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.

Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study.

Importance: It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. Objective: To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. Design, Setting, and Participants: This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. Exposures: Mohs surgery for nonmelanoma skin cancer. Main Outcomes and Measures: Reason for treatment selection. Results: Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance: This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Sebaceous carcinoma: evidence-based clinical practice guidelines.

Sebaceous carcinoma usually occurs in adults older than 60 years, on the eyelid, head and neck, and trunk. In this Review, we present clinical care recommendations for sebaceous carcinoma, which were developed as a result of an expert panel evaluation of the findings of a systematic review. Key conclusions were drawn and recommendations made for diagnosis, first-line treatment, radiotherapy, and post-treatment care. For diagnosis, we concluded that deep biopsy is often required; furthermore, differential diagnoses that mimic the condition can be excluded with special histological stains. For treatment, the recommended first-line therapy is surgical removal, followed by margin assessment of the peripheral and deep tissue edges; conjunctival mapping biopsies can facilitate surgical planning. Radiotherapy can be considered for cases with nerve or lymph node involvement, and as the primary treatment in patients who are ineligible for surgery. Post-treatment clinical examination should occur every 6 months for at least 3 years. No specific systemic therapies for advanced disease can be recommended, but targeted therapies and immunotherapies are being developed.

Finger Pad Squamous Cell Carcinoma: Report of Squamous Cell Carcinoma of the Distal Palmar Digit and Review of Associated Risk Factors, Mimickers, and Treatment of Squamous Cell Carcinoma of Ventral Hand Digits.

BACKGROUND: Squamous cell carcinoma of the palmar digits is rare. PURPOSE: The authors describe a man with squamous cell carcinoma of the pulp of his left fourth finger, and review the risk factors that may be associated with squamous cell carcinoma development on the ventral digits of the hand. the authors also summarize the clinical differential diagnoses and treatment of squamous cell carcinoma at this location. METHODS: the authors retrospectively reviewed the literature using PubMed and searched for the following terms: squamous cell carcinoma, squamous cell carcinoma in situ, finger, thumb, palmar, and ventral. Papers were critically evaluated and their cited references reviewed. RESULTS: Skin biopsy established the patient's diagnosis. His tumor was excised using Mohs technique with microscopic examination of the tissue margins; viral changes were noted in the keratinocytes. Local or systemic carcinogen exposure, congenital conditions, suppressed host immunity, coincidental bacterial or viral infection, local radiation exposure, and trauma to the affected digit are risk factors associated with the development of palmar digit squamous cell carcinoma. The clinical differential diagnoses of squamous cell carcinoma on the ventral digits include chronic dermatitis and keratoderma, epidermoid cyst, infection, melanoma, and verrucae. Successful treatment involves removal of the tumor; this is usually accomplished by surgical excision of the tumor, which may include some or all of the affected digit. CONCLUSIONS: The diagnosis of squamous cell carcinoma of the ventral hand digits is often not initially suspected by the patient and/or the clinician. However, despite the occasional delay in diagnosis or subsequent large tumor size, the prognosis for these patients is usually favorable following adequate treatment of the cancer.

Recurrence Rate of Melanoma in Situ when Treated with Serial Disk Staged Excision: A Case Series.

BACKGROUND: Cutaneous melanoma is one of the fastest rising cancer diagnoses in recent years. Melanoma in situ (MIS) constitutes a large proportion of all diagnosed melanomas. While surgical excision is considered the standard of therapy, the literature is not clear on which surgical technique minimizes local recurrence. A common technique is serial staged excision (SSE), in which a series of mapped excisions are made according to histopathological examination of tissue. Previously published recurrence rates for SSE ranges from 0-12%, over a range of 4.7-97 months of mean follow-up. OBJECTIVE: To investigate the recurrence rate of MIS when excised using a serial disk staged excision technique with tissue marked at 12 O'clock for mapping, rush permanent processing and histologic examination, 3-suture tagging for subsequent stages, and "breadloafing" microscopic analysis. Additionally, to determine the relationship between initial lesion size and subsequent stages of excision required for clearance, and final surgical margin. METHODS: Single-institution retrospective chart review of 29 biopsy confirmed MIS lesions treated with our variant of SSE. Statistical analysis via independent t-tests. RESULTS: No recurrences were observed with mean follow-up of 31.5 months (SD 13.9), over range of 12-58 months. Mean surgical margin of 13.1 mm (SD 5.9). A trend towards larger surgical margin was seen with increasing pre-operative lesion size. CONCLUSION: This method of SSE for treatment of MIS is comparable in efficacy to other SSE techniques, and may offer physicians a relatively simple, efficacious, and accessible alternative to wide local excision and Mohs micrographic surgery.

Squamous cell carcinoma with aggressive subclinical extension: 5-year retrospective review of diagnostic predictors.

BACKGROUND: Squamous cell carcinoma with aggressive subclinical extension (SCC-ASE) is a tumor whose extensive spread becomes revealed during surgery or pathologic review, particularly during Mohs micrographic surgery. Limited clinical awareness of these lesions may result in unanticipated longer surgical times and larger postoperative defects. SCC-ASE-associated clinical risk factors are not well studied. OBJECTIVE: We sought to evaluate the incidence of and risk factors associated with SCC-ASE. METHODS: We conducted a retrospective analysis of SCC treated with Mohs micrographic surgery between 2007 and 2012 at a single academic surgical center. SCC-ASE was defined as a lesion requiring at least 3 Mohs stages with a final surgical margin of ≥1 cm. RESULTS: Of 954 cases studied, 31% were SCC-ASE. In multivariable analysis, sex (P = .001), history of previous nonmelanoma skin cancer (P < .001), Fitzpatrick skin types II and III (P = .004 and <.001, respectively), immunosuppression related to solid organ transplant (P < .001), and cigarette use (P < .001) were significant predictors of SCC-ASE. LIMITATIONS: Single academic center selection bias, not-controlled for sun exposure differences, no information on medication regimens of solid organ transplant patients, and a small sample size are all limitations of our study. CONCLUSION: Easily attainable demographic factors, especially immunosuppressed status and cigarette use, can help predict the occurrence of SCC-ASE and thereby optimize surgical planning and patient preparedness.

Single treatment of non-melanoma skin cancers using a pulsed-dye laser with stacked pulses.

BACKGROUND AND OBJECTIVE: Non-melanoma skin cancers are the most common cause of cancer worldwide. Within this grouping, the most common skin cancer is basal cell carcinoma (BCC) followed by squamous cell carcinoma (SCC). Recent evidence has shown that BCCs can be cleared by a pulsed-dye laser after multiple treatments using a single pass setting. Given the necessity for multiple treatments in the prior studies, we sought to determine whether tumor clearance could instead be achieved using a single treatment of the pulsed-dye laser in a stacked pulse setting. STUDY DESIGN/MATERIALS AND METHODS: Twenty patients with 23 biopsy-proven BCCs and SCCIS that measured 0.4-3 cm in size and located on the trunk and extremities were recruited for this study. The lesions were randomized into three study arms: a control group (no treatment), first treatment group (S1), and second treatment group (S2). The S1 group was treated using a 595 nM pulsed-dye laser (PDL) at pulse energy of 15 J/cm(2), 3-millisecond pulse length, with no dynamic cooling, using a 7-mm spot size with 10% overlap of pulses and two passes. The S2 group was treated using the same 595 nM PDL at 7.5 J/cm(2), 3-millisecond pulse length, with no dynamic cooling, using a 10-mm spot size with 10% overlap of pulses and double stacked pulses. All the treated lesions were treated with a 4 mm margin of clinically normal skin. The lesions were subsequently surgically excised and examined by histopathology. RESULTS: There was no significant difference in the dimensions of the tumors between the three study arms, with a mean area of 94 mm(2) [SEM ± 15.2] for the control group, 88 mm(2) [SEM ± 12.1] for the S1 treatment group, and 105 mm(2) [SEM ± 23.6] for the S2 treatment group. In the control group, there were two out seven lesions with no residual tumors, representing a background tumor clearance rate of approximately 28%. The S1 treatment group had two out of eight lesions with no residual lesion representing a clearance rate of 25%, similar to the background clearance rate. The S2 treatment group had a clearance rate of five out seven lesions, representing a clearance rate of 71%. The two lesions with residual tumors were noted to be beyond the central treatment zone by histopathology and if excluded, results in a clearance rate of 100%. By the Fisher's exact test with a Bonferroni correction, there is a trend towards significance between the S2 treatment group and the control group with a P-value of 0.028. CONCLUSIONS: The results of our pilot study suggest that BCCs and SCCIS can be cleared in a single treatment using a pulsed-laser in a stacked pulse setting. However, given the small sample size of this pilot study, further larger scale studies will be needed to determine statistical significance and long-term recurrence rate and to further validate these findings.

Onion extract gel versus petrolatum emollient on new surgical scars: prospective double-blinded study.

BACKGROUND: Cutaneous scars resulting from surgical procedures can be erythematous, hypertrophic, pruritic, painful, or cosmetically unacceptable. An onion extract-based topical gel (Mederma, Merz Pharmaceuticals, Greensboro, NC, USA) has been marketed as a product to improve scar appearance and texture. However, few data are available to substantiate these claims. OBJECTIVE: To compare the efficacy between the onion extract gel and a petrolatum-based emollient (Aquaphor, Beiersdorf, Inc., Wilton, CT, USA) in improving the appearance and symptoms of new surgical scars. METHODS: Twenty-four patients with new surgical wounds of at least 4 cm in length were enrolled in the study. Using a randomized, double-blinded, split-scar study design, each scar was divided into two equal portions, and each half was assigned treatment with either onion extract gel or petrolatum ointment at the time of suture removal. Each product was applied three times daily for 8 weeks, and patients were evaluated at 2, 8, and 12 weeks following initiation of treatment. A follow-up telephone interview was conducted at least 11 months postoperatively. RESULTS: Scar halves were evaluated by blinded investigators for overall cosmetic appearance, erythema, and hypertrophy. Patients also independently rated side-specific erythema, pruritus, burning, and pain. Using the paired t-test and the Wilcoxon signed rank test, we found no statistically significant difference (p < .1) between the two treatment groups in any of the outcome variables studied. CONCLUSION: Petrolatum-based topical agents constitute standard therapy in the management of postoperative wounds. In this side-by-side, randomized, double-blinded, split-scar study, the onion extract gel did not improve scar cosmesis or symptomatology when compared with a petrolatum-based ointment.

Presurgical curettage appropriately reduces the number of Mohs stages by better delineating the subclinical extensions of tumor margins.

BACKGROUND: Whether presurgical curettage (PC), light curettage performed before Mohs surgery to delineate tumor margin, is appropriate or causes unnecessary removal of normal tissue has not been well established. OBJECTIVE: We aim to determine histologically whether PC appropriately increases the size of the stage I specimen or causes unnecessary removal of healthy tissue. METHODS: Before a surgical margin guided by PC was taken, a hypothetical margin determined by visual and tactile assessment alone (no curettage [NC]) was marked outside the clinically defined tumor. Histologic analysis at the NC and the PC margins revealed whether the increase in the stage I specimen as a result of PC was appropriate. RESULTS: PC appropriately increased the stage I specimen in 21 cases and unnecessarily removed normal tissue in only 1 case. The estimation of tumor margins with PC was 15 times more accurate than with NC (p value = .0012). CONCLUSION: For basal cell and squamous cell carcinomas at least 4 mm in diameter, light curettage performed prior to Mohs surgery could better delineate subclinical extensions of the tumor margin and appropriately increase the size of the stage I specimen.

Genital leiomyoma: surgical excision for both diagnosis and treatment of a unilateral leiomyoma of the male nipple.

We describe a rare case of unilateral leiomyoma of the nipple in a man presenting with pruritus of the nipple for 3 months. A conservative surgical excision is performed for diagnosis. Histologic examination and immunostaining confirmed the diagnosis of leiomyoma. The leiomyoma is completely excised, and the patient denies pruritus after surgery. Conservative surgical excision of a persistently hard and pruritic nipple can be effectively used as both diagnostic measure and treatment modality.

Use of ex vivo confocal scanning laser microscopy during Mohs surgery for nonmelanoma skin cancers.

BACKGROUND: Ex vivo confocal scanning laser microscopy offers rapid optical reflectance imaging of excised tissue without conventional frozen histopathology that can potentially expedite Mohs surgery. OBJECTIVE: The objective was to determine the feasibility of using ex vivo confocal scanning laser microscopy during Mohs surgery for detecting residual basal cell carcinoma and squamous cell carcinoma. METHODS: One-hundred fifteen Stage I Mohs surgery excisions (92 basal cell carcinoma, 23 squamous cell carcinoma) were imaged with acetowhitening and confocal scanning laser microscopy and compared to conventional Mohs frozen histologic sections for normal and tumor features. RESULTS: Large aggregates of residual tumor such as nodular basal cell carcinoma were easily detected by ex vivo confocal scanning laser microscopy, whereas smaller tumor foci were not consistently identified. Confocal morphology of tumor subtypes is described. CONCLUSION: Ex vivo confocal scanning laser microscopy can potentially expedite Mohs surgery in rapidly detecting large nodular basal cell carcinomas without conventional frozen histopathology. Further improvements in instrumentation and image quality are necessary to allow broader application and acceptance of this novel technology in Mohs surgery.

A modified running subcuticular suturing technique for the closure of defects after Mohs micrographic surgery.

BACKGROUND: The running subcuticular suturing technique is useful for the closure of surgical defects with minimal tension. OBJECTIVE: To determine the safety and efficacy of a modified running subcuticular suturing technique for the closure of facial wounds produced by Mohs micrographic surgery. METHODS: Five patients between the ages of 58 and 92 years, each with one Mohs defect on the face, were studied. One half of each defect was repaired with simple interrupted sutures, and the other half was repaired using the modified running subcuticular technique. RESULTS: There were no major differences in cosmetic outcome of the surgical sites at suture removal and at 1-week and 3-month follow-up examinations. No surgical complications occurred in any of the patients studied. CONCLUSION: We demonstrate that the modified running subcuticular suturing technique may be a safe and effective alternative for the primary, layered closure of defects from Mohs micrographic surgery.

Photocontact allergy to diallyl disulfide.

Although phototoxic reactions to plants are common, photoallergic contact dermatitis to plants and plant products rarely occurs. Our objective was to review the importance of including diallyl disulfide in the evaluation of patients with suspected photosensitivity. Phototests for ultraviolet B, ultraviolet A, and visible light as well as patch tests and photopatch tests for 49 allergens from the New York University Skin and Cancer Unit Photopatch Test Series were performed. Three patients had positive photopatch-test results to diallyl disulfide, which is the allergen in garlic. The authors conclude that although photocontact allergy to diallyl disulfide is rare, this allergen should be included in photopatch-test series.