Establishing Consensus for Mohs Micrographic Surgical Techniques in the Treatment of Melanoma in Situ for Future Clinical Trials: A Modified Delphi Study.

BACKGROUND: Mohs micrographic surgery (MMS) is a promising treatment modality for melanoma in situ (MIS). However, variations in surgical technique limit the generalizability of existing data and may impede future study of MMS in clinical trials. METHODS: A modified Delphi method was selected to establish consensus on optimal MMS techniques for treating MIS in future clinical trials. The Delphi method was selected due to the limited current data, the wide range of techniques used in the field, and the intention to establish a standardized technique for future clinical trials. A literature review and interviews with experienced MMS surgeons were performed to identify dimensions of the MMS technique for MIS that (1) likely impacted costs or outcomes of the procedure, and (2) showed significant variability between surgeons. A total of 8 dimensions of technical variation were selected. The Delphi process consisted of 2 rounds of voting and commentary, during which 44 expert Mohs surgeons across the United States rated their agreement with specific recommendations using a Likert scale. RESULTS: Five of eight recommendations achieved consensus in Round 1. All 3 of the remaining recommendations achieved consensus in Round 2. Techniques achieving consensus in Round 1 included the use of a starting peripheral margin of ≤5 mm, application of immunohistochemistry, frozen tissue processing, and resecting to the depth of subcutaneous fat. Consensus on the use of Wood's lamp, dermatoscope, and negative tissue controls was established in Round 2. CONCLUSIONS: This study generated 8 consensus recommendations intended to offer guidance for Mohs surgeons treating MIS. The adoption of these recommendations will promote standardization to facilitate comparisons of aggregate data in multicenter clinical trials.

Risk factors for developing depressive symptoms in the immediate postoperative period after Mohs micrographic surgery.

PURPOSE: Mohs micrographic surgery (MMS) is a highly efficacious, tissue sparing method of skin cancer removal. Nevertheless, in the months to years after MMS, psychosocial distress has been described. The present study addressed the immediate period after MMS and assessed the frequency and risk factors for development of depressive symptoms. METHODS: Subjects undergoing MMS at two physician practices (JL, FS) were included in this prospective cohort study. Preoperatively, a standardized depression screening, the Patient Health Questionnaire-8 (PHQ-8), was administered. After MMS, the PHQ-8 was readministered at weeks 1, 2, 4, 6, and 12. Average PHQ-8 score by week and change from baseline PHQ-8 score were the primary outcomes. RESULTS: Sixty-three subjects were included of which 49 (78%) had a facial site. Twenty-two subjects (35%) had some increase in score during the 12-week follow-up period, of which 18 had a facial site. The oldest subjects (83-99 years, n = 14) had significantly higher PHQ-8 scores at week 4 (p < 0.01) and week 6 (p = 0.02) than all other age groups. There were no differences in scores between location groups. CONCLUSIONS: One-third of subjects had some increase in score during the follow-up period. Those in the oldest age cohort were at highest risk of increased score. In contrast to prior literature, those with facial sites were not at higher risk. This difference may be explained by increased masking during the ongoing COVID-19 pandemic. Ultimately, consideration of patients' psychologic status in the immediate postoperative period after MMS, particularly in the elderly population, may enhance perceived patient outcomes.

A Cross-Sectional Analysis of Sharps Injuries Among Dermatologic Surgeons: A Survey of American College of Mohs Surgery Members.

BACKGROUND: There is a paucity of data on sharps injuries and bloodborne pathogen exposure among Dermatologic Surgeons. OBJECTIVE: Quantify occupational risks from sharps injuries among Mohs surgeons. Determine rate of injury, reporting, and confidence in staff's sharps handling. METHODS: A cross-sectional analysis performed using survey responses from Mohs surgeons with membership in the American College of Mohs Surgery (ACMS). RESULTS: A total of 60 ACMS members completed the survey. Overall, 56.7% reported at least 1 sharps injury within the past year, of which 14.7% resulted in a bloodborne exposure (odds of exposure: 7.5% per year). The most common type of injury was self-inflicted suture needlestick (76.5%). Forty-four-point-one percent did not report their injuries. Ninety-five percent reported access to postexposure prophylaxis at their workplace. In addition, respondents in academic and single-specialty practices were more likely to report high or moderate confidence in staff sharps handling knowledge and in injury reporting compared with respondents from multispecialty and solo practices (88% vs 54% p = .02, 76%-81% vs 27% p = .0004, respectively). CONCLUSION: Sharps injuries and under-reporting of these injuries are common among Mohs surgeons. Despite reporting of higher confidence in staff knowledge and training in academic and single-specialty practices, there was no correlation with surgeon's rate of injury.

UV biomarker genes for classification and risk stratification of cutaneous actinic keratoses and squamous cell carcinoma subtypes.

Currently, there is no sensitive molecular test for identifying transformation-prone actinic keratoses (AKs) and aggressive squamous cell carcinoma (SCC) subtypes. Biomarker-based molecular testing represents a promising tool for risk stratifying these lesions. We evaluated the utility of a panel of ultraviolet (UV) radiation-biomarker genes in distinguishing between benign and transformation-prone AKs and SCCs. The expression of the UV-biomarker genes in 31 SCC and normal skin (NS) pairs and 10 AK/NS pairs was quantified using the NanoString nCounter system. Biomarker testing models were built using logistic regression models with leave-one-out cross validation in the training set. The best model to classify AKs versus SCCs (area under curve (AUC) 0.814, precision score 0.833, recall 0.714) was constructed using a top-ranked set of 13 UV-biomarker genes. Another model based on a 15-gene panel was developed to differentiate histologically concerning from less concerning SCCs (AUC 1, precision score 1, recall 0.714). Finally, 12 of the UV-biomarker genes were differentially expressed between AKs and SCCs, while 10 genes were uniquely expressed in the more concerning SCCs. UV-biomarker gene subsets demonstrate dynamic utility as molecular tools to classify and risk stratify AK and SCC lesions, which will complement histopathologic diagnosis to guide treatment of high-risk patients.

Recurrent Squamous Cell Carcinoma Arising Within a Linear Porokeratosis

Here we report a case of linear porokeratosis with recurrent malignant degeneration to squamous cell carcinoma (SCC) recurring six years after excision of initial SCC. A 79-year-old woman presented with a friable tumor located within a longstanding lesion on her posterior thigh. Six years prior, she was diagnosed with SCC arising within the same lesion, which had been surgically excised with negative margins. Physical examination revealed a 3.5 x 2.7 cm friable tumor on the left proximal posterior thigh. The tumor was located within a hyperpigmented and erythematous scaly linear plaque within a line of Blaschko, extending from the left buttock to the left distal posterior thigh. Two 4 mm punch biopsies were performed: one of the erythematous plaque on the left buttock and one from the friable tumor on the left posteromedial thigh. Histology from the left buttock revealed a cornoid lamella consistent with porokeratosis and the left posteromedial thigh revealed SCC. The patient underwent Mohs micrographic surgery with negative margins, followed by a linear repair. Porokeratosis is a disorder of epidermal keratinization that has been associated with malignant degeneration, although such cases are rare. The risk of recurrence of SCC arising within a porokeratosis is unknown. This case emphasizes the importance of ongoing monitoring for malignant degeneration within these lesions. J Drugs Dermatol. 2020;19(2)205-206. doi:10.36849/JDD.2020.4640

Effect of Postoperative Telephone Calls on Patient Satisfaction and Scar Satisfaction After Mohs Micrographic Surgery.

BACKGROUND: Mohs micrographic surgery is considered the gold standard for high-risk nonmelanoma skin cancer. Postoperative telephone follow-up (TFU) is linked to higher patient satisfaction; however, there are no randomized, blinded studies examining whether TFU after Mohs surgery improves patient satisfaction. OBJECTIVE: To perform a randomized single-blinded prospective survey study examining whether patient satisfaction or scar satisfaction varied between Mohs patients who received a postoperative call and patients who did not. METHODS: Patients were enrolled into "post-op call" or "no post-op call" groups. Both arms completed surveys at suture removal and 3-month follow-up visits. RESULTS: One hundred four subjects were enrolled, and demographics, the number of Mohs stages, and type of repair were controlled. At suture removal, both arms reported similar overall high satisfaction on the 5-point Likert scale (4.90 "call arm" vs 4.88 "no-call arm", p = .80). Patient and Observer Scar Assessment Scale (POSAS) scores were 3.37 in the "call arm" versus 3.81 in the "no-call arm", p = .31. At 3-month follow-up, results were similar. CONCLUSION: High overall satisfaction was reported in both arms. The TFU group reported higher overall satisfaction, but this difference was not significant. Scar satisfaction did not vary statistically between the arms, but POSAS scores in the call arm trended favorably.

An Inferiorly Based Rotation Flap for Defects Involving the Lower Eyelid and Medial Cheek.

We report a series of 20 patients who underwent inferiorly based rotation flaps for reconstruction of defects of the medial and infraorbital cheek and lower eyelid following Mohs micrographic surgery for nonmelanoma skin cancer. Defects ranged from 1.2 to 3.2 cm in longest diameter and patients ranged from 27 to 91 years of age. All 20 patients had excellent functional and cosmetic outcome with up to 2-year follow-up and no subsequent surgical or laser revision. There were no instances of partial or complete flap necrosis, hematoma, or ectropion. Our series includes defects that originated on the cheek as far laterally as directly below the lateral canthus, and terminated as far medially as the nasal sidewall. An inferiorly based rotation flap is a viable alternative to a laterally based rotation flap and should be in the armamentarium of reconstructive dermatologic and facial plastic surgeons.

Metastatic squamous cell carcinoma presenting as an erythematous nodule in a man with lung adenocarcinoma.

Skin metastases from visceral malignancies have been well documented in the literature, and may be the presenting sign of an occult internal malignancy. Lung cancer in particular is a relatively common cause of skin metastases, which are considered a poor prognostic sign. Rarely, patients with lung cancer develop a second primary lung cancer that may require a novel chemotherapeutic regimen. The frequency of second primary malignancies presenting with metastatic skin lesions is not documented in the literature. We present a case of a 50-year-old man with a history of metastatic lung adenocarcinoma who was referred for evaluation of a nodule overlying his right mandible, which had been progressively enlarging for two weeks. Biopsy demonstrated metastatic squamous cell carcinoma. Subsequent CT-guided biopsy of a left retroperitoneal lymph node was conducted and notable for squamous cell carcinoma. Therefore, this patient's skin lesion was the presenting sign of a second primary visceral tumor, likely originating in the lung. We present this case to raise clinical awareness of the rare phenomenon that cutaneous metastasis may be the first sign of a visceral cancer, even in the setting of a previous distinct primary malignancy.

A variant of palpable migratory arciform erythema.

Palpable migratory arciform erythema is a T-cell pseudolymphoma with no well-established treatment. The disease is rarely reported in the literature, perhaps because it is difficult to diagnose. We present a case of a variant of PMAE in a 30-year-old healthy man with no history of medication use and erythematous to violaceous annular and arciform plaques on his face, scalp and trunk. This case is of particular significance because gene rearrangement studies and histopathologic findings are concerning for folliculotropic mycosis fungoides while the clinical course does not support this diagnosis. The authors' emphasize that clinical history is imperative for definitive diagnosis of palpable migratory arciform erythema as it can clinically and histopathologically resemble other cutaneous lymphocytic diseases.

New world cutaneous leishmaniasis.

A 24-year-old Bangladeshi man presented with a 12-week history of a pruritic papule on his left elbow that had enlarged and ulcerated. He was without any constitutional or systemic symptoms. He reported a history of extensive travel in the two years prior to presentation that included Bangladesh, South and Central America, and Mexico. Histopathologic features were consistent with leishmaniasis. Speciation by the Centers for Disease Control showed L. brasiliensis.

Surgical corner:a poliglecaprone 25-only approach to wound closure:cosmetic and financial advantages.

The primary concerns when performing surgical excisions include adequate control of surgical margins and cosmetic outcome. The ideal repair combines perfect wound approximation, tensile strength, and minimal scarring. Various techniques and suture materials are utilized by dermatologic surgeons to achieve this goal. We describe a Monocryl-only bilayered repair, which can lead to excellent cosmetic results and may reduce the burden of return visits for patients. In this paper, we describe the technique used to place deep Monocryl sutures, as well as a running subcuticular suture, and illustrate this technique with photographs.