RESUMO
BACKGROUND: Mohs micrographic surgery efficiently treats skin cancer through staged resection, but surgeons' varying resection rates may lead to higher medical costs. OBJECTIVE: To evaluate the cost savings associated with a quality improvement. MATERIALS AND METHODS: The authors conducted a retrospective cohort study using 100% Medicare fee-for-service claims data to identify the change of mean stages per case for head/neck (HN) and trunk/extremity (TE) lesions before and after the quality improvement intervention from 2016 to 2021. They evaluated surgeon-level change in mean stages per case between the intervention and control groups, as well as the cost savings to Medicare over the same time period. RESULTS: A total of 2,014 surgeons performed Mohs procedures on HN lesions. Among outlier surgeons who were notified, 31 surgeons (94%) for HN and 24 surgeons (89%) for TE reduced their mean stages per case with a median reduction of 0.16 and 0.21 stages, respectively. Reductions were also observed among outlier surgeons who were not notified, reducing their mean stages per case by 0.1 and 0.15 stages, respectively. The associated total 5-year savings after the intervention was 92 million USD. CONCLUSION: The implementation of this physician-led benchmarking model was associated with broad reductions of physician utilization and significant cost savings.
Assuntos
Redução de Custos , Medicare , Cirurgia de Mohs , Melhoria de Qualidade , Neoplasias Cutâneas , Humanos , Estudos Retrospectivos , Medicare/economia , Estados Unidos , Melhoria de Qualidade/economia , Redução de Custos/estatística & dados numéricos , Neoplasias Cutâneas/cirurgia , Neoplasias Cutâneas/economia , Cirurgia de Mohs/economia , Seguimentos , Padrões de Prática Médica/economia , Padrões de Prática Médica/estatística & dados numéricos , Masculino , Feminino , Cirurgiões/economia , Cirurgiões/estatística & dados numéricos , Neoplasias de Cabeça e Pescoço/cirurgia , Neoplasias de Cabeça e Pescoço/economiaRESUMO
BACKGROUND: Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. OBJECTIVE: The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. METHODS: Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. RESULTS: Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. LIMITATIONS: Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes. CONCLUSION: With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.
Assuntos
Neoplasias Cutâneas , Cirurgiões , Humanos , Neoplasias Cutâneas/cirurgia , Cirurgia de Mohs , Consenso , BenchmarkingRESUMO
The Accreditation Council for Graduate Medical Education (ACGME) granted accreditation to the first 5 Procedural Dermatology Fellowship Training Programs in 2004. The name of the training program was changed from Procedural Dermatology to Micrographic Surgery and Dermatologic Oncology by the ACGME/Residency Review Committee for Dermatology in 2014. The American Board of Dermatology/American Board of Medical Specialties conducted the first certification examination in Micrographic Dermatology Surgery in October 2021. This article chronicles the history and development of the subspecialty. J Drugs Dermatol. 2022;21(8):861-863.: doi:10.36849/JDD.6933.
Assuntos
Bolsas de Estudo , Internato e Residência , Acreditação , Certificação , Educação de Pós-Graduação em Medicina , Humanos , Estados UnidosRESUMO
BACKGROUND: Limited data exist on sentinel lymph node biopsy (SLNB) for cutaneous squamous cell carcinoma (cSCC) of the head and neck. OBJECTIVE: To review the results of SLNB for patients with cSCC of the head and neck at the authors' institution. MATERIALS AND METHODS: A retrospective review was completed for patients who underwent SLNB for cSCC of the head and neck over 19 years. Patient demographics, immune status, tumor stage, total patients with positive SLNB, local recurrence, nodal recurrence, in-transit metastasis, and disease-specific death were recorded. RESULTS: Sixty patients underwent lymphoscintigraphy, and an SLN was identified in 58 patients. The mean follow-up was 3.2 years (range, 15 days-16 years). Four patients (6.9%) had a positive SLNB. All were Brigham and Women's Hospital (BWH) stage T2b tumors. Three of these patients were immunosuppressed, 3 patients underwent neck dissection, and 2 patients received adjuvant radiation. None developed local or regional recurrence. Of the 53 patients with a negative SLNB, there were 4 local recurrences, 2 in-transit metastases, and no nodal recurrences. CONCLUSION: Immunosuppressed patients with tumors BWH stage T2b or greater may be a reasonable cohort to focus future prospective studies on the utility of SLNB in cSCC of the head and neck.
Assuntos
Carcinoma de Células Escamosas , Neoplasias de Cabeça e Pescoço , Neoplasias Cutâneas , Adulto , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Linfonodos/patologia , Estudos Prospectivos , Recidiva , Estudos Retrospectivos , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Carcinoma de Células Escamosas de Cabeça e Pescoço/cirurgiaRESUMO
Artificial intelligence is generating substantial interest in the field of medicine. One form of artificial intelligence, deep learning, has led to rapid advances in automated image analysis. In 2017, an algorithm demonstrated the ability to diagnose certain skin cancers from clinical photographs with the accuracy of an expert dermatologist. Subsequently, deep learning has been applied to a range of dermatology applications. Although experts will never be replaced by artificial intelligence, it will certainly affect the specialty of dermatology. In this first article of a 2-part series, the basic concepts of deep learning will be reviewed with the goal of laying the groundwork for effective communication between clinicians and technical colleagues. In part 2 of the series, the clinical applications of deep learning in dermatology will be reviewed and limitations and opportunities will be considered.
Assuntos
Aprendizado Profundo , Neoplasias Cutâneas , Humanos , Inteligência Artificial , Dermatologistas , Algoritmos , Neoplasias Cutâneas/diagnósticoRESUMO
The aim of this study is to report our institution's experience with pediatric skin malignancies. A single institution retrospective review of pediatric patients with a primary skin malignancy from 1992 to 2020 was performed. Demographics, tumor characteristics and treatment outcomes were reviewed. Ninety-nine patients with 109 primary malignant skin lesions were reviewed. The most common lesion was malignant melanoma [MM] (n = 50, 45.9%). Compared to non-melanoma skin cancer (NMSC), MM were more likely to present on trunk or extremities (p=.01, OR = 3.2), and be misdiagnosed (p=.03, OR = 2.7). NMSC were more common in the head and neck region (p=.01, OR = 3.2), and were associated with a personal history of skin cancer (p=.0005, OR = 17.1) or a known risk factor (p=.04, OR = 2.5). Patients with MM were 12.4-times more likely to develop metastatic disease compared to NMSC (p<.0001). Increased Breslow's thickness also increased the odds of developing metastatic disease (p=.03, OR = 1.6 per 1-mm increase). Interval time between lesion recognition and diagnostic biopsy or surgical treatment did not impact overall survival. Malignant melanoma was the most common malignancy in our cohort, followed by basal cell carcinoma. Malignant melanoma was the most likely tumor to be misdiagnosed and/or metastasize. Treatment delays did not impact risk of metastasis, recurrence or survival rate, though some patients succumbed to disease. These results may be attributed to small sample size or the biology of melanoma in pediatric patients. Awareness of skin malignancies in the pediatric population is imperative to providers and the public, with low threshold for specialty consultation and excision when warranted.
Assuntos
Carcinoma Basocelular , Melanoma , Neoplasias Cutâneas , Criança , Humanos , Melanoma/epidemiologia , Estudos Retrospectivos , PeleRESUMO
Cutaneous operations are generally safe procedures with minimal major risks. Excessive bleeding occasionally occurs, especially for patients taking antithrombotic medications. Conversely, stopping these medications before cutaneous surgery may increase the risk of a thromboembolic event. We aimed to synthesize the evidence regarding the risk of hemorrhage and thromboembolic events for patients undergoing cutaneous surgery while taking antithrombotic therapy. We performed a comprehensive search to identify randomized controlled trials and cohort studies that compared rates of hemorrhage and/or thromboembolic events between patients receiving antithrombotic therapy at cutaneous surgery and patients not receiving it. Odds ratio (OR) and risk difference for complications were calculated with random-effects models. Of 9214 patients taking anticoagulant or antiplatelet medications, 323 (3.5%) had hemorrhagic complications; of 21,696 control patients, 265 (1.2%) had hemorrhagic complications. Patients taking antithrombotic therapy had increased bleeding risk relative to control patients (OR 2.63 [95% CI 1.90-3.63]; P < 0.001) and an increased but less clinically important risk difference (OR 0.02 [95% CI 0.01-0.03]; P < 0.001) with high heterogeneity. No difference was observed in hemorrhage rates among patients whose antithrombotic therapy was stopped vs continued (OR 1.16 [95% CI 0.73-1.83]; P = 0.54). No difference was seen in rates of thromboembolic events among patients taking antithrombotic therapy vs control patients. However, two serious thromboembolic events were noted in a cohort of 59 patients whose antithrombotic therapy was stopped. Because of potentially devastating effects of thromboembolic events, the current accepted practice is indicated for continuation of antithrombotic therapy for patients undergoing cutaneous surgery.
Assuntos
Fibrinolíticos , Tromboembolia , Anticoagulantes/efeitos adversos , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/complicações , Hemorragia/epidemiologia , Humanos , Inibidores da Agregação Plaquetária/efeitos adversos , Tromboembolia/induzido quimicamente , Tromboembolia/epidemiologia , Tromboembolia/prevenção & controleRESUMO
IMPORTANCE: There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs). OBJECTIVE: To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs. EVIDENCE REVIEW: Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses. FINDINGS: The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately ≥20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC. CONCLUSIONS AND RELEVANCE: Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.
Assuntos
Carcinoma de Células Escamosas , Ceratose Actínica , Transplante de Órgãos , Neoplasias Cutâneas , Carcinoma de Células Escamosas/etiologia , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/prevenção & controle , Técnica Delphi , Humanos , Ceratose Actínica/etiologia , Ceratose Actínica/patologia , Ceratose Actínica/prevenção & controle , Transplante de Órgãos/efeitos adversos , Neoplasias Cutâneas/etiologia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/prevenção & controle , TransplantadosRESUMO
BACKGROUND: Perioperative anxiety can negatively impact patient satisfaction and can complicate outpatient dermatologic procedures. OBJECTIVE: Evaluate adverse events associated with oral midazolam as a perioperative anxiolytic during dermatologic surgery and assess whether an enhanced monitoring approach is associated with an increased detection rate. MATERIALS AND METHODS: Five hundred cases (250 before and after change in monitoring) where patients were administered oral midazolam between July 2015 and May 2017 were retrospectively reviewed. The number of procedures, type of procedures, dose in milligrams, number of doses, major and minor adverse events, and vital signs were recorded. RESULTS: The difference in number of treatment sites, types of procedures, and total dose administered was not significant. There were minor but significant differences in the mean change in blood pressure, heart rate, respiratory rate, and Richmond Agitation and Sedation Scale score before and after the procedure but not oxygen saturation. These vital sign changes were not clinically significant. There were zero major adverse events in both groups. There were 2 patients who became transiently hypoxic. CONCLUSION: Oral midazolam administration was not associated with major adverse events including in the more intensively monitored group. This supports its use as an anxiolytic for outpatient dermatologic procedures.
Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Ansiolíticos/efeitos adversos , Ansiedade/prevenção & controle , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Midazolam/efeitos adversos , Administração Oral , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/psicologia , Ansiolíticos/administração & dosagem , Ansiedade/etiologia , Ansiedade/psicologia , Procedimentos Cirúrgicos Dermatológicos/psicologia , Relação Dose-Resposta a Droga , Monitoramento de Medicamentos/estatística & dados numéricos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Feminino , Humanos , Masculino , Midazolam/administração & dosagem , Pessoa de Meia-Idade , Satisfação do Paciente , Assistência Perioperatória/efeitos adversos , Assistência Perioperatória/métodos , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy, but to the authors' knowledge, limited data exist regarding the safety and efficacy of these agents in transplant recipients. Herein, the authors have reported their experience with 17 patients who were treated with ICIs for metastatic malignancies after undergoing solid organ transplantation. METHODS: Data were abstracted for solid organ transplant recipients who received ICIs for the treatment of malignancy between January 1, 2016, and September 30, 2019. The authors identified 7 kidney, 8 liver, and 2 heart transplant recipients. Outcomes of interest were adverse drug reactions, cancer progression, and patient survival. RESULTS: The most common malignancies treated with ICIs were metastatic squamous cell carcinoma (5 patients; 29%) and hepatocellular carcinoma (5 patients; 29%), which were noted exclusively among liver transplant recipients. The median duration on ICIs was 1.7 months (interquartile range, 0.4-7.6 months). Five patients (29%) developed adverse reactions, including 4 patients (24%) with immune-related adverse events(irAEs), 3 patients (18%) with acute allograft rejections, 1 patient (6%) with autoimmune colitis, and 1 patient (6%) with ICI-induced cardiotoxicity (the patient was a heart transplant recipient). The cumulative incidence of cancer progression was 50% and 69%, respectively, at 6 months and 12 months. Eleven patients (65%) died over the median follow-up period of 4.6 months (interquartile range, 1.5-13.2 months) from the time of ICI initiation, with cancer progression being the most common cause of death. CONCLUSIONS: ICIs can be used as individualized therapy in selected patients who have undergone solid organ transplantation but more studies are needed to determine how best to use these agents to improve outcomes further.
Assuntos
Inibidores de Checkpoint Imunológico/uso terapêutico , Neoplasias/tratamento farmacológico , Transplante de Órgãos/métodos , Idoso , Humanos , Inibidores de Checkpoint Imunológico/farmacologia , Pessoa de Meia-Idade , Metástase NeoplásicaRESUMO
BACKGROUND: Malignancy is a major cause of late post-heart transplantation (HT) mortality. Sirolimus (SRL) exerts antiproliferative properties and its long-term use in HT as primary immunosuppression (IS) is associated with decreased mortality risk that is not fully explained by attenuation of cardiac allograft vasculopathy progression. OBJECTIVES: This study sought to examine whether conversion from calcineurin inhibitor (CNI)-based to SRL-based IS was associated with decreased risk of malignancy post-HT. METHODS: Overall, 523 patients underwent HT between 1994 and 2016 at a single institution. The main outcomes included incidence of overall de novo malignancies (excluding non-melanoma skin cancers [NMSCs]), post-transplantation lymphoproliferative disorders (PTLD), and first and subsequent primary occurrences of NMSC post-HT. RESULTS: The study identified 307 patients on SRL-based and 216 on CNI-based maintenance IS. Over a median follow-up of 10 years after HT, overall de novo malignancies (non-NMSC) occurred in 31% of CNI patients and in 13% of SRL patients (adjusted hazard ratio [HR]: 0.34; 95% confidence interval [CI]: 0.18 to 0.62; p < 0.001). The incidence of the first NMSC was similar in the SRL and CNI groups (HR: 0.92; 95% CI: 0.66 to 1.28; p = 0.62). However, conversion to SRL was significantly associated with a decreased risk of subsequent primary occurrences of NMSC compared with that of CNI (adjusted HR: 0.44; 95% CI: 0.28 to 0.69; p < 0.001). The adjusted PTLD risk was significantly decreased in the SRL group (HR: 0.13; 95% CI: 0.03 to 0.59; p = 0.009). Late survival post-HT was markedly decreased in patients who developed non-NMSC, PTLD, or non-PTLD compared with patients who did not develop these malignancies, whereas NMSC had no significant effect on survival. CONCLUSIONS: Conversion to SRL was associated with a decreased risk of all de novo malignancies, PTLD, and subsequent primary occurrences of NMSC after HT. These findings provided further explanation of the late survival benefit with long-term SRL use.
Assuntos
Inibidores de Calcineurina/efeitos adversos , Transplante de Coração/mortalidade , Imunossupressores/efeitos adversos , Neoplasias/epidemiologia , Sirolimo/efeitos adversos , Adulto , Idoso , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Neoplasias/induzido quimicamente , Estudos Retrospectivos , Neoplasias Cutâneas/induzido quimicamente , Neoplasias Cutâneas/epidemiologiaRESUMO
BACKGROUND: Little information is available to predict which patients require opioid analgesia following cutaneous surgery. When opioids are indicated, information regarding the optimal opioid agent selection and dosage is lacking. OBJECTIVE: To make recommendations for opioid prescription after cutaneous surgery. METHODS: A PubMed literature search was conducted to review the available literature. Recommendations are presented on the basis of available evidence and the opinion of the authors. RESULTS: Most patients undergoing cutaneous surgery do not require opioid analgesia. For those who do, the duration of pain warranting opioid analgesia is generally less than 36 hours. Opioid refill requests warrant a follow-up visit to ascertain the cause of ongoing pain after excisional procedures. LIMITATIONS: The recommendations are not based on prospective randomized trials. CONCLUSIONS: The presented recommendations for opioid prescription practice are derived from available evidence, recommendations, and expert opinion.
Assuntos
Analgésicos Opioides/uso terapêutico , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Prescrições de Medicamentos , Humanos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/etiologia , Guias de Prática Clínica como AssuntoRESUMO
BACKGROUND: Undifferentiated pleomorphic sarcoma (UPS) encompasses rare neoplasms that can arise either in the dermis or in the subfascial soft tissue. The behavior of UPS ranges from indolent to aggressive, but data predicting outcomes are limited. OBJECTIVE: Identify predictors of poor outcomes by analyzing a large collection of UPS cases. METHODS: We evaluated all available cases of UPS (including those termed atypical fibroxanthoma, malignant fibrous histiocytoma, pleomorphic dermal sarcoma, and subfascial UPS) across 3 tertiary care centers. RESULTS: Among the 319 patients, 45 experienced recurrence, 33 experienced metastasis, and 96 died of any cause. Risk factors for recurrence were clinical tumor size larger than 5 cm and invasion beyond subcutaneous fat. Risk factors for distant metastases were tumor site, tumor size larger than 2 cm, invasion beyond subcutaneous fat, and lymphovascular invasion. Risk factors for overall mortality were age, immunosuppression, tumor size larger than 2 cm, and lymphovascular invasion. History of skin cancer was associated with a lower risk of recurrence and metastasis. LIMITATIONS: This was a retrospective study. CONCLUSIONS: Using the unbiased approach of pooling all UPS cases regardless of terminology, we identified clinical and histologic factors predicting poor outcomes. We propose subcategorization of UPS (into superficial versus deep UPS), which is consistent with the American Joint Committee on Cancer staging of soft-tissue sarcoma.
Assuntos
Histiocitoma Fibroso Maligno/patologia , Cirurgia de Mohs/métodos , Recidiva Local de Neoplasia/patologia , Sarcoma/patologia , Neoplasias Cutâneas/patologia , Neoplasias de Tecidos Moles/patologia , Adulto , Idoso , Análise de Variância , Biópsia por Agulha , Carcinoma/mortalidade , Carcinoma/patologia , Carcinoma/cirurgia , Estudos de Coortes , Intervalo Livre de Doença , Feminino , Histiocitoma Fibroso Maligno/mortalidade , Histiocitoma Fibroso Maligno/cirurgia , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/cirurgia , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Sarcoma/mortalidade , Sarcoma/cirurgia , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/cirurgia , Neoplasias de Tecidos Moles/mortalidade , Neoplasias de Tecidos Moles/cirurgia , Análise de Sobrevida , Estados UnidosRESUMO
BACKGROUND: Merkel cell carcinoma (MCC) is a rare cutaneous malignancy of neuroendocrine origin with a high propensity for lymph node metastasis. Sentinel lymph node (SLN) status is important for accurate staging; however, the optimal treatment following SLN biopsy, regardless of nodal status, remains unclear. METHODS: 150 patients with MCC who underwent SLN biopsy from 1995 to 2011 at 3 Mayo Clinic sites were reviewed. RESULTS: Of 150 patients with MCC who underwent SLN biopsy, 39 (26%) were positive and 111 (74%) were negative. There was no significant difference between the sex, age, tumor location, or size of primary in the positive and negative SLN groups. While there was no difference in the cumulative incidence of any regional recurrence between SLN groups, the rate of in-transit recurrences was significantly higher in patients with a positive SLN (p = 0.022). The disease-specific survival for MCC was 97.0%, 82.4%, and 82.4% at 1, 3, and 5 years with a positive SLN and 99.0%, 94.9%, and 86.8% with a negative SLN (p = 0.31). Among those alive at last follow up, the median follow up was 3.8 years (IQR, 2.1-8.4) and 2.9 years (IQR, 1.8-6.1) for positive and negative SLN cohorts respectively. CONCLUSIONS: Occult nodal metastasis is common in MCC(26%). No tumor or patient characteristics were identified to predict SLN positivity. Patients with a positive SLN have a higher risk of in-transit recurrence and may benefit from adjuvant radiation with inclusion of the in-transit field in amenable cases. When patients with a positive SLN receive additional treatment to the at-risk nodal basin, both OS and DSS are similar to patients with a negative SLN.
Assuntos
Carcinoma de Célula de Merkel/patologia , Recidiva Local de Neoplasia/patologia , Biópsia de Linfonodo Sentinela , Linfonodo Sentinela/patologia , Neoplasias Cutâneas/secundário , Idoso , Carcinoma de Célula de Merkel/cirurgia , Feminino , Seguimentos , Humanos , Metástase Linfática , Masculino , Invasividade Neoplásica , Recidiva Local de Neoplasia/cirurgia , Prognóstico , Estudos Retrospectivos , Linfonodo Sentinela/cirurgia , Neoplasias Cutâneas/cirurgia , Taxa de SobrevidaAssuntos
Carcinoma de Apêndice Cutâneo/patologia , Carcinoma de Apêndice Cutâneo/cirurgia , Cirurgia de Mohs , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Adulto , Distribuição por Idade , Idoso , Biópsia por Agulha , Carcinoma de Apêndice Cutâneo/mortalidade , Estudos de Coortes , Intervalo Livre de Doença , Neoplasias Faciais/mortalidade , Neoplasias Faciais/patologia , Neoplasias Faciais/cirurgia , Feminino , Humanos , Imuno-Histoquímica , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Distribuição por Sexo , Neoplasias Cutâneas/mortalidade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Most primary cutaneous squamous cell carcinomas are cured with surgery. A subset, however, may develop local and nodal metastasis that may eventuate in disease-specific; death. This subset has been variably termed high risk. Herein, we review; an emerging body of data on the risks of these outcomes and propose an evidence-based; risk stratification for low-, intermediate-, and high-risk tumors that takes into; account both tumor and patient characteristics. Finally, we discuss a framework for; management of these tumors on the basis of data, when available, and our; recommendations when data are sparse.
Assuntos
Carcinoma de Células Escamosas/epidemiologia , Carcinoma de Células Escamosas/patologia , Linfonodos/patologia , Neoplasias Cutâneas/epidemiologia , Neoplasias Cutâneas/patologia , Adulto , Idoso , Biópsia por Agulha , Carcinoma de Células Escamosas/terapia , Gerenciamento Clínico , Medicina Baseada em Evidências , Feminino , Humanos , Imuno-Histoquímica , Excisão de Linfonodo/métodos , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Prognóstico , Risco Ajustado , Neoplasias Cutâneas/terapia , Análise de Sobrevida , Estados UnidosRESUMO
BACKGROUND: Extramammary Paget disease (EMPD) is a rare intraepithelial adenocarcinoma occurring mainly in the anogenital region. Traditional management with wide local excision has shown high recurrence rates, thus Mohs micrographic surgery (MMS) has emerged as a promising treatment option. OBJECTIVE: To compare long-term outcomes after treatment with MMS or excision for primary EMPD. METHODS AND MATERIALS: Retrospective cohort review was conducted for 207 patients with EMPD treated at Mayo Clinic in Rochester, MN, between 1961 and 2012. RESULTS: Of the 25 patients treated with MMS, 19 primary tumors were included for outcome analysis, with an estimated 5-year recurrence-free survival rate of 91% (95% confidence interval [CI], 75-100) using Kaplan-Meier curve analysis. Of 158 patients treated with local excision, 124 were included for the analysis, with an estimated 5-year recurrence-free survival rate of 66% (95% CI, 56-78). The hazard ratio (HR) for association of treatment was 0.4 (95% CI, 0.10-1.65; p = .20). Estimated 5-year overall survival rates were 79% for MMS (95% CI, 61-100) and 68% for excision (95% CI, 59-78) (HR, 1.39 [95% CI, 0.69-2.82]; p = .36). CONCLUSION: Although treatment of primary EMPD with MMS versus excision did not show statistical difference, MMS demonstrated favorable long-term outcomes and was associated with a higher recurrence-free survival rate.
Assuntos
Cirurgia de Mohs , Doença de Paget Extramamária/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Feminino , Neoplasias dos Genitais Masculinos/cirurgia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Doença de Paget Extramamária/mortalidade , Estudos Retrospectivos , Escroto/cirurgia , Resultado do Tratamento , Neoplasias Vulvares/cirurgiaRESUMO
Importance: Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population-based incidence in the United States. Objective: To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. Design, Setting, and Participants: This multicenter retrospective cohort study examined 10â¯649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. Main Outcomes and Measures: Incident skin cancer was determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100â¯000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). Results: Overall, 10â¯649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59â¯923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100â¯000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100â¯000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). Conclusions and Relevance: Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.
Assuntos
Carcinoma de Célula de Merkel/epidemiologia , Carcinoma de Células Escamosas/epidemiologia , Melanoma/epidemiologia , Transplante de Órgãos/estatística & dados numéricos , Neoplasias Cutâneas/epidemiologia , Adolescente , Adulto , Fatores Etários , Idoso , Carcinoma de Célula de Merkel/etnologia , Carcinoma de Células Escamosas/etnologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Melanoma/etnologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Neoplasias Cutâneas/etnologia , Estados Unidos/epidemiologia , População Branca/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a soft tissue tumor with slow infiltrative growth and local recurrence if inadequately excised. OBJECTIVE: To compare long-term outcomes after Mohs micrographic surgery (MMS) and wide local excision (WLE). MATERIALS AND METHODS: Records of patients with DFSP surgically treated with WLE or MMS from January 1955 through March 2012 were retrospectively reviewed. RESULTS: Mean follow-up for patients treated with MMS (n = 67) and WLE (n = 91) was 4.8 and 5.7 years, respectively. Twenty-eight patients (30.8%) with WLE had recurrence (mean, 4.4 years), whereas only 2 (3.0%) with MMS had recurrence (1.0 and 2.6 years). Recurrence-free survival rates at 1, 5, 10, and 15 years were significantly higher with MMS (p < .001). Mean preoperative lesion sizes were similar (5-6 cm) between the 2 groups, whereas mean (standard deviation) postoperative defect sizes were 10.7 (4.3) cm and 8.8 (5.5) cm for WLE and MMS, respectively (p = .004). Primary closure was used for 73% of MMS cases, whereas WLE more commonly used flaps, grafts, or other closures (52%). Two Mohs layers typically were required for margin control. CONCLUSION: Surgical excision with meticulous histologic evaluation of all surgical margins is needed for DFSP treatment to achieve long-term high cure rates and low morbidity.