How dermatologic surgeons decide to proceed with surgery for nonmelanoma skin cancer when site identification is initially uncertain: A nationwide, multicenter, prospective study.

BACKGROUND: Few studies show how dermatologic surgeons manage problems with site identification. OBJECTIVE: To estimate frequency and characterize management of skin cancer treated by surgery when the anatomic location of the tumor is in question. METHODS: Nationwide, prospective, multisite cohort study. RESULTS: Among 17,076 cases at 22 centers, 98 (0.60%) were lesions in question for which site identification was initially uncertain, with these more often in patients who were male, older, and biopsied more than 30 days ago. Surgeons employed on average 5.0 (95% CI: 4.61-5.39) additional techniques to confirm the site location, with common approaches including: re-checking available documentation (90 lesions, 92%); performing an expanded physical examination (89 lesions, 91%); and asking the patient to point using a mirror (61 lesions, 62%). In 15%, photographs were requested from the biopsying provider, and also in 15%, frozen section biopsies were obtained. In 10%, the referring physician was contacted. Eventually, surgeons succeeded in definitively identifying 82% (80 of 98) of initially uncertain sites, with the remaining 18% (18 of 98) postponed. Most postponed surgeries were at non-facial sites. LIMITATIONS: Sites were academic centers. CONCLUSIONS: When the anatomic location of the tumor is uncertain, dermatologic surgeons use multiple methods to identify the site, and sometimes cases are postponed.

Histopathologic upgrading of cutaneous squamous cell carcinomas during Mohs micrographic surgery: A retrospective cohort study.

BACKGROUND: Initial biopsies of cutaneous squamous cell carcinomas (cSCCs) may not reveal aggressive histologic features, which would otherwise inform appropriate surgical management and patient education. OBJECTIVE: To assess the incidence of, and risk factors for, histopathologic upgrading of cSCC during Mohs micrographic surgery (MMS). METHODS: This was a retrospective cohort study of invasive cSCCs treated with MMS between 2017 and 2019 at 1 academic institution. An "upgrade" was defined as a lesser degree of differentiation (poor or moderate) and/or bony or perineural invasion identified during MMS that was not reported in histopathologic evaluation of the initial biopsy. RESULTS: Of the 1558 tumors studied, 115 (7.4%) were upgraded during MMS. In multivariate logistic regression analysis, male sex, prior field treatment, location on the ear/lip, rapid growth of cSCC, and tumor diameter ≥2 cm were significant predictors of tumor upgrading. Upgraded tumors were more likely to require ≥3 MMS stages to clear, complicated closure (flap or graft), or outside (referral) repairs. LIMITATIONS: Single-center study, retrospective, and inter-rater variability. CONCLUSIONS: A significant proportion of cSCCs is histopathologically upgraded with more aggressive features during MMS. Routinely documented patient and tumor characteristics can predict tumor upgrading and assist clinicians in directing the management of potentially high-risk cSCC patients.

Complications After Mohs Micrographic Surgery in Patients Aged 85 and Older.

BACKGROUND: As the US population ages, safe surgical procedures are necessary for treatment of cutaneous neoplasms in very elderly patients. OBJECTIVE: To determine the incidence of complications associated with Mohs micrographic surgery (MMS) in patients aged 85 and older, and the risk factors that predispose to complications. METHODS: A 9-year retrospective chart review of patients aged 85 and older who underwent MMS at our institution between 07/2007 and 11/2016 was performed. Six types of complications associated with scalpel-based cutaneous surgery were recorded, as well as patient, tumor, and repair characteristics. RESULTS: This study included 949 patients totaling in 1683 MMS cases. There were 30 complications: infection (N = 11), wound dehiscence (N = 6), hematoma (N = 6), hemorrhage (N = 5), flap necrosis (N = 1), and graft necrosis (N = 1), resulting in an overall complication rate of 1.78%. Independent risk factors associated with a statistically higher incidence of complications were anticoagulant use (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.26-6.13; p = .012), extremity location (OR, 2.80; 95% CI, 1.19-6.54; p = .018), greater than 2 MMS stages (OR, 2.43; 95% CI, 1.08-5.46; p = .032), and flap repair (OR, 2.27; 95% CI, 1.05-4.90; p = .036). CONCLUSION: Mohs micrographic surgery is a safe procedure for treatment of cutaneous neoplasms in the very elderly.

Extramammary Paget Disease: A Review of the Literature-Part I: History, Epidemiology, Pathogenesis, Presentation, Histopathology, and Diagnostic Work-up.

BACKGROUND: Extramammary Paget disease (EMPD) is a rare malignancy with unclear pathophysiology that occurs predominantly on apocrine rich skin. Surgery is the treatment of choice; however, procedures tend to be extensive and associated with a high rate of recurrence. OBJECTIVE: To review the current literature on EMPD regarding epidemiology, pathogenesis, clinical presentation, histology, diagnostic work-up, treatment, and prognosis. MATERIALS AND METHODS: Literature review using PubMed search for articles related to EMPD. RESULTS: Extramammary Paget disease classically presents as a slowly growing red plaque, which often mimics an inflammatory condition leading to significant delay in diagnosis. Diagnosis requires histopathologic examination and is often supported by immunohistochemical analysis. Once a diagnosis of EMPD is made, the patient must be risk-stratified and evaluated for an underlying malignancy. CONCLUSION: Standard of treatment is surgery, with data suggesting that Mohs micrographic surgery may have superior clinical outcomes and lower recurrence rates. Alternatives such as photodynamic therapy and topicals have been explored and may be appropriate in certain situations. Patients with EMPD generally have a good prognosis with a 5-year overall survival rate of 75% to 95%.

Extramammary Paget's Disease: A Review of the Literature Part II: Treatment and Prognosis.

BACKGROUND: Extramammary Paget's disease (EMPD) is a rare malignancy with unclear pathophysiology that occurs predominantly on apocrine-rich skin. Surgery is the treatment of choice; however, procedures tend to be extensive and associated with a high rate of recurrence. OBJECTIVE: To review the current literature on EMPD regarding treatment and prognosis. MATERIALS AND METHODS: Literature review using PubMed search for articles related to EMPD. RESULTS: Extramammary Paget's disease classically presents as a slowly growing red plaque, which often mimics an inflammatory condition leading to significant delay in diagnosis. Diagnosis requires histopathologic examination and is often supported by immunohistochemical analysis. Once a diagnosis of EMPD is made, the patient must be risk-stratified and evaluated for an underlying malignancy. CONCLUSION: Standard of treatment is surgery, with data suggesting that Mohs micrographic surgery may have superior clinical outcomes and lower recurrence rates. Alternatives such as photodynamic therapy and topicals have been explored and may be appropriate in certain situations. Patients with EMPD generally have a good prognosis with a 5-year overall survival rate of 75% to 95%.

Positive Bacterial Culture Results at a Dermatologic Surgery Center: A Single-Site Retrospective Review.

BACKGROUND: Typical prophylactic coverage of suspected cutaneous surgical-site infections (SSIs) predominantly covers gram-positive bacteria. Data regarding the frequency of infection with unusual bacteria, not covered by prophylaxis, are not available. OBJECTIVE: A retrospective 10-year review of culture-positive infections at a single academic site was performed. MATERIALS AND METHODS: All positive bacterial culture results at the Washington University Center for Dermatologic and Cosmetic Surgery between October 31, 2007, and October 31, 2017, were collected and analyzed. RESULTS: Coagulase-negative staphylococcus accounted for 20.8% of positive culture results. Staphylococcus aureus caused 45.4% of infections. The remaining 33.8% were due to non-S. aureus bacteria, most frequently with Pseudomonas aeruginosa (10.8%). Numerous other gram-negative organisms and unusual gram-positive organisms were cultured. The lower extremity and ear were the only sites more likely to be infected with non-S. aureus bacteria. Smokers and immunosuppressed individuals were not more likely to have an SSI with non-S. aureus bacteria. CONCLUSION: A significant proportion of all SSIs with positive culture results was due to bacteria that are not sensitive to beta-lactam prophylaxis. Broader coverage for suspected SSI should be considered, particularly on the lower extremity and ear.

Squamous Cell Carcinoma of the Hand: A Retrospective Study in Immunosuppressed and Immunocompetent Individuals.

BACKGROUND: Cutaneous squamous cell carcinoma (SCC) of the hand presents a treatment challenge because of the anatomical complexity of this location. Immunosuppressed patients are disproportionately affected by cutaneous SCC. Existing data on SCC of the hand are primarily presented in the orthopedic literature, and may thus be affected by referral bias. OBJECTIVE: Characterization of epidemiology and treatment outcomes for hand versus nonhand cutaneous SCC in immunosuppressed versus immunocompetent patients, across all clinical departments. MATERIALS AND METHODS: Single-institution retrospective cohort study of cutaneous SCC evaluated over 3 years and hand SCC over an additional 5 years. RESULTS: A cohort of 522 hand SCC cases (1,746 total SCC) was ascertained among 1,064 patients, of whom 175 were immunosuppressed. Occurrence on the hand was more common for SCC arising in immunosuppressed versus immunocompetent patients (38% vs 24% of cases respectively). Hand SCC cases demonstrated balanced laterality and comparable spectra of differentiation regardless of immunosuppression. No cases of hand SCC metastasis were observed over greater than 2 years' mean follow-up, and digital amputation was only required in approximately 1% of hand SCCs. CONCLUSION: In our cohort, assessment of hand SCC across all clinical departments suggests more favorable prognosis than reflected in the previous literature.

Histopathologic upgrading of nonmelanoma skin cancer at the time of Mohs micrographic surgery: A prospective review.

BACKGROUND: Anecdotal experience and data from multiple retrospective studies have suggested that a significant percentage of nonmelanoma skin cancers (NMSCs) display an aggressive histologic subtype that is not diagnosed on initial biopsy. OBJECTIVE: To prospectively determine the proportion of NMSCs upgraded at the time of Mohs micrographic surgery (MMS) and examine the surgical parameters of upgraded lesions. METHODS: In this prospective, cross-sectional study, all patients undergoing MMS for NMSC at our institution over the course of 1 year were screened for inclusion. Frozen sections were reviewed independently by 2 fellowship-trained Mohs surgeons. RESULTS: In total, 265 of 2578 (10.3%) tumors displayed a more aggressive skin cancer histologic subtype on frozen-section analysis at the time of surgery than at the initial biopsy. Upgraded tumors required significantly more stages to reach tumor clearance, had a larger postoperative defect size, and more often required complicated repairs than nonupgraded tumors. LIMITATIONS: Single center study, limited time period, and cross-sectional design. CONCLUSION: A significant portion of MMS cases were upgraded at the time of surgery to a more aggressive subtype than that seen at the initial biopsy. Upgraded cases were larger and more surgically challenging than nonupgraded ones. This finding has important implications for primary dermatologists' referral practices and Mohs appropriate use criteria guidelines.

Pacemakers, Deep Brain Stimulators, Cochlear Implants, and Nerve Stimulators: A Review of Common Devices Encountered in the Dermatologic Surgery Patient.

BACKGROUND: In dermatologic and procedural surgery settings, there are commonly encountered devices in patients. Safe surgical planning requires familiarity with these devices. OBJECTIVE: To review the current implanted devices in patients and recommendations for surgical planning around these devices. METHODS AND MATERIALS: A comprehensive review using PubMed and published device recommendations was performed, searching for those most relevant to dermatologic surgery. RESULTS: Devices such as pacemakers and implantable cardiac defibrillators, deep brain stimulators, cochlear implants, and various nerve stimulators are potential devices that may be encountered in patients and specific recommendations exist for each of these devices. CONCLUSION: Dermatologic surgeons' knowledge of implanted devices in patients is paramout to safe surgical procedures.

Clinical Characteristics of Basal Cell Carcinoma in African Americans: A 10-Year Retrospective Review at a Single Academic Institution.

BACKGROUND: Basal cell carcinoma (BCC) is an uncommon diagnosis in African Americans, and as a result, there is a limited amount of data available. OBJECTIVE: We sought to describe the clinical characteristics of BCC in African Americans treated with Mohs micrographic surgery (MMS). METHODS: We performed a retrospective case series in an ambulatory referral center at a single academic institution from 2007 to 2017 to characterize BCCs in African Americans treated with MMS. RESULTS: A total of 17 patients, who identified as black or African American, with 18 BCCs were included for analysis. Patients were predominantly female (82%) with a mean age at diagnosis of 61 years. Seventy-eight percent of tumors were located in the head and neck region with 50% of BCCs located in high-risk areas. The average preoperative and postoperative defect size was 1.78 and 5.90 cm, respectively, with a mean number of 2.2 Mohs stages required for tumor clearance. One patient had Gorlin syndrome. CONCLUSION: The presented retrospective review adds to limited available reported studies regarding BCC in African Americans to potentially aid in early recognition of these tumors.

Sebaceous Carcinoma Treated With Mohs Micrographic Surgery.

BACKGROUND: Sebaceous carcinoma is a rare and potentially aggressive adnexal neoplasm with historic data indicating high rates of recurrence, metastasis, and cancer-specific mortality. OBJECTIVE: To evaluate the incidence of local recurrence, metastasis, disease-specific mortality, and all-cause mortality and to identify work-up approaches. PATIENTS AND METHODS/MATERIALS: Retrospective review of patients with sebaceous carcinoma treated with Mohs micrographic surgery between 2001 and 2013 at one institution. RESULTS: Thirty-seven patients had 45 sebaceous carcinomas located on the periocular region (13%), non-periocular face (47%), scalp (7%), neck (4%), trunk (9%), and extremities (20%). The mean age was 66.1 years, and 24 (65%) patients were male. Five patients had Muir-Torre syndrome (MTS) or Lynch syndrome. Seven of 12 tumors showed loss of expression of ≥1 mismatch repair gene. The most common work-up involved taking a detailed personal and family medical history. No local recurrences, metastases, or disease-specific deaths occurred during an average follow-up of 3.6 years. CONCLUSION: Mohs micrographic surgery is an effective treatment for sebaceous carcinoma. Detailed history taking, age-appropriate cancer screening, and immunohistochemical staining with MLH1, MSH2, or MSH6 is helpful in identifying which patients should be referred to a geneticist for work-up of MTS.

Adjuncts to Improve Nasal Reconstruction Results.

The final cosmetic appearance of nasal reconstruction scars is of paramount importance to both the patient and surgeon. Ideal postreconstruction nasal scars are flat and indistinguishable from surrounding skin. Unfortunately, even with meticulous surgical execution, nasal scars can occasionally be suboptimal. Abnormal fibroblast response can lead to hypertrophic nasal scars, and excessive angiogenesis may lead to telangiectasias or an erythematous scar. Imperfect surgical closure or poor postoperative management can lead to surgical outcomes with step-offs, depressions, suture marks, or dyspigmentation. Aesthetically unacceptable nasal scars can cause pruritus, tenderness, pain, sleep disturbance, and anxiety and depression in postsurgical patients. Fortunately, there are several minimally invasive or noninvasive techniques that allow for enhancement and improvement of cosmetic results with minimal risk and associated downtime. This article provides an overview of adjuncts to improve nasal reconstruction with a focus on techniques to be used in the postoperative period. Armed with an understanding of relevant available therapies, skillful surgeons may drastically improve the final cosmesis and outcome of nasal reconstruction scars.

Sebaceous carcinoma: review of the literature.

BACKGROUND: Sebaceous carcinoma is an uncommon adnexal neoplasm with a documented capability for regional and distant metastasis. Traditionally, sebaceous carcinoma has been associated with high rates of recurrence after excision. OBJECTIVE: To review the current literature on sebaceous carcinoma and detail its epidemiology, pathogenesis, clinical presentation, histopathology, diagnostic workup, treatment, and prognosis. MATERIALS AND METHODS: Literature review using PubMed search for articles related to sebaceous carcinoma. RESULTS: Sebaceous carcinoma typically presents as a painless pink or yellow nodule. Diagnosis requires histopathologic examination, and immunohistochemical analysis often assists in the differentiation of sebaceous carcinoma from other benign and malignant skin neoplasms. Sebaceous carcinoma should prompt a workup for Muir-Torre syndrome. Periorbital sebaceous carcinoma has an increased tendency for regional metastasis, although cancer-specific mortality rates are similar among all anatomic locations. CONCLUSION: Surgery is the preferred treatment for local disease. Limited data suggest that Mohs micrographic surgery may provide superior clinical outcomes, but more research is needed regarding the long-term outcomes. Radiation and systemic chemotherapy are reserved for recurrent or metastatic disease.

Histopathologic characteristics of therapy-associated cutaneous neoplasms with vemurafenib, a selective BRAF kinase inhibitor, used in the treatment of melanoma.

BACKGROUND: Activating mutations in BRAF have been observed in up to 60% of melanomas, indicating a pivotal role for kinase deregulation in tumor progression. Vemurafenib is a specific inhibitor of BRAF for treatment of melanomas with activating BRAF V600E mutations and has been a major advancement in melanoma treatment. Treatment with vemurafenib, and to a lesser extent, sorafenib, a relatively non-specific inhibitor of BRAF, has been associated with cutaneous squamous cell carcinoma (SCC). METHODS: Clinical and microscopic characteristics of cutaneous neoplasms were evaluated following vemurafenib administration. RESULTS: Twenty-four of 47 (51%) patients receiving vemurafenib at our institution developed 146 total cutaneous neoplasms, with 75% developing multiple lesions. The median number of lesions in affected patients was three. Body distribution included head/neck (29%), chest/back (21%), upper (23%) and lower extremities (27%). Lesions were biopsied and pathologically showed multiple types of epidermal tumors including, but not limited to, verrucous keratoses with/without partial thickness dysplasia, actinic keratoses and well-differentiated and invasive SCCs with/without keratoacanthomatous features. CONCLUSIONS: We describe the histopathologic findings of skin lesions potentially associated with vemurafenib. Additional investigation is necessary to further elucidate cutaneous neoplasms associated with vemurafenib; however, frequent dermatologic evaluation is warranted in all patients receiving BRAF inhibitors.

Combination therapy for perianal squamous cell carcinoma in situ with imiquimod and photodynamic therapy.

Perianal squamous cell carcinoma in situ (SCCIS) is a relatively rare intraepidermal neoplasm that has the potential to progress to invasive squamous cell carcinoma. First-line treatment is surgical excision, though nonsurgical treatment modalities such as 5-aminolevulinic acid-based photodynamic therapy (ALA-PDT) and imiquimod also have been investigated for this neoplasm. Unfortunately, recurrences are known to occur after both surgical and nonsurgical monotherapies. We report a case of perianal SCCIS that was successfully treated with a novel combination of ALA-PDT and imiquimod.