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

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

No Recurrence in Primary Invasive Stage 1a and 1b Melanoma and Melanoma in Situ Treated With Serial Disk Staged Excision.

BACKGROUND: Optimal surgical treatment modality for invasive melanoma (IM) and melanoma in situ (MIS) has been debated with proponents for standard wide local excision (WLE), serial disk staged excision, and Mohs micrographic surgery. OBJECTIVE: The purpose of this study is to identify the recurrence rates and surgical margins of invasive stage 1 melanoma and MIS lesions using serial disk staged excision technique with rush permanent processing and "bread loafing" microscopic analysis. MATERIALS AND METHODS: Recurrence rates and surgical margins of 63 IM and 207 MIS at the University of California Dermatology Surgery Unit were retrospectively reviewed. RESULTS: No recurrences were observed with average follow-up of 34 and 36 months for IM and MIS, respectively (range, 10-92 months). Average surgical margins were 19.8 mm (SD 9.7) for IM and 12.1 mm (SD 12.2) for MIS. CONCLUSION: This SSE technique for the treatment of IM and MIS is comparable in efficacy to other SSE techniques, and it offers physicians a simple and accessible alternative to WLE and MMS.

Effectiveness of a 595-nm Pulsed Dye Laser for the Treatment of Basal Cell Carcinoma Using One Double-Stacked Pulse Session: A Randomized, Double-Blinded Controlled Trial.

BACKGROUND: Surgical and nonsurgical methods are used for treating basal cell carcinoma (BCC). Few randomized controlled trials exist on the effectiveness of the pulsed dye laser (PDL) on BCC treatment. OBJECTIVE: We investigated the effectiveness of PDL treatment in a single session for the management of nodular and superficial BCCs on the trunk and extremities of adults using a randomized, double-blind, controlled technique. METHODS: We used settings of fluence 7.5 J/cm2, 3-ms pulse duration, no dynamic cooling, 10-mm spot size, 10% overlap between pulses, and 2 stacked pulses on a 595-nm wavelength laser. Histopathologic clearance on excision of tumor with 4-mm margins was the primary outcome measure. RESULTS: Twenty-four patients were included in the study, with 14 in the laser treatment group and 10 patients in the sham/control group. In total, 10/14 (71.4%) of the tumors in the treatment group were successfully treated with no residual tumor on excisional specimen histology, compared with 3/10 (30.0%) of the control group (p = .045). CONCLUSION: Our study shows that PDL may be an effective treatment for low-risk BCCs of the trunk and extremities, but the cure rate is lower than those of other treatments for BCC. Thus, PDL under the current settings cannot be recommended.

Characteristics of Superficial Basal Cell Carcinomas Containing More Aggressive Subtypes on Final Histopathologic Diagnosis.

BACKGROUND: The prognosis and treatment of basal cell carcinoma (BCC) are largely dependent on tumor subtype, which is typically determined by punch or shave biopsy. Data regarding concordance between BCC subtype on initial biopsy and final histopathology for Mohs micrographic surgery (MMS) or excision with frozen sections (EFS) are limited. OBJECTIVES: To determine the concordance between initial biopsy and final MMS or EFS subtyping of BCC. We aim to investigate the incidence and clinical characteristics of lesions initially diagnosed as superficial BCC (sBCC) that are later found to have a nodular, micronodular, or infiltrative component. METHODS: We conducted a retrospective review of all MMS or EFS cases performed at a single academic center from August 1, 2015 to August 31, 2017. Inclusion criteria were a biopsy-proven diagnosis of sBCC and presence of residual tumor following stage I of MMS or EFS. Fisher’s exact test was used to evaluate significance of clinical characteristics and outcomes associated with the presence of a nodular, micronodular, or infiltrative BCC component. RESULTS: A total of 164 MMS or EFS cases had an initial biopsy showing sBCC. Of these, 117 had residual BCC on stage I, and 43 (37%) were found to have a nodular, micronodular, or infiltrative component. Significant predictors of reclassified BCC subtype included age over 60 years (P=0.006) and location on the head or neck (P=0.043). Reclassified lesions required significantly more stages of MMS to clear (P=0.036). Shave biopsy was used to diagnose 114 (98%) of the included cases. CONCLUSIONS: Over one third of shave biopsies that initially diagnosed sBCC failed to detect a nodular, micronodular, or infiltrative component. Management of biopsy-proven sBCC should take into account the possible presence of an undiagnosed deeper tumor component with appropriate margin-assessment treatment modalities when clinically indicated. J Drugs Dermatol. 2021;20(3):283-288. doi:10.36849/JDD.5383.

Urgent safety considerations for dermatologic surgeons in the COVID-19 pandemic.

Dermatologic surgeons are at increased risk of contracting SARS-COV-2. At time of writing, there is no published standard for the role of pre-operative testing or the use of smoke evacuators, and personal protective equipment (PPE) in dermatologic surgery. Risks and safety measures in otolaryngology, plastic surgery, and ophthalmology are discussed. In Mohs surgery, cases involving nasal or oral mucosa are highest risk for SARS-COV-2 transmission; pre-operative testing and N95 masks should be urgently prioritized for these cases. Other key safety recommendations include strict control of patient droplets and expanded pre-clinic screening. Dermatologic surgeons are encouraged to advocate for appropriate pre-operative tests, smoke evacuators, and PPE. Future directions would include national consensus guidelines with continued refinement of safety protocols.

A 4-year retrospective assessment of postoperative complications in immunosuppressed patients following Mohs micrographic surgery.

BACKGROUND: Many patients undergoing Mohs micrographic surgery for basal and squamous cell carcinomas are immunocompromised, yet postoperative complications associated with different types of immunosuppression are largely unstudied. OBJECTIVE: To determine the incidence and nature of postoperative complications in immunosuppressed patients undergoing Mohs micrographic surgery. METHODS: A retrospective cross-sectional chart review of patient characteristics, clinical characteristics, and complications. RESULTS: Univariable analysis showed that compared with immunocompetence, immunosuppression was associated with 9.6 times the odds of postoperative complication (P = .003), with solid organ transplant recipients having 8.824 times higher odds (P = .006) and immunosuppressive therapy use displaying 5.775 times higher odds (P = .021). Surgical site infection (2.5%) and dehiscence (0.51%) were more prevalent among immunosuppressed patients, with an overall complication rate of 5.4% in the immunosuppressed population. Multivariable analysis of the association between immunosuppression and postoperative complication closely trended toward, but did not meet, significance (P = .056). LIMITATIONS: This was a single-center, retrospective study. Other limitations include lack of non-solid organ transplants, limited medication-related data on nontransplant patients, and exclusion of cases involving patients with double transplants or multiple sources of immunosuppression. CONCLUSIONS: Immunosuppression overall, particularly owing to solid organ transplant and immunosuppressive therapy use, places patients at higher risk for postoperative complications, including surgical site infection and wound dehiscence following MMS.

An expanded study of long-pulsed 1064 nm Nd:YAG laser treatment of basal cell carcinoma.

BACKGROUND AND OBJECTIVE: Basal cell carcinoma (BCC) is an indolent form of skin cancer that is rarely life threatening, but can cause significant cosmetic and functional morbidity. Surgical treatments often result in disfiguring scars, while topical therapies frequently result in recurrence. The need for a more effective nonsurgical alternative has led to the investigation of laser treatment of BCC. We have previously conducted a pilot study which showed 100% histologic clearance at high fluences. Treatments were well tolerated with no significant adverse events. The objective of this larger study was to confirm preliminary results that the 1064 nm Nd:YAG laser is a safe and effective method for treating non-facial BCC. DESIGN: This is an IRB-approved, prospective, multi-center study evaluating the safety and efficacy of the 1064 nm Nd:YAG laser for the treatment of BCC on the trunk and extremities. Thirty-three subjects seeking treatment for biopsy-proven BCC that did not meet the criteria for Mohs surgery were recruited. Subjects on current anticoagulation therapy, or with a history of immunosuppression were excluded. Subjects received one treatment with the 1064 nm Nd:YAG laser as follows: 5-6 mm spot, fluence of 125-140 J/cm2 and a pulse duration of 7-10 ms. Standard excision with 5 mm clinical margins was performed at 30 days after laser treatment to evaluate clinical and histologic clearance of BCC. Standardized photographs and adverse assessments were taken at the baseline visit, immediately after laser treatment and on the day of excision. RESULTS: Thirty-one subjects completed the study. BCC tumors had a 90% (28 of 31 BCC tumors) histologic clearance rate after one treatment with the long-pulsed 1064 nm Nd:YAG laser. Treatments were generally well tolerated without any anesthesia. Immediate side effects included edema and erythema. At 1-month follow-up, some patients had residual crusting. No significant adverse events occurred. CONCLUSION: The 1064 nm long-pulsed Nd:YAG laser is an alternative for treating non-facial BCC for those that are poor surgical candidates. Lasers Surg. Med. © 2018 Wiley Periodicals, Inc.

Clinical Characteristics of Lower Extremity Surgical Site Infections in Dermatologic Surgery Based Upon 24-Month Retrospective Review.

Dermatologic surgery performed on the lower extremities has an increased risk for surgical site infections (SSI). Our objective was to evaluate the clinical characteristics associated with SSI following Mohs micrographic surgery (MMS) and wide local excisions (WLE) performed below the knee. We performed a single-center retrospective chart review of patients (n=271) that underwent these procedures. Within 14 days of the lower extremity procedure, four of 175 MMS patients (2.3%) developed SSI compared to eight of 96 WLE patients (8.3%; P=0.029). Subcuticular sutures and vertical mattress sutures as a group were associated with reduced 30-day infection rate when compared to other suture methods (P=0.006). Comparison of patients on prophylactic antibiotics to control patients without antibiotics did not reveal a statistically significant difference in infection rate. MMS infection rates trended lower as compared to WLE in the 14-day post-operative window. Doxycycline prophylaxis did not produce a statistically significantly lower rate of SSI, though results approached significance. A prospective study may be warranted to further compare cephalexin and doxycycline for dermatologic surgery below the knee. Subcuticular or vertical mattress sutures may be preferred when closing wounds due to their association with reduced infection rate. J Drugs Dermatol. 2018;17(7):766-771.

Basal Cell Carcinoma of the Dorsal Foot: An Update and Comprehensive Review of the Literature.

BACKGROUND: Ultraviolet radiation is a well-known risk factor for basal cell carcinoma (BCC). Therefore, the high incidence of BCCs in sun-exposed areas such as the head and neck is unsurprising. However, unexpectedly, BCCs on the sun-protected dorsal foot have also been reported, and tumor occurrence here suggests that other factors besides ultraviolet radiation may play a role in BCC pathogenesis. Because only few dorsal foot BCCs have been reported, data on their clinical features and management are limited. OBJECTIVE: To perform an updated review of the literature on clinical characteristics and treatment of dorsal foot BCCs. METHODS: We conducted a comprehensive literature review by searching the PubMed database with the key phrases "basal cell carcinoma dorsal foot," "basal cell carcinoma foot," and "basal cell carcinoma toe." RESULTS: We identified 20 cases of dorsal foot BCCs in the literature, 17 of which had sufficient data for analysis. Only 1 case was treated with Mohs micrographic surgery. We present 8 additional cases of dorsal foot BCCs treated with Mohs micrographic surgery. CONCLUSION: Basal cell carcinomas on the dorsal foot are rare, and potential risk factors include Caucasian descent and personal history of skin cancer. Mohs micrographic surgery seems to be an effective treatment option.

Squamous Cell Carcinoma In Situ Upstaged to Invasive Squamous Cell Carcinoma: A 5-Year, Single Institution Retrospective Review.

BACKGROUND: Shave biopsy may not be able to accurately distinguish squamous cell carcinoma in situ (SCCIS) from invasive squamous cell carcinoma (SCC). Information on the incidence of biopsy-proven SCCIS upstaged to SCC after a more complete histologic examination is limited. OBJECTIVE: To determine the incidence and clinical risk factors associated with upstaging the biopsy diagnosis of SCCIS into invasive SCC based on findings during Mohs micrographic surgery (MMS). METHODS: All MMS cases of SCCIS performed between March 2007 and February 2012 were identified, MMS operative notes were examined, and invasive dermal components were confirmed by the MMS slide review. Upstaged SCCIS was defined as biopsy-diagnosed SCCIS subsequently found to be an invasive SCC during MMS. RESULTS: From 566 cases with the preoperative diagnosis of SCCIS, 92 (16.3%) cases were SCCIS upstaged to SCC. Location of ears, nose, lips, and eyelids, preoperative diameter >10 mm, and biopsy report mentioning a transected base were significant predictors of upstaged SCCIS. CONCLUSION: Considering the possibility that over 16% of SCCIS may be truly invasive SCC, biopsy-proven SCCIS should be treated adequately with margin-assessed treatment modalities such as surgical excision or Mohs surgery when indicated.

A Systematic Review of Completeness of Reporting in Randomized Controlled Trials in Dermatologic Surgery: Adherence to CONSORT 2010 Recommendations.

BACKGROUND: Randomized controlled trials are the gold standard for comparing safety and effectiveness of surgical interventions. Reporting guidelines are available for conveying the results of such trials. OBJECTIVE: To assess adherence to standard reporting guidelines among randomized controlled trials in dermatologic surgery. MATERIALS AND METHODS: Systematic review. Data source was randomized controlled trials in the journal Dermatologic Surgery, per PubMed search, 1995 to 2014. Studies were appraised for the number of the 37 CONSORT 2010 Checklist criteria reported in each. Analysis included comparison of reporting across 4 consecutive periods. RESULTS: Three hundred sixty-three studies were eligible. The mean number of items reported per study increased monotonically from 14.5 in 1995 to 1999 to 16.2 in 2002 to 2004, 17.7 in 2005 to 2009, and 18.0 in 2010 to 2014 (p < .0001). A limitation was that study procedures may have been performed without being reported. CONCLUSION: Completeness of reporting in randomized controlled trials in dermatologic surgery has improved significantly during the preceding 2 decades. Some elements are still reported at lower rates.

Mohs micrographic surgery for eccrine porocarcinoma: an update and review of the literature.

BACKGROUND: Eccrine porocarcinoma (EPC) is a rare malignancy of the eccrine sweat glands that is locally aggressive with a high propensity to metastasize. Most cases have been treated by wide local excision (WLE) with 20% local recurrence rate. There have been 20 cases of EPC treated with Mohs micrographic surgery (MMS) in the literature. OBJECTIVE: To review the literature regarding the management of this aggressive tumor using MMS. METHODS: A comprehensive literature review was conducted by searching the PubMed database using the keywords Mohs, porocarcinoma, malignant eccrine poroma, and eccrine neoplasms. RESULTS: Most of the reported cases of EPC were treated by WLE, and only 20 cases were treated with MMS. Of the 20 EPC cases treated with MMS, there was only 1 nodal recurrence and no local recurrence. Other reported treatment modalities include radiation and excision with frozen sections. The authors report the second case of EPC on the temple, and the 21st case successfully treated with MMS. CONCLUSION: Eccrine porocarcinoma is a rare neoplasm with potentially aggressive clinical behavior. In cases where tissue conservation is important, MMS should be considered.

Knowledge, understanding, and use of preventive strategies against nonmelanoma skin cancer in healthy and immunosuppressed individuals undergoing Mohs surgery.

BACKGROUND: Despite various national recommendations advising individuals to reduce their exposure to ultraviolet radiation, many people still do not use these skin cancer prevention strategies. OBJECTIVES: To assess patient sources of medical information, knowledge of sun protection strategies, and barriers to implementing these strategies and to compare the overall rate of use of skin cancer prevention strategies of healthy and immunocompromised patients. MATERIALS AND METHODS: Survey-based study conducted on 140 individuals undergoing Mohs surgery. RESULTS: Seventy-three percent of healthy and 74% of immunosuppressed participants identified sunscreen use as a form of protective strategy, whereas 36% and 27%, respectively, used sunscreen daily. Participants cited physicians and the internet as equal sources of medical information. Knowing two or more strategies correlated to a higher self-rating of daily use of any protective strategy. CONCLUSION: General knowledge regarding sun protection strategies is limited, but awareness of multiple strategies correlated with greater sun protective behavior. Despite having a much higher incidence of skin cancers, the immunosuppressed group did not show more awareness of prevention strategies or higher use than healthy participants.

Treatment of surgical scars using a 595-nm pulsed dye laser using purpuric and nonpurpuric parameters: a comparative study.

BACKGROUND: Many studies have examined laser treatment of scars, but cosmetic results have been variable. Although no studies have examined the effect of purpura on scar improvement using the pulsed dye laser (PDL), many clinicians believe inducing purpura results in better and quicker improvement. OBJECTIVE: To determine whether PDL treatment of fresh surgical scars with purpura-inducing settings improves clinical appearance more than non-purpura-inducing settings or no treatment. METHODS: Twenty-six subjects with surgical scars enrolled in this prospective study. Scars were divided into three equal segments; treatment was randomized: 595-nm PDL with purpuric (1.5 ms) or nonpurpuric (10 ms) settings or no treatment. Fluences were adjusted to Fitzpatrick skin type. Scars were treated three times, 1 month apart, beginning at suture removal. Outcome measures included Vancouver Scar Scale (VSS) and blind clinical ratings. RESULTS: The nonpurpuric condition showed significant improvement on the VSS total score, vascularity, and pliability ratings. The purpuric condition demonstrated a trend for improvement on the VSS total. According to blind observer ratings, all conditions improved, without differences between groups. CONCLUSION: Nonpurpuric settings on the PDL resulted in significant improvements in the appearance of fresh surgical scars for vascularity, pliability, and VSS total scores, although all scar segments improved over time.

Surgical smoke in dermatologic surgery.

BACKGROUND: Potential dangers associated with smoke generated during electrosurgery have been described. However, the use of smoke management in dermatology is unknown. There is no objective data showing the amount or the composition of the smoke generated in dermatologic surgeries. OBJECTIVE: To assess the use of smoke management in dermatologic surgery and provide data on the amount and chemical composition of surgical smoke. METHODS: A total of 997 surveys were sent to dermatologic surgeons across the United States to assess the use of smoke management. Amounts and concentrations of particulates and chemical composition were measured during electrosurgery using a particulate meter and the Environmental Protection Agency-standardized gas chromatography-mass spectrometry analysis. RESULTS: Thirty-two percent of the surgeons responded to the survey, and 77% of the respondents indicated no use of smoke management at all. Only approximately 10% of surgeons reported consistent use of smoke management. Active electrosurgery produced significant amounts of particulates. In addition, surgical smoke contained high concentrations of known carcinogens, such as benzene, butadiene, and acetonitrile. CONCLUSION: Surgical smoke contains toxic compounds and particulates. Most dermatologic surgeons do not use smoke management within their practices. Raising the awareness of the potential risks can help increase the use of smoke management.