Industry Payments Comparison Between Female and Male Mohs Surgeons From 2015 to 2021.

BACKGROUND: There are limited data on female Mohs surgeon industry relationships. OBJECTIVE: To evaluate industry payment activity between female and male Mohs surgeons. MATERIALS AND METHODS: A retrospective review of the U.S. Centers for Medicare and Medicaid Services open payments data was performed between 2015 and 2021 for Mohs surgeons in the United States. Gender, academic affiliation, practice region, annual total payment, cumulative payment, and industry payment type was collected. RESULTS: Male Mohs surgeons received higher mean total payments than female Mohs surgeons ( p = .04), which persisted when data were stratified based on industry payment type and practice region. Both genders had similar median total payments ( p = .4). Females in academic practice received higher mean total payments than those in private practice. Females experienced a significant lower mean total payment compared with males in the South ( p = .03). CONCLUSION: High total payments received by male Mohs surgeons skewed the data, which is supported by a significant mean total payment difference despite a similar median total payment distribution. Female Mohs surgeons receiving the top payments may address this mean payment difference. Females seem to have higher payments if they practice in the Northeast and are in academics. Further studies are needed to evaluate this payment gap.

Systematic Review of the Role of Mohs Micrographic Surgery in the Management of Early-Stage Melanoma of the Head and Neck.

BACKGROUND: The role of Mohs micrographic surgery (MMS) in the management of melanoma of the head and neck (HNM) has been controversial. The authors systematically reviewed the local recurrence rate of melanoma in situ (MIS) and T1a melanomas using MMS compared with conventional wide local excision (WLE) and staged excision (SE). OBJECTIVE: To systematically review the local recurrence rate of early-stage melanomas of the HNM treated with MMS versus WLE or SE. METHODS AND MATERIALS: A search of English medical literature was conducted through the common databases until November 26, 2019. Using PRISMA guidelines for the treatment of MIS and T1a melanoma with MMS, WLE, or SE, our search yielded a total of 32 articles. RESULTS: Mohs micrographic surgery has a lower local recurrence rate for early-stage melanomas over both SE and WLE {pooled recurrence risk 0.8% (95% confidence interval [CI] 0.4-1.1) versus 2.5% (95% CI 1.5-3.4) versus 8.7% (95% CI 5.1-12.2) (p < .001), respectively}. CONCLUSION: Mohs micrographic surgery may offer a lower recurrence rate than SE or WLE in the management of early-stage melanomas of the face or HNM. Further clinical validation in a randomized controlled trial is required.

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.

Cemiplimab for Kidney Transplant Recipients With Advanced Cutaneous Squamous Cell Carcinoma.

PURPOSE: Cemiplimab is approved for treating locally advanced or metastatic cutaneous squamous cell carcinoma (CSCC). Solid organ transplant recipients have been excluded from immunotherapy trials, given concern for allograft rejection despite their increased risk of skin cancers. Chronic immunosuppression is necessary to prevent organ rejection but may attenuate antitumor response with PD-1 inhibitors. METHODS: We report a phase I study of cemiplimab for kidney transplant recipients (KTRs) with advanced CSCC. After cross-taper to a mammalian target of rapamycin (mTOR) inhibitor and pulsed dose corticosteroids (prednisone 40 mg once daily, the day before and on days 1-3 of each cycle, followed by 20 mg once daily on days 4-6, then 10 mg once daily until the day before each subsequent cycle), patients received cemiplimab 350 mg intravenously once every 3 weeks for up to 2 years and were assessed for response every 8 weeks. The primary end point was the rate of kidney rejection, with key secondary end points including rate and duration of response, and survival. RESULTS: Twelve patients were treated. No kidney rejection or loss was observed. A response to cemiplimab was observed in five of 11 evaluable patients (46%; 90% CI, 22 to 73), including two with durable responses beyond a year. Median follow-up was 6.8 months (range, 0.7-29.8). Treatment-related grade 3 or greater adverse events occurred in five patients (42%), including diarrhea, infection, and metabolic disturbances. One patient died of angioedema and anaphylaxis attributed to mTOR inhibitor cross-taper. CONCLUSION: mTOR inhibitor and corticosteroids represent a favorable immunosuppressive regimen for KTRs with advanced CSCC receiving immunotherapy. This combination resulted in durable antitumor responses with no kidney rejection events (funded by Regeneron Pharmaceuticals [ClinicalTrials.gov identifier: NCT04339062]).

Systemic and skin-limited delayed-type drug hypersensitivity reactions associate with distinct resident and recruited T cell subsets.

Delayed-type drug hypersensitivity reactions are major causes of morbidity and mortality. The origin, phenotype, and function of pathogenic T cells across the spectrum of severity require investigation. We leveraged recent technical advancements to study skin-resident memory T cells (TRMs) versus recruited T cell subsets in the pathogenesis of severe systemic forms of disease, Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and drug reaction with eosinophilia and systemic symptoms (DRESS), and skin-limited disease, morbilliform drug eruption (MDE). Microscopy, bulk transcriptional profiling, and single-cell RNA-sequencing (scRNA-Seq) plus cellular indexing of transcriptomes and epitopes by sequencing (CITE-Seq) plus T cell receptor sequencing (TCR-Seq) supported clonal expansion and recruitment of cytotoxic CD8+ T cells from circulation into skin along with expanded and nonexpanded cytotoxic CD8+ skin TRM in SJS/TEN. Comparatively, MDE displayed a cytotoxic T cell profile in skin without appreciable expansion and recruitment of cytotoxic CD8+ T cells from circulation, implicating TRMs as potential protagonists in skin-limited disease. Mechanistic interrogation in patients unable to recruit T cells from circulation into skin and in a parallel mouse model supported that skin TRMs were sufficient to mediate MDE. Concomitantly, SJS/TEN displayed a reduced Treg signature compared with MDE. DRESS demonstrated recruitment of cytotoxic CD8+ T cells into skin as in SJS/TEN, yet a pro-Treg signature as in MDE. These findings have important implications for fundamental skin immunology and clinical care.

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.