Mohs Surgeons Dominate Cutaneous Reconstructions in Cosmetically and Functionally Sensitive Sites: Medicare Trends From 2013 to 2019.

BACKGROUND: Although dermatologists perform more cutaneous reconstructions than any other specialists for the Medicare population, the perception of dermatologists as surgeons may not be as fully recognized. Mohs surgeons are trained in complex reconstructions of cosmetically and functionally sensitive (CFS) sites, although the proportion they account for is unknown. OBJECTIVE: To quantify the proportion of cutaneous reconstructions in CFS sites performed by Mohs surgeons compared with other specialists, and to identify trends from 2013 to 2019. METHODS: A cross-sectional analysis was performed using the Medicare Public Use Files for 2013 to 2019. Data were stratified by physician specialty, with dermatologists further subdivided into Mohs surgeons and non-Mohs dermatologists. RESULTS: Mohs surgeons performed 75.3% of all reconstructions in 2019, a significant increase from 2013 ( p < .0001). Mohs surgeons dominated nearly every type of CFS cutaneous reconstruction, with significant increases in proportion ( p < .0001) from 2013 to 2019 for every category except interpolation flaps. Complex repairs were the most commonly performed cutaneous reconstruction type. CONCLUSION: Mohs surgeons perform far more cutaneous reconstructive surgeries in CFS sites than any other specialty for the Medicare population, with significant increases in their lead over the study period.

Sebaceous Carcinoma of the Eyelid: Proposed Nomenclature for Multifocal and Multicentric Disease.

PURPOSE: To review clinical presentations of periocular sebaceous carcinoma (SC) and introduce standardized nomenclature for multicentric and multifocal disease presentation. METHODS: A comprehensive PubMed/Medline search was conducted to identify all articles reporting periocular multicentric or multifocal SC presentations. The authors also highlight an additional case of SC presenting with 2 clinically distinct tumor foci and complete secondary invasion of the lacrimal gland. RESULTS: This review summarizes clinical presentations of periocular SC exhibiting discrete foci of microinvasion reported in the literature. Discrete microinvasion was associated with high rates of misdiagnosis (80%), simultaneous involvement of both upper and lower eyelids (80%), pagetoid spread (80%), multinodular growth (33%), local tumor spread (60%), previous eyelid manipulation (40%), and local recurrence (40%). Eyelid multifocality with clinically discrete nodules (42%) was associated with more advanced disease including orbital extension and regional invasion (80%). CONCLUSIONS: Despite previous reported associations with poorer outcomes, there is no consensus in the definition or nomenclature for discrete microinvasive or clinical disease presentations in periocular SC. The authors recommend defining multicentric disease as discrete foci of microinvasive tumor with basement membrane disruption and multifocal disease as discrete clinically evident nodules involving both the upper and lower eyelids. Differentiating between discrete microinvasive (multicentric) and clinically nodular (multifocal) disease may improve risk stratification to most accurately identify patients who require more aggressive management and surveillance.

Varicella Zoster Aseptic Meningitis Presenting as an Atypical Mucocutaneous Eruption Involving All Three Divisions of the Trigeminal Nerve.

Herpes zoster involving all three divisions of the trigeminal nerve is extremely rare and may pose a diagnostic challenge, especially in young and immunocompetent patients. We present a unique case of herpes zoster involving all three divisions of the trigeminal nerve and illustrate that this uncommon eruption can be a presenting sign of varicella zoster aseptic meningitis. This case emphasizes the importance of fundamental morphology recognition, particularly its ability to aid in clinical diagnosis and its potential to decrease patient morbidity and mortality by expediting the initiation of appropriate treatment.

Behavior of Cutaneous Adnexal Malignancies: a Single Institution Experience.

Cutaneous adnexal malignancies are biologically and pathologically diverse, and associated with a range of clinical outcomes. Given their rarity, the prognosis and optimal treatment of these neoplasms remains unclear. A single institution database from a tertiary care cancer center of patients treated for malignant cutaneous adnexal tumors was retrospectively analyzed. Clinicopathologic variables and outcome measures were analyzed in patients undergoing wide excision with or without sentinel node biopsy. 103 patients were analyzed; the majority of tumors were of eccrine sweat gland derivation (n = 69, 70%), and these exhibited a higher rate of nodal involvement and overall worse outcome. Sixteen patients (16%) demonstrated nodal metastasis, which included 10 (10%) with nodal disease at presentation and 6 who developed nodal metastasis during followup. 20 patients underwent sentinel node biopsy, and 2 (10%) had a positive sentinel node. 62% of nodal metastases occurred in patients with porocarcinoma. Seven patients died of disease (7%) with a median time from diagnosis to death of 48 months (range, 10-174). After a median follow up of 44.7 months, age > 70 years and larger tumor size were significantly associated with worse overall survival. Adnexal malignancies are rare tumors, and there is a paucity of information to guide the clinician in determining optimum surgical and medical treatment. Tumors of eccrine derivation, especially porocarcinomas, have a high risk of nodal involvement and may be considered for sentinel node biopsy.

Cyclosporine for corticosteroid-refractory acute generalized exanthematous pustulosis due to hydroxychloroquine.

Acute generalized exanthematous pustulosis most often manifests 1-2 days following exposure to a characteristic drug, such as aminopenicillins, calcium-channel blockers, or terbinafine. Recovery is usually rapid following drug withdrawal, and systemic corticosteroids represent the historic treatment of choice. Herein, acute generalized exanthematous pustulosis incited by hydroxychloroquine is briefly reviewed: a prolonged latency and recalcitrance to corticosteroids are noteworthy. In this unique context, cyclosporine tapered over several months is an effective therapeutic option.

Treatment of Head and Neck Melanoma In Situ With Staged Contoured Marginal Excisions.

Staged marginal evaluation of melanoma in situ (MIS) is performed to avoid reconstruction on positive margins. Contoured marginal excision (CME) is an excision of a 2-mm wide strip of normal-appearing skin taken approximately 5 mm from the visible tumor periphery. If positive, a new CME is excised; the tumor is resected once negative margins are confirmed. The purpose of this study is to report our experience using this technique for the treatment of head/neck MIS. Clinicopathological data were abstracted for all patients who underwent staged CME followed by central tumor resection for head/neck MIS; patients with invasive melanoma were excluded. Statistical analyses included χ test and t test. Overall, 127 patients with MIS were identified. Fifty-six percent were men; the average age was 68 years. The median number of CME procedures per patient was 1 (range, 1-4). Twenty-three percent of patients required more than 1 CME procedure to achieve negative margins. Local recurrence occurred in 3 of 127 patients after a median follow-up of 5 months. Patients requiring multiple CME procedures were more likely to experience local recurrence (P < 0.001). In conclusion, this technique is an effective method to avoid reconstruction on positive MIS margins with high local disease control rates.

Robotic-Assisted Transperitoneal Pelvic Lymphadenectomy for Metastatic Melanoma: Early Outcomes Compared with Open Pelvic Lymphadenectomy.

BACKGROUND: In the absence of iliac or obturator nodal involvement, the role of pelvic lymphadenectomy (PLND) for melanoma is controversial, but for select patients, long-term survival can be achieved with the combination of superficial inguinal (inguinofemoral) and PLND. Open PLND (oPLND) is often limited in visual exposure and can be associated with considerable postoperative pain. Robotic PLND (rPLND) is a minimally invasive technique that provides excellent visualization of the iliac and obturator nodes. Outcomes comparing the open and robotic techniques have not been reported previously for patients with melanoma. STUDY DESIGN: We reviewed our experience with rPLND for melanoma and compared clinical and pathologic results with oPLND. We evaluated operative times, nodal yield, and short-term oncologic outcomes. RESULTS: Thirteen rPLND (2013 to 2015) (15 attempted, 87% success rate) and 25 oPLND (2010 to 2015) consecutive cases were completed. Pelvic lymphadenectomy was combined with an open inguinofemoral dissection in 8 of 13 (62%) robotic and 17 of 25 (68%) open cases. Median length of stay was shorter in the rPLND group, with 1.0 vs 3.5 days for pelvic-only cases (p < 0.001) and 2.5 vs 4.0 days (p < 0.001) for combined ilioinguinal cases. Median operative time (227 vs 230 minutes; p = 0.96) and nodal yield (11 vs 10 nodes; p = 0.53) were not different between rPLND and oPLND. CONCLUSIONS: Robotic PLND offers a safe, effective, minimally invasive approach to resect the pelvic lymph nodes in patients with melanoma, with no significant difference in nodal yield or operative times, but a shorter length of stay compared with oPLND.