Tumescent local anesthesia in geriatric patients with head and neck skin cancer - a retrospective study of 782 patients.

BACKGROUND AND OBJECTIVES: Due to frailty, dermatosurgery in the elderly is preferably performed under tumescent local anesthesia, but data is limited. The aim was to evaluate tumescent local anesthesia for skin cancer surgery in the elderly with focus on clinical benefits (treatment processes, pain management) and local postoperative complication risk. PATIENTS AND METHODS: Investigation of patients ≥ 75 years with inpatient head and neck skin cancer surgery under tumescent local anesthesia. RESULTS: 2,940 procedures in 782 patients (mean age 83.3 years) were performed with the aim of complete tumor resection during the inpatient stay. 3.8 (range: 1-20) interventions were done over an average of 4.9 days (range: 1-28). 43.2% did not require any postoperative analgesia. 53.5% received NSAIDs, 3.3% opioids. Infection (13.6%) was the most common local postoperative complication. Surgical intervention due to bleeding was required in 2.8%. None was hemoglobin relevant or life-threatening. Suture dehiscence and necrosis were rare (0.6%). CONCLUSIONS: Tumescent local anesthesia is an effective method for skin cancer surgery in the elderly. By avoiding general anesthesia, treatment processes can be optimized and anesthesiologic risks minimized. Local postoperative complications are still low and well treatable. The long-lasting analgesia results in a reduced need for analgesics and drug interactions.

S3 guideline "actinic keratosis and cutaneous squamous cell carcinoma" - update 2023, part 2: epidemiology and etiology, diagnostics, surgical and systemic treatment of cutaneous squamous cell carcinoma (cSCC), surveillance and prevention.

Actinic keratosis (AK) are common lesions in light-skinned individuals that can potentially progress to cutaneous squamous cell carcinoma (cSCC). Both conditions may be associated with significant morbidity and constitute a major disease burden, especially among the elderly. To establish an evidence-based framework for clinical decision making, the guideline "actinic keratosis and cutaneous squamous cell carcinoma" was updated and expanded by the topics cutaneous squamous cell carcinoma in situ (Bowen's disease) and actinic cheilitis. The guideline is aimed at dermatologists, general practitioners, ear nose and throat specialists, surgeons, oncologists, radiologists and radiation oncologists in hospitals and office-based settings, as well as other medical specialties, policy makers and insurance funds involved in the diagnosis and treatment of patients with AK and cSCC. A separate guideline exists for patients and their relatives. In this part, we will address aspects relating to epidemiology and etiology, diagnostics, surgical and systemic treatment of cutaneous squamous cell carcinoma (cSCC), surveillance and prevention.

Risk analysis of systemic side effects of tumescent local anaesthesia in the surgical treatment of geriatric and multimorbid patients with skin cancer.

BACKGROUND: Due to demographic change and increased UV exposure, the number of dermatosurgical procedures in the elderly is increasing. Data on the occurrence of systemic side effects during and after treatment with tumescent local anaesthesia are limited and do not refer to details such as volume and composition of local anaesthetics or epinephrine additive. OBJECTIVES: The aim of this study was to investigate the risk of systemic side effects in elderly patients undergoing skin tumour surgery with tumescent local anaesthesia. METHODS: Investigation of systemic complications in patients (≥75 years) who underwent head and neck skin tumour surgery under tumescent local anaesthesia at the Department of Dermatology, University Medical Centre Tübingen, between October 2018 and March 2020. RESULTS: In total 782 patients (479 males, 303 females) with a mean age of 83.3 years (range: 75.1-102.2 years) could be included. A total of 2940 procedures were performed. Patients were assigned to two groups. The old-old group (≥75-84 years) included 491 patients and the oldest-old group (≥85 years) included 291 patients. The total inpatient stay and thus mean follow-up period was 4.9 days (range 1-28 days). 92.0% (719/782) suffered from pre-existing comorbidities. Systemic complications occurred in 10.2% (80/782; old-olds: 8.6%, oldest-olds: 13.1%). Hypertensive crisis (>180/120 mmHg) requiring intervention (6.7%) that occurred intraoperatively or during the inpatient stay was the most frequent systemic complication. Cardiac arrhythmias occurred postoperatively in 0.8% of cases. No life-threatening complications directly related to tumescent local anaesthesia were found. CONCLUSIONS: Skin tumour surgery in tumescent local anaesthesia for the elderly is safe, and complications caused by general anaesthesia can be avoided. Systemic complications can occur, but are usually mild, are caused by pre-existing diseases and perioperative excitement, and can be rapidly detected and well treated by monitoring. There is no direct correlation of complications to high-tumescent concentrations or volume quantities.

What causes the death of patients with cutaneous squamous cell carcinoma? A prospective analysis in 1400 patients.

INTRODUCTION: Cutaneous squamous cell carcinoma (cSCC) is a common tumor of elderly Caucasian patients. METHODS: Competing multivariable risk models to analyze different types of cSCC associated death (local infiltration [LI], locoregional [LR], and distant metastases [DM]) in terms of prognostic factors. RESULTS AND DISCUSSION: 1400 patients were analyzed. In the adjusted multivariable subdistribution hazard approach for tumor volume, the best model for death of cSCC overall revealed the presence of desmoplasia (HR 4.52; p < 0.001), bone invasion (HR 10.06; p < 0.01), and immunosuppression (HR 3.19; p = 0.003) as significant factors. Death due to LI indicated desmoplasia (HR 15.39; p < 0.01) and bone invasion (HR 16.9; p < 0.001) as significant factors. For death by LM, immunosuppression with a HR of 3.27; p = 0.004 was the only significant prognostic factors as well as in death by DM with a HR of 4.54; p = 0.02. CONCLUSIONS: The three types of death caused by cSCC can be distinguished based on risk factors with different weights. Patients with these factors should be monitored closely.

Local Tumor Infiltration and Locoregional Recurrence in Desmoplastic Cutaneous Squamous Cell Carcinoma.

BACKGROUND: Perusal of the literature of cutaneous squamous cell carcinoma (SCC) reveals that the role of the desmoplastic subtype is indistinct. Data on local infiltration and recurrence are inconsistent dependent on surgical technique, histological method, and investigated collective. OBJECTIVE: The aim of the study was to analyze local infiltration and locoregional recurrence of the desmoplastic subtype under a uniform procedure. METHODS AND MATERIALS: Between 2005 and 2015, 320 SCCs were analyzed and histological sections of all tumors were examined. Data collection included locoregional recurrence, metastasis rate, and tumor-specific death. The median follow-up was 36.5 months. RESULTS: The desmoplastic subtype required significant more re-excisions (70.0% vs 23.9%, p < .001), more interventions until tumor-free margins were achieved (maximal 6 vs 2; p < .001), showed more widespread tumor infiltration with larger excisional margins (median 9 mm, 2-51 mm vs median 4 mm, 1-10 mm; p < .001), and a 5-fold higher local recurrence rate (26.7% vs 5.0%, p < .001). The metastasis rate (16.6% vs 2.3%, p < .001) was increased. CONCLUSION: The desmoplastic subtype is characterized by a widespread local infiltration associated with perineural infiltration. It seems to be a marker for decreased histological detectability with a high rate of locoregional recurrence and metastasis.

Use of local anesthetics with an epinephrine additive on fingers and penis - dogma and reality.

Epinephrine supplements in local anesthetics are regularly used for surgery in areas with terminal vessels. According to the pharmaceutical guidelines, the use of epinephrine as an additive to local anesthetics is contraindicated for these areas. This review provides an overview of the current scientific data as well as new clinical developments in various fields. It also reviews the current legal situation. A literature research was carried out to survey the current status of relevant data. Written inquiries to several German institutions (Institute for Quality and Efficiency in Health Care, National Association of Statutory Health Insurance Physicians, Center for Clinical Studies Tübingen, Federal Institute for Drugs and Medical Devices) were made to determine the legal situation. No evidence was found in the literature for a causal relationship between the use of epinephrine as a vasoconstrictor and necrosis of the finger or penis. Studies and reviews show that the use of local anesthetics with epinephrine on the fingers or penis is a safe procedure with many clinical and economic advantages. In routine clinical practice, the WALANT method (Wide Awake Local Anesthesia No Tourniquet) as well as the increasing incidence of skin tumors in acral areas has led to a tendency towards increasing use. However, its use is still legally contraindicated, and the pharmaceutical companies show no interest in supporting a drug study. Further clinical trials - regardless of the strength of the evidence - would not change the current legal contraindication.

Local Recurrence Rates of Skin Tumors After Resection With Complete Circumferential Peripheral and Deep Margin Assessment-Identification of High-Risk Entities.

BACKGROUND: The local recurrence rates of malignant skin tumors after micrographic controlled surgery using complete circumferential peripheral and deep margin assessment (CCPDMA) are reported to be low. However, in daily practice, tumor entities with a significantly higher recurrence rate are found. OBJECTIVE: The aim of the investigation was to identify these high-risk tumors to develop approaches for risk stratification. PATIENTS AND METHODS: We included different malignant tumors that were surgically treated and examined with CCPDMA using paraffin sections and H&E staining. Re-excisions were performed until the tumor was completely removed. RESULTS: Ninety-nine thousand three hundred seventy-two tumors were included in the study; the follow-up period was 4 years (median). Eight tumor entities were identified as high-risk entities, showing a significantly higher local recurrence rate of over 20%: desmoplastic squamous cell carcinoma, desmoplastic melanoma, Merkel cell carcinoma, microcystic adnexal carcinoma, pleomorphic sarcoma, liposarcoma as well as angiosarcoma, and extramammary Paget's disease. CONCLUSION: Complete circumferential peripheral and deep margin assessment allows complete control of the resection margins and enables skin-sparing resections with low recurrence rates for basal cell carcinomas, nondesmoplastic squamous cell carcinomas, lentiginous melanomas, and dermatofibrosarcoma protuberans. However, other tumors show significantly higher recurrence rates and therefore need to be classified as high-risk tumors.

Sentinel lymph node biopsy for high-thickness cutaneous squamous cell carcinoma.

Squamous cell carcinomas are among the most common skin tumors and show a risk of metastasis depending on various factors such as tumor thickness, localization, histological subtype and immune status of the patient. Sentinel lymph node biopsy (SLNB) SLNB represents a possibility for assessing the locoregional lymph node status. In this study, the role of the SLNB in lymph node status and survival was analyzed. Retrospectively, 720 patients with high-risk squamous cell carcinoma (tumor thickness > 5 mm) were examined. 150 patients agreed to SLNB, 570 patients did not undergo histologic confirmation of lymph node status and were included directly in follow-up. In 101 patients, a sentinel lymph node was successfully marked and extirpated, followed by regular follow-up examinations.A total of 11.11% of the patients showed lymph node metastasis in the course of their treatment, with no difference in the proportion of patients in the SLNB group (11.9%) and the observation group (11.4%) (p = 0.873). The proportion of distant metastasis also did not differ between the groups (p = 0.898). In 3.96% of the patients in the SLNB group, a metastasis was found in the sentinel lymph node. Tumor-specific death was observed in 7.14% of the patients in the SLNB group and 4.74% in the observation group (p = 0.269). Although SLNB is a principally suitable method for determining lymph node status, the available data do not provide any benefit regarding further metastasis or tumor-specific survival.

[Surgical techniques in the treatment of basal cell carcinoma-a prospective investigation]. / Chirurgische Techniken in der Therapie des Basalzellkarzinoms ­ eine prospektive Untersuchung.

BACKGROUND: Basal cell carcinomas are the most frequent epithelial skin tumors and a frequent indication for dermatological interventions. Despite the establishment of drug treatment options, surgery is still the treatment of choice. Various options are available ranging from curettage to complex dermatosurgical procedures. In addition to the main aspect of low local recurrence rates, esthetic factors and the number of procedures are also important for the choice of treatment. METHODS: In this study 347 patients with 398 basal cell carcinomas (nodular type, diameter up to 10 mm) were prospectively examined. The patients were randomized into two treatment arms: in one group the tumor was treated by ring curettage and in the other group the tumor was excised. Patients who underwent 3D histologically controlled surgery due to basal cell carcinoma during the same investigation period served as controls. RESULTS: The highest local recurrence rate was observed after curettage (14.0%), whereas the group with 3D histology had the lowest recurrence rate (0.9%, p < 0.001). In the 3D group, more re-excisions were required to achieve complete tumor clearance compared to the group who underwent excisions with serial section histology. Patients rated the esthetic outcome best after curettage. The median follow-up was 3.9 years. CONCLUSION: The choice of surgical treatment for small nodular basal cell carcinomas depends on individual circumstances. Excisions controlled by 3D histology with wound closure after complete tumor clearance showed the lowest recurrence rate in our study; however, curettage is also a possible surgical treatment option with minimal effort and an acceptable recurrence rate, which can lead to good esthetic results.

S3 guideline for actinic keratosis and cutaneous squamous cell carcinoma (cSCC) - short version, part 2: epidemiology, surgical and systemic treatment of cSCC, follow-up, prevention and occupational disease.

Actinic keratoses (AKs) are common lesions in light-skinned individuals that can potentially progress to cutaneous squamous cell carcinoma (cSCC). Both conditions may be associated with significant morbidity and constitute a major disease burden, especially among the elderly. To establish an evidence-based framework for clinical decision making, the guidelines for actinic keratosis and cutaneous squamous cell carcinoma were developed using the highest level of methodology (S3) according to regulations issued by the Association of Scientific Medical Societies in Germany (AWMF). The guidelines are aimed at dermatologists, general practitioners, ENT specialists, surgeons, oncologists, radiologists and radiation oncologists in hospitals and office-based settings as well as other medical specialties involved in the diagnosis and treatment of patients with AKs and cSCC. The guidelines are also aimed at affected patients, their relatives, policy makers and insurance funds. In the second part, we will address aspects relating to epidemiology, etiology, surgical and systemic treatment of cSCC, follow-up and disease prevention, and discuss AKs and cSCC in the context of occupational disease regulations.

S3 guideline for actinic keratosis and cutaneous squamous cell carcinoma - short version, part 1: diagnosis, interventions for actinic keratoses, care structures and quality-of-care indicators.

Actinic keratoses (AK) are common lesions in light-skinned individuals that can potentially progress to cutaneous squamous cell carcinoma (cSCC). Both conditions may be associated with significant morbidity and constitute a major disease burden, especially among the elderly. To establish an evidence-based framework for clinical decision making, the guideline "actinic keratosis and cutaneous squamous cell carcinoma" was developed using the highest level of methodology (S3) according to regulations issued by the Association of Scientific Medical Societies in Germany (AWMF). The guideline is aimed at dermatologists, general practitioners, ENT specialists, surgeons, oncologists, radiologists and radiation oncologists in hospitals and office-based settings as well as other medical specialties involved in the diagnosis and treatment of patients with AK and cSCC. The guideline is also aimed at affected patients, their relatives, policy makers and insurance funds. In the first part, we will address aspects relating to diagnosis, interventions for AK, care structures and quality-of-care indicators.

Prognostic Impact of Perineural Invasion in Cutaneous Squamous Cell Carcinoma: Results of a Prospective Study of 1,399 Tumors.

Perineural infiltration (PNI) and desmoplasia are believed to be high-risk factors in the prognosis of squamous cell carcinoma (SCC). In the literature, dependences between PNI, de-differentiation, and desmoplasia remain unclear. The aim of this study was to analyze the respective prognostic impact of these factors in regard to local recurrence and metastasis. Between 2005 and 2015, 1,399 unselected primary SCCs of 1,434 patients were diagnosed. If a patient had multiple tumors, the tumor with the highest risk profile was selected. Histological sections of all tumors with a tumor thickness of ≥6 mm and desmoplastic SCC with a tumor thickness of 2.1-5.9 mm were re-examined for PNI. Median follow-up was 36.5 months. PNI was present exclusively within tumors of the desmoplastic type (14.5%). PNI was present significantly more often in patients developing lymph node metastasis (3% all non-desmoplastic SCC, 17% desmoplastic SCC, and 29% desmoplastic SCC with PNI) and local recurrence (3%, 26%, and 64%) and associated with overall tumor-specific death (4%, 25%, and 54%). Using a multivariate model of disease recurrence, tumor thickness ≥6 mm, tumor horizontal size ≥20 mm, immunosuppression, desmoplasia, and PNI remained significant factors. In conclusion, PNI was found to be an additional marker indicative of an unfavorable prognosis and an independent high-risk factor within the desmoplastic type of SCC.

Local surgical treatment of cutaneous squamous cell carcinoma: deficits and controversies in the literature.

The prognostic impact of primary excision in the treatment of cutaneous squamous cell carcinoma depends on certain tumor characteristics (risk factors), the surgical approach chosen and the subsequent histological examination. For the development of the AWMF (Association of Scientific Medical Societies in Germany) guidelines for squamous cell carcinoma, the most conclusive guidelines available were evaluated using the DELBI tool (German Instrument for the Methodological Appraisal of Guidelines). These were the Scottish and Canadian guidelines as well as the joint guidelines published by EDF, EADO and EORTC. The primary literature on the aforementioned topics that was used for these guidelines included 49 studies and 9 reviews. None of the studies had a prospective, randomized design; 19 studies contained prospective data; 30 studies provided retrospective data. Overall, the results were heterogeneous. Not only were there discrepancies in terms of the validity of the various risk factors for locoregional disease progression - such as dedifferentiation, desmoplasia and perineural invasion - but also with respect to tumor thickness and surgical consequences. Differences were also found regarding the histological processing method used. In general, there are two such methods: conventional histology (bread loaf technique) and complete histological assessment of excision margins. The latter was found to be associated both with low recurrence rates and low metastatic rates, possibly due to the fact that patients treated with the latter method had lower-risk tumors. Publications on bread loaf histology lacked precise information as to how the tissue was actually processed. Likewise, there was a lack of usable data in terms of the surgical margins used in the primary excision. Conclusion: The current literature is inconsistent and insufficient with regard to the various prognostic factors and the surgical approach to cutaneous squamous cell carcinoma.

Multidisciplinary long-term care and modern surgical treatment of congenital melanocytic nevi - recommendations by the CMN surgery network.

In recent years, our knowledge of congenital melanocytic nevi (CMN) has greatly expanded. This has led to a paradigm shift. The present article represents a commentary by an interdisciplinary group of physicians from German-speaking countries with extensive experience in long-term care and surgical treatment of children and adults with CMN (CMN surgery network, "Netzwerk Nävuschirurgie", NNC). The authors address aspects such as the indication for treatment as well as treatment planning and implementation under these new premises. Adequate counseling of parents on conservative and/or surgical management requires an interdisciplinary exchange among physicians and individualized planning of the intervention, which frequently involves a multi-stage procedure. Today, the long-term aesthetic outcome is at the center of any therapeutic endeavor, whereas melanoma prevention plays only a minor role. The premise of "removal at any cost" no longer holds. Potential treatment-related adverse effects (hospitalization, wound healing disorders, and others) must be carefully weighed against the prospects of a beneficial outcome. In this context, the use of dermabrasion in particular must be critically evaluated. At a meeting of the NNC in September 2018, its members agreed on a consensus-based position on dermabrasion, stating that the procedure frequently leads to impaired wound healing and cosmetically unfavorable or hypertrophic scarring. Moreover, dermabrasion is considered to be commonly associated with considerable repigmentation that usually occurs a number of years after the procedure. In addition, the NNC members saw no benefit in terms of melanoma prevention. In the future, physicians should therefore thoroughly caution about the potential risks and often limited cosmetic benefits of dermabrasion.