasis rates, and disease-specific survival rates. Recommendations for predetermined excision margins were proposed and were based on the surgical margin widths that achieved complete melanoma removal in 97% of the cases in this study.

RESULTS

Mohs micrographic surgery for the treatment of head and neck melanoma achieved five-year local recurrence rates, metastasis rates, and disease specific survival rates comparable to or better than historical controls after Breslow thickness stratification. The size of the surgical margin required for complete excision was significantly related to tumor thickness but not tumor size or specific location.

CONCLUSION

Mohs micrographic surgery is an effective treatment modality for primary cutaneous melanoma, and may contribute to favorable outcomes especially on the head and neck where extensive sub-clinical spread is relatively common.

Paramedian forehead flap reconstruction for nasal defects

BACKGROUND

The paramedian forehead flap is the ultimate reconstructive method for repair of extensive nasal defects. Changes in technique have resulted in the evolution of the modern-day forehead flap, which is a streamlined, efficient, reliable flap that can be counted on to provide superior function and cosmesis in the reconstruction of large nasal defects.

OBJECTIVE

Consistent success in the execution of a forehead flap hinges on a careful stepwise approach to the defect, the patient, and the surgical technique. Characterization of these steps was undertaken to assist the surgeon in achieving consistent post- operative results.

METHODS

The process of executing a paramedian forehead flap beginning with preoperative assessment through the intraoperative procedure and culminating in the postoperative care is elucidated and discussed.

RESULTS

Through thoughtful planning and correct execution of technique, very large nasal defects are reconstructed, with excellent functional and esthetic results. Specific examples illustrate the range of approaches that can be used to address a variety of nasal tissue loss.

CONCLUSION

With careful attention to the reconstruction of all components of a nasal defect, a forehead flap can restore virtually any large nasal defect with excellent functional and cosmetic results. The skill sets that help optimize the process of nasal reconstruction are important to acquire. With careful planning and surgical finesse, forehead flaps can often result in nearly imperceptible restoration of the nose.

Auricular reconstruction

Reconstruction strategies for the ear should address the major aesthetic goals of maintaining the helical curvature and the symmetric frontal profile. When the auditory canal is involved, maintaining its patency is a major functional goal. The anatomic location of the defect, by virtue of its topographic features and adjacent donor pools, will dictate the appropriate reconstructive option. Familiarity with these anatomically-specific options will enable the surgeon to more simply and effectively reconstruct the ear.

Extramammary Paget's disease: Surgical treatment with Mohs micrographic surgery

BACKGROUND

Extramammary Paget's disease (EMPD) is an uncommon tumor that has a high rate of recurrence after conventional surgical treatments.

OBJECTIVE

Our purpose was to establish the efficacy of Mohs micrographic surgery (MMS) in the treatment of EMPD, and to make treatment recommendations with regard to surgical margins. We also attempted to summarize the published recurrence rates of EMPD after standard surgical management.

METHODS

In a retrospective chart review, pertinent demographic data, tumor data, treatment characteristics, and follow-up data were tabulated. A search of the literature for recurrence rates after MMS and non-MMS surgical treatment modalities was performed.

RESULTS

The recurrence rate after treatment with MMS was 16% for primary EMPD and 50% for recurrent EMPD. The 5-year tumor-free rates (Kaplan-Meier analysis) were 80% for primary tumors and 56% for recurrent tumors. Using MMS, the salvage rate (and, hence, overall cure rate) was 100%. Margins of 5 cm were required to clear 97% of the tumors. The recurrence rate after non-MMS (from the literature) is 33% to 60%.

CONCLUSION

MMS is effective, and superior to standard surgical management in the treatment of EMPD. We recommend a 5-cm margin of normal skin if MMS cannot be offered.

Immunostaining melanoma frozen sections: the 1-hour protocol

BACKGROUND

There is significant debate over the use of frozen section processing in Mohs micrographic surgery (MMS) for melanoma. Opponents argue that individual melanocytes are too subtle to view consistently on frozen sections. On the other hand, proponents state that (1) melanocytes are visible on well-prepared frozen sections and (2) MMS using frozen sections for evaluation of melanoma surgical margins achieves comparable recurrence rates when compared with MMS using paraffin-embedded, permanent sections.

OBJECTIVE

To introduce a new immunohistochemical (IHC) staining protocol that consistently produces melanoma frozen section slides in 1 hour that are easily evaluated during MMS.

METHODS

We adapted a polymer-based IHC staining protocol to use with MMS frozen sections for the evaluation of melanoma surgical margins.

RESULTS

When used with antibody directed against MART-1 for frozen section evaluation of melanoma, the section staining is reproducible and specific for melanocytes.

CONCLUSIONS

In contrast to current IHC protocols that are time consuming (2 to 2.5 hours), we present a new frozen section protocol that takes approximately 1 hour to perform. This technique benefits patients, histotechnicians, and surgeons.

Local control of primary Merkel cell carcinoma: review of 45 cases treated with Mohs micrographic surgery with and without adjuvant radiation

BACKGROUND

Optimal treatment of primary Merkel cell carcinoma (MCC) is unknown. High local recurrence rates after excision alone compel some physicians to advocate postoperative radiation therapy to improve local control.

OBJECTIVE

We wondered whether marginal recurrence and survival rates differed between patients with primary MCC treated with Mohs surgery alone and those treated with Mohs surgery and adjuvant postoperative radiation.

METHODS

A collaborative retrospective study was performed; the study group consisted of 45 patients with stage I MCC who were histologically and clinically free of disease after Mohs excision. Twenty patients subsequently received elective postoperative radiation to the primary site, and 25 patients had no adjuvant radiation therapy.

RESULTS

One marginal recurrence (4%) and 3 in-transit metastases were observed in the Mohs surgery alone group, whereas none were observed in the Mohs surgery and radiation group. The proportion of patients with these events was not significantly different between treatment groups. Overall survival, relapse-free survival, and disease-free survival were not significantly different between treatment groups.

CONCLUSION

Adjuvant radiation appears unessential to secure local control of primary MCC lesions completely excised with Mohs micrographic surgery. Adjuvant radiation is recommended for patients unable to have complete excision or if complete histologic margin control is unavailable and should be considered for patients with large or recurrent tumors.

Atrophic dermatofibroma: a case report and review of the literature

BACKGROUND

Atrophic dermatofibroma is an uncommon variant of dermatofibroma. It lacks the classic clinical features of a dermatofibroma and is often misdiagnosed.

OBJECTIVE

To describe the clinical and histologic features of atrophic dermatofibroma.

METHODS

Case report and review of the literature.

RESULTS

A 45-year-old white woman was found to have a 7 mm x 5 mm atrophic, depressed lesion in the right axilla. A clinical diagnosis of anetoderma was made and the lesion was excised with minimal margins. Histopathologic examination revealed findings consistent with dermatofibroma. However, focal CD34 staining and involvement of superficial subcutaneous tissue raised concern regarding an early dermatofibrosarcoma protuberans developing in a dermatofibroma. The patient underwent Mohs micrographic surgery (MMS) for definitive treatment. The final diagnosis is thought to be atrophic dermatofibroma. Reported cases in the English language literature are reviewed and the clinical and histopathologic findings are described.

CONCLUSION

Atrophic dermatofibroma is a well-described, yet uncommon, variant of dermatofibroma. It is often clinically misdiagnosed, and histopathologic evaluation can be misleading. The clinician and pathologist should consider this diagnosis in the evaluation of atrophic, depressed lesions.