Identifying critical quality metrics in Mohs Surgery: A national expert consensus process.

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.

Clinical spectrum of atypical fibroxanthoma and undifferentiated pleomorphic sarcoma in solid organ transplant recipients: a collective experience.

BACKGROUND: Atypical fibroxanthoma (AFX) and undifferentiated pleomorphic sarcoma (UPS) are uncommon, spindle cell cutaneous malignancies. Solid organ transplant recipients (SOTRs) are immunosuppressed and therefore have a higher incidence of cutaneous malignancies. OBJECTIVE: We describe the clinical spectrum of AFX and a more-aggressive, deeper variant, UPS, in SOTRs. MATERIALS AND METHODS: A retrospective chart review of AFX and UPS in SOTRs was implemented. Cases from Vanderbilt University, Emory University, Mayo Clinic-Jacksonville, and University of Rochester were included. A literature search included previously published cases. RESULTS: The average age of SOTRs at time of tumor presentation was younger than typically seen in immunocompetent patients for AFX. Rates of local recurrences and metastases were higher in the SOTRs than is noted in the immunocompetent literature. Rates of recurrence were higher in those treated with excision than in those treated with Mohs micrographic surgery (MMS). CONCLUSION: AFX and UPS may have a greater risk for recurrence, metastases, and mortality in SOTRs, in whom early treatment with MMS may demonstrate certain advantages in terms of minimizing risk of recurrence and metastasis. UPS and recurrent tumors should be staged appropriately and may respond to adjuvant radiation therapy and reduction of immunosuppression. Immunohistochemical evaluation is recommended to exclude other spindle cell tumors.

The public's perception of dermatologists as surgeons.

BACKGROUND: Dermatologists perform more cutaneous surgical procedures than any other medical specialists, including plastic surgeons, especially for treating skin cancers, but anecdotal evidence suggests that the public may not identify dermatologists as surgeons. OBJECTIVE: Our study was designed to assess the public's perception of expertise in surgery of the skin of three medical specialties: dermatology, plastic surgery, and general surgery. We also investigated whether the physician's specialty biases people when they assess the cosmetic appearance of a surgical scar. MATERIALS AND METHODS: We administered an institutional review board-approved survey to individuals at the Emory Student Center and the Emory Dermatology Clinic. Participants rated the perceived skills and training of the different medical specialties and scored the cosmetic appearance of 16 surgical scars created by a fellowship-trained Mohs surgeon labeled as the work of different specialists. RESULTS: Results from 467 participants were overwhelmingly in favor of plastic surgeons (p<.001). The physician's specialty did not bias participants in assessing the cosmetic appearance of surgical scars. CONCLUSION: The study population had greater confidence in the surgical skills of plastic surgeons than in those of dermatologists, although participants were objective in rating the cosmesis of surgical scars, regardless of the purported surgeon's specialty. Although dermatologic surgeons must continually refine our surgical expertise, we must also educate the public about the breadth and depth of our work. The authors have indicated no significant interest with commercial supporters.

Non-surgical treatments of primary, non-melanoma eyelid malignancies: a review.

The diagnosis and management of periocular cutaneous malignancies are essential components of an ophthalmologist's practice. Skin cancers comprise nearly one-third of newly diagnosed malignancies. Furthermore, the incidence of skin cancer appears to be increasing. Multiple treatment modalities exist for periocular cutaneous malignancy. Surgical extirpation, often with the combined expertise of a Mohs micrographic surgeon, is typically the first line therapy and is often curative in the periocular region, depending on a variety of factors, including tumour histology, specific location, depth of invasion and surgical technique. However, there are instances where a less invasive, non-surgical treatment option is warranted, including patients who are poor surgical risks or those with diffuse disease. The purpose of this article is to review the literature and describe the non-surgical treatment options, indications and efficacies for non-melanoma primary eyelid malignancies.

Mohs versus traditional surgical excision for facial and auricular nonmelanoma skin cancer: an analysis of cost-effectiveness.

OBJECTIVE: To evaluate and compare Mohs micrographic surgery and traditional excision in terms of cost and outcomes. DESIGN: We developed a computer-simulation, probabilistic, decision model to perform a cost-effectiveness analysis, with each patient serving as his or her own control. SETTING: University of Connecticut dermatology clinic, a tertiary care referral center. PARTICIPANTS: Input data were derived from results of a consecutive sample of 98 patients with nonmelanoma skin cancer on the face and ears, estimates in the literature on 5-year recurrence rates, and a query of healthy focus-group participants. INTERVENTION: We considered Mohs and traditional excision strategies. MAIN OUTCOME MEASURES: Outcomes were measured in quality-adjusted life years, cost, and cost-effectiveness. RESULTS: The Mohs strategy was $292 less expensive than the traditional surgical strategy and was more effective by an incremental quality-adjusted life year of 0.056 (translating to approximately 3 weeks of optimal quality of life). Results were robust to subgroup and sensitivity analyses. CONCLUSIONS: Mohs may be more cost-effective than traditional excision in eradicating nonmelanoma skin cancer. Further investigation of costs from various geographic payment localities and assessment of quality-of-life outcomes from a population-based sample are needed.

The impact of total body photography on biopsy rate in patients from a pigmented lesion clinic.

BACKGROUND: Total body cutaneous photography is increasingly being used by dermatologists to monitor patients at risk for the development of melanoma, but limited evidence exists regarding the impact of such photography on melanoma and melanoma-related outcomes. OBJECTIVE: We sought to compare biopsy number in patients with multiple atypical nevi in their first year of care at our pigmented lesion clinic (PLC) between those who received total body skin examination alone and those who received total body skin examination and total body digital photography (TBDP). We sought to identify predictors of biopsy number and number of dysplastic nevi diagnosed in patients with multiple atypical nevi. METHODS: A chart review was performed of patients attending the PLC during the years 1998 to 2003 to identify the number of biopsies performed in the first year of care. Patient demographics, melanoma risk factors, and melanoma outcome events were also abstracted from the charts. RESULTS: The mean number of biopsies performed in patients in their first year of care at the PLC in those who did not receive TBDP was equal to the mean number of biopsies performed in patients who did receive TBDP (0.82 and 0.8, respectively). Linear regression analysis revealed that the interaction term between a lack of both personal history of melanoma and severe dysplastic nevi (-0.930, P = .005) has a significant protective effect on the number of biopsies. Similar regression analysis also showed that the interaction term between a lack of both personal history of melanoma and of severe dysplastic nevi (-1.209, P < .0001), increasing provider experience (-0.047, P = .029), and increased number of biopsies before the initial PLC (-0.028, P = .050) have a statistically significant protective effect on the number of dysplastic nevi diagnosed in the first year of PLC. TBDP did not have an effect on the number of biopsies or on the number of dysplastic nevi diagnosed in the first year of care at the PLC. LIMITATIONS: This study is limited by being retrospective in nature, having a small sample size, and having a short follow-up period. CONCLUSION: Overall, this small retrospective study does not provide evidence that would suggest that TBDP changes provider behavior in caring for patients at high risk for melanoma. Rather, our study supports the fact that a patient's positive history of melanoma and a history of severe dysplastic nevi have the most significant impact on provider biopsy behavior, resulting in a lower threshold to biopsy suggestive lesions.

Interferon Alfa-2b or not 2b? Significant differences exist in the decision-making process between melanoma patients who accept or decline high-dose adjuvant interferon Alfa-2b treatment.

BACKGROUND: Patients with thick (Breslow>4 mm) primary melanoma and/or regional nodal metastasis have a high risk of tumor recurrence. High-dose adjuvant interferon (IFN) alfa-2b offers/=50% risk of recurrence/disease-related mortality and offered IFN. Telephone surveys delineated reasons behind patients' decisions to accept IFN. RESULTS: Acceptors, 60 of 135 (45%), decided to take IFN alfa-2b whereas 75 of 135 (55%) declined. Being female (OR, 2.4; 95% CI, 1.17-5.03; p=.017) and positive SLN status (OR, 2.2; 95% CI, 1.01-4.97; p=.048) were strongly associated with patients who chose IFN. Acceptors of IFN were younger, more influenced by physicians, and less affected by depression and side effect profile (p<.05 for all). Decliners were more concerned by strained relationships with family and social life (p<.05). CONCLUSIONS: Gender and positive SLN were predictive of high-risk melanoma patients' acceptance of IFN treatment. Physician insight into melanoma patients' therapeutic decision-making process can guide patients through this difficult disease.

Morpheaform basal cell carcinoma in African Americans.

BACKGROUND: Although it has been established that basal cell carcinoma is an uncommon diagnosis in black patients, the morpheaform subtype is very rare among these individuals. OBJECTIVE: The objective is to present two cases of morpheaform basal cell carcinoma in African-American patients. METHODS: This is a case series and a literature review using the Ovid Medline Database. Key words used in the search include "basal cell carcinoma," "African American," "black," "African," "negros," "morpheaform," "sclerosing," "fibrosing," and "scar-like basal cell carcinoma." The Ovid Medline Database was searched from 1966 to present and was restricted to the English language. RESULTS: A review of the Emory Dermatology clinic charts from 1989 to 2004 revealed two black patients with morpheaform basal cell carcinomas. CONCLUSIONS: Although extremely rare, morpheaform pattern basal cell carcinoma must be considered in the differential diagnosis for black patients presenting with nonhealing lesions.

Myofibrosarcoma treated with Mohs micrographic surgery.

BACKGROUND: Myofibrosarcoma is a rare malignant mesenchymal tumor composed predominantly of differentiated myofibroblasts. These tumors occur in both children and adults alike and are most commonly located on the head and neck. Recurrences rates range from 44% to 75%, and metastatic disease has been reported in up to 44% of cases. OBJECTIVE: The objective was to present a case of a myofibrosarcoma treated with Mohs micrographic surgery and discuss the use of ultrastructural evaluation in the diagnosis of this rare tumor. METHODS: A 31-year-old African American woman who presented to the Emory University Dermatologic Surgery Clinic with a 4-month history of a 2.5 x 2.5-cm indurated firm painful right upper lateral thigh nodule. A prior biopsy revealed a proliferation of somewhat bland spindled cells with large zones of necrosis with prominent mitotic figures, changes compatible with a cellular dermatofibroma. Because the lesion exhibited clinically suspicious characteristics such as rapid growth and deep infiltration, the patient was subsequently referred to Emory for further evaluation. There was no evidence of lymphadenopathy and a chest X-ray was unremarkable. RESULTS: A two-staged (five and four sections, respectively) uneventful Mohs micrographic surgery procedure was performed resulting in a defect measuring 3.5 x 3.5 x 1.0 cm. Primary closure was achieved with no complication, and the final scar measured 10 cm. Because of the suspicious clinical behavior of this tumor debulking specimen was sent for permanent section. Histopathologic interpretation of these sections was consistent with a fibrosarcoma with myofibroblastic differentiation. No clinical recurrence noted after 14-month follow-up. CONCLUSION: Mohs micrographic surgery is a technique that has been shown to provide superior cure rates in the treatment of many mesenchymal tumors. Here, we report the first case of myofibrosarcoma treated with Mohs micrographic surgery. Myofibrosarcoma is a rare but aggressive tumor that can be difficult to distinguish from other somewhat less aggressive malignancies such as dermatofibrosarcoma protuberans or malignant fibrous histiocytoma. Specific histopathologic criteria are reviewed. We recommend including Mohs micrographic surgery in the armamentarium for the treatment of this rare tumor.

Keloids demonstrate high-level epidermal expression of vascular endothelial growth factor.

BACKGROUND: Keloids are a major cause of morbidity, and arise after operation, injury, or cutaneous infection. Clinically, keloids differ from hypertrophic scars in that they grow beyond the original borders of the injury. Keloids occur most commonly for patients of African and Asian descent, and treatment options are multiple, indicating that there is no entirely satisfactory treatment for keloids. Angiogenesis inhibition has been shown to be effective in treatment of malignancy in both animal models and human beings. OBJECTIVE: We sought to determine whether keloids produce the potent angiogenic factor vascular endothelial growth factor (VEGF). METHODS: We performed in situ hybridization for VEGF on keloid tissue and normal skin. RESULTS: Our study demonstrated abundant production of VEGF in keloids and, surprisingly, the major source of VEGF was the overlying epidermis. CONCLUSIONS: Our results suggest that the overlying epidermis is the major source of keloid angiogenesis. These findings demonstrate that keloids are angiogenic lesions. Topical antiangiogenic therapy, directed at either down-regulating epidermal VEGF or inhibiting keratinocyte-derived VEGF activity on its endothelial receptors, may be useful in the treatment of keloids.

Multiple, clustered dermatofibroma: a rare clinical variant of dermatofibroma.

BACKGROUND: Although patients with one to two dermatofibromas are common, cases of "multiple" dermatofibromas (more than 15 lesions) are rare and may occur in the context of altered or normal immune function. Patients with multiple dermatofibromas clustered in one anatomic area, by contrast, are strikingly rare. OBJECTIVE: The aim of our study was to present an additional case of multiple, clustered dermatofibroma (MCDF) and to summarize the literature concerning this entity. METHODS: We performed a MEDLINE (1960-2001) database search using keywords "dermatofibroma" AND "clustered" OR "agminated" OR "grouped." RESULTS: Five case reports were identified using this search strategy. These cases demonstrated substantial similarity in clinical features and behavior, specifically, the presence of pruritic symptoms, no clear inciting incident, an early active growth phase followed by stabilization, predilection for the lower extremity, and no report of sarcomatous transformation. CONCLUSION: Despite an active early growth phase, MCDF appears to follow a benign clinical course, with no report of sarcomatous transformation at up to 20 years followup.

Acral lentiginous melanoma mimicking benign disease: the Emory experience.

BACKGROUND: Plantar and subungual melanoma exhibits a higher misdiagnosis rate relative to other anatomic sites. Misdiagnosis and delay in diagnosis are statistically associated with poorer patient outcome. Awareness of atypical presentations of acral melanoma may, thus, be important to decrease misdiagnosis rates and improve patient outcome. METHODS: We conducted a retrospective case review of plantar or lower-extremity subungual melanoma performed at Winship Cancer Center, a tertiary care, referral center affiliated with Emory University, between 1985 and 2001. RESULTS: A total of 53 cases of plantar or lower-extremity subungual melanoma were identified. Of 53 cases with a final diagnosis of melanoma, 18 were initially misdiagnosed. Misdiagnoses included wart, callous, fungal disorder, foreign body, crusty lesion, sweat gland condition, blister, nonhealing wound, mole, keratoacanthoma, subungual hematoma, onychomycosis, ingrown toenail, and defective/infected toenail. Of the 18 misdiagnosed cases, 9 were clinically amelanotic. CONCLUSION: Awareness that amelanotic variants of acral melanoma may assume the morphology of benign hyperkeratotic dermatoses may increase the rate of correct diagnosis and improve patient outcome.