Intraoperative Frozen Section Analysis for the Excision of Nonmelanoma Skin Cancer: A Single-Center Experience.

Surgical resection of nonmelanoma skin cancer (NMSC) may be performed via Mohs micrographic surgery (MMS) or standard surgical excision with complete margin analysis. Whereas MMS may necessitate delayed reconstruction surgery, intraoperative frozen section analysis (IFSA) may be used to ensure clear surgical margins before proceeding with reconstruction. To achieve curative resection while optimizing aesthetic outcomes, surgeons may use surgical excision guided by IFSA to forego extensive or delayed reconstruction. Patients undergoing wide local excision for NMSC using IFSA from October 2008 to November 2016 were evaluated. Analysis included IFSA versus permanent section outcomes, the number of required excisions, and the recurrence rate. Our analysis contained 145 patients involving 162 lesions. IFSA demonstrated that 73.4 per cent of margins were negative after one excision and 26.5 per cent were re-excised until achieving negative margins. Analysis revealed one false-positive case (0.62%) and four false-negative cases (2.47%). Nine patients had local recurrence (5.56%). Frozen section sensitivity was 88.99 per cent and specificity 99.20 per cent. The positive predictive value was 96.97 per cent, and negative predictive value was 96.90 per cent. Mean follow-up time was 39 months. Both resection and recurrence data of excised NMSC lesions at our institution suggest that surgical excision using IFSA is a safe and effective alternative to MMS.

Minimizing bone gaps when using custom pediatric cranial implants is associated with implant success.

OBJECT: Occasionally after a craniotomy, the bone flap is discarded (as in the case of osteomyelitis) or is resorbed (especially after trauma), and an artificial implant must be inserted in a delayed fashion. Polyetheretherketone (PEEK) implants and hard-tissue replacement patient-matched implants (HTR-PMI) are both commonly used in such cases. This study sought to compare the failure rate of these 2 implants and identify risk factors of artificial implant failure in pediatric patients. METHODS: This was a retrospective cohort study examining all pediatric patients who received PEEK or HTR-PMI cranioplasty implants from 2000 to 2013 at a single institution. The authors examined the following variables: age, sex, race, mechanism, surgeon, posttraumatic hydrocephalus, time to cranioplasty, bone gap width, and implant type. The primary outcome of interest was implant failure, defined as subsequent removal and replacement of the implant. These variables were analyzed in a bivariate statistical fashion and in a multivariate logistic regression model for the significant variables. RESULTS: The authors found that 78.3% (54/69) of implants were successful. The mean patient age was 8.2 years, and a majority of patients were male (73%, 50/69); the mean follow-up for the cohort was 33.3 months. The success rate of the 41 HTR-PMI implants was 78.1%, and the success rate of the 28 PEEK implants was 78.6% (p = 0.96). Implants with a bone gap of > 6 mm were successful in 33.3% of cases, whereas implants with a gap of < 6 mm had a success rate of 82.5% (p = 0.02). In a multivariate model with custom-type implants, previous failed custom cranial implants, time elapsed from previous cranioplasty attempt, and bone gap size, the only independent risk factor for implant failure was a bone gap > 6 mm (odds ratio 8.3, 95% confidence interval 1.2-55.9). CONCLUSIONS: PEEK and HTR-PMI implants appear to be equally successful when custom implantation is required. A bone gap of > 6 mm with a custom implant in children results in significantly higher artificial implant failure.

Surgical Excision of Non-Melanoma Skin Cancer in an Elderly Veteran's Affairs Population.

BACKGROUND: Non-melanoma skin cancer (NMSC) is the most common malignancy in the United States. Recommended treatment for NMSC remains surgical excision following a positive biopsy. Evidence of complete spontaneous regression of residual NMSC exists in the case of small lesions macroscopically removed by shave biopsy, but with a positive microscopic margin. The present study investigates the rate at which residual tumor is present at subsequent excisional biopsy, with the aim to assess if recommendation to forgo surgical excision can be made. METHODS: A total of 233 shave biopsies of basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) were performed during a 5-year period. All specimens included in the study were less than 2 cm in diameter, were macroscopically removed by shave biopsy, and had a positive initial microscopic margin. RESULTS: On subsequent surgical excisional biopsy, 42% of BCC specimens were negative for residual tumor, 38% had residual tumor, but the tumor was completely contained in the excised specimen, and 20% of the specimens had positive margin residual tumor. For SCC specimens, 73% were negative for residual tumor, 21% had residual tumor, but the tumor was completely contained in the excised specimen, and 6% of the specimens had positive margin residual tumor. CONCLUSIONS: Although reduction of residual tumor at reexcision is noted with both BCC and even more so with SCC, the rate at which this occurs is not sufficient that a general recommendation to forgo surgical excision can be made.

Overnight activities of medical students on call: is it really educational?

BACKGROUND: To validate self-report of activities and to assess time allocation of medical students taking in-house call during their third-year surgery clerkship. METHODS: Informed consent was obtained from students who agreed to participate while rotating on the third-year surgery clerkship. Students were randomized to 1 of 2 groups, either the self-report group or the shadow group. All students kept a log of their activities during weekdays. Students randomized to the self-report group kept a log of their activities on nights (6 pm to 7 am weeknights) and weekends (7 am to 7 am Saturday and Sunday) when they were assigned to in-house call. Students randomized to the shadow group kept a log of their activities and also were shadowed while on call by a research assistant (observer) who recorded their activities. All students categorized each activity as patient-care activities related to educational objectives (educational), patient-care activities unrelated to educational objectives (noneducational), and personal care (personal). To validate self-report, student and observer logs were compared. Percentages of time engaged in educational versus other activities were compared between the shadowed and nonshadowed groups and among weekdays (WD), weeknights (WN), weekend days (WED), and weekend nights (WEN). RESULTS: A total of 34 students (16 shadow, 18 self-report) agreed to participate. Five (15%) students, all in the self-report group, did not turn in their logs. Data were available for the remaining 29 students for 138 shifts (WD, 44; WN, 46; WED, 24; WEN, 24). Observer and self-report were correlated highly for educational and personal activities, but not for noneducational activities. On WD, students averaged 76.1% of their time in educational activities, compared with 46.7%, 63.3%, and 50.2% of their time while on WN, WED, and WEN, respectively (P <.05 for WD vs. all others). Students spent between 9% and 14% of their time in noneducational activities, and between 9% and 49% of their time in personal activities during call shifts. CONCLUSIONS: This study validates student self-report of activities while on surgery call. Students spend significantly more time engaged in educational activities during weekdays than any call shifts (weeknights, weekend days, weekend nights). This information can be used for curricular planning.