Practice Patterns for Mohs Surgeons of Varying Clinical Experience: A Cross-Sectional Analysis of a Medicare Claims Database.

BACKGROUND: Use of Mohs micrographic surgery (MMS) is highly prevalent, but little data are available on how surgeon experience affects surgical practice patterns. OBJECTIVE: To determine differences in use of MMS among surgeons of varying experience. MATERIALS AND METHODS: This cross-sectional study sampled from clinicians billing ≥200 mean annual Mohs surgery claims from the 2012 to 2018 Medicare Public Use File. The primary outcome was mean annual Mohs surgery claims for clinicians of varying experience. Secondary outcomes included use of flaps/grafts and prescribing of oral antibiotics, benzodiazepines, and opioids. RESULTS: Among 1,759 unique surgeons, those with 16 to 20 years of experience performed the most mean annual (95% confidence interval) Mohs surgical cases (578.7 [556.7-600.6]). Surgeons with 21 to 25 years of experience prescribed the most antibiotics (240.2 [216.5-263.8] mean annual claims), whereas those with >35 years of experience prescribed the longest courses (15.3 [14.2-16.4] days). CONCLUSION: Midcareer surgeons performed the most mean annual Mohs surgery cases, whereas later career surgeons prescribed more frequent and longer courses of antibiotics suggesting changing practice patterns with additional years of experience.

Indications and Outcomes of Mohs Micrographic Surgery Using a Multidisciplinary Approach: A Decade of Experience.

BACKGROUND: Traditional approaches of staged outpatient Mohs Micrographic Surgery (MMS) in nonmelanoma skin cancer (NMSC) followed by reconstruction is not possible in a subset of patients. OBJECTIVE: Assess the indications and outcomes of a multidisciplinary approach MMS. METHODS AND MATERIALS: Retrospective, single-surgeon, single Mohs specialist, university-based tertiary care referral practice, including all MMS performed in the operating room setting with concurrent reconstruction in patients from 2008 to 2018 with minimum follow-up of 6 months. Patients with NMSCs who completed multidisciplinary MMS approach were included. Number of Mohs stages, duration of procedure, reconstruction techniques, and complications including flap loss, bleeding, hematoma, wound infections, dehiscence, and local recurrence rates were reviewed. RESULTS: Three hundred twenty patients were included, 160 male and 160 female with mean ages of 71.6 and 72.1 years, respectively. Indications for a multidisciplinary approach MMS were as follows: neuro/psych 22.5%, extensive anticipated defect size 55%, patient request/convenience 4.4%, medical intolerance 5%, multiple reasons 8.1%, and unknown in 5%. Average stage required to clear margins was 1.57 ± 0.64. Mean operative times by increasing Mohs stages up to 3 including reconstruction were 125.1, 159.3, and 195.5 minutes, respectively (p < .00001). CONCLUSION: Indications for a multidisciplinary approach MMS were extensive defects and neuro/psych issues. Advantages include patient tolerance and single-stage procedure.

Pigmented epithelioid melanocytoma (animal-type melanoma): An institutional experience.

BACKGROUND: Pigmented epithelioid melanocytoma (PEM) is an uncommon, recently described entity with unknown biologic behavior. There is a high rate of regional metastases, but limited evidence of distant metastases or disease-related death. OBJECTIVE: We sought to report our series of patients given a diagnosis of PEM at our institution and provide mutational analysis of genes commonly implicated in melanoma in 2 cases. METHODS: The pathology database was queried for cases of PEM diagnosed at the University of Rochester. Charts were reviewed for follow-up information. Mutational analysis of melanoma-associated genes was performed on 2 cases. RESULTS: Nine cases of PEM were retrieved in a 10-year retrospective review. Five patients underwent sentinel lymph node biopsy with 3 of 5 having a positive sentinel lymph node. All 9 patients are alive and disease-free with average follow-up of 38.75 months. Two tumors were tested for common melanoma-associated mutations, and were negative, except for a telomerase reverse transcriptase promoter deletion detected in 1 sample. The deletion has not been associated with melanoma, and therefore its biologic significance is unclear. LIMITATIONS: Small sample size, retrospective nature, and single institution experience are limitations. CONCLUSIONS: PEM appears to have an indolent behavior. However, currently the evidence is too limited to provide insight into its true biologic potential.

Retention of Mohs surgeons in academic dermatology.

BACKGROUND: Retention of academic Mohs surgeons is important for the growth of this specialty and teaching of residents and students. OBJECTIVE: To examine factors that influence retention of Mohs surgeons in academics and to better understand reasons for their departure. MATERIALS AND METHODS: A survey was electronically distributed to academic Mohs surgeons in the American College of Mohs Surgery, asking them to rate the importance of several variables on their decision to remain in academia. Private practice Mohs surgeons who had left academics were also surveyed. RESULTS: Two hundred thirty-six dermatologic surgeons completed the survey. Twenty-nine percent work full time in academics, and approximately 7% work part time. The top reasons for practicing in the academic setting are intellectual stimulation, teaching opportunities, and collaboration with other university physicians and researchers. Seventy-one percent of respondents reported they would stay in academics, 7% indicated they would not, and 22% were unsure. Unfair compensation, inadequate support staff, poor leadership, increased bureaucracy, and decreased autonomy were top reasons that may compel a Mohs surgeon to leave. CONCLUSION: Opportunities for intellectual stimulation, collaboration, and teaching remain the main draw for academic Mohs surgeons. A supportive environment, strong leadership, and establishing fair compensation are imperative in ensuring their stay.

Current status of surgery in dermatology.

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

Malignant tumors of the penis.

BACKGROUND: Although penile cancer is rare in developed countries, it occurs more frequently in other parts of the world and causes significant morbidity and mortality. OBJECTIVE: To review the current literature on the pathogenesis, risk factors, clinical presentation, staging, and treatment of premalignant and malignant tumors of the penis. MATERIALS AND METHODS: A literature review using PubMed was conducted searching for articles on penile malignancies. RESULTS: The majority of penile cancers are in situ or invasive squamous cell carcinomas, although other rare tumors of the penis occur, such as melanoma, basal cell carcinoma, extramammary Paget's disease, and soft tissue sarcomas. CONCLUSION: Physicians should be aware of the risk factors and clinical presentation of penile malignancies because early diagnosis is essential in effective management and cure. Accurate staging is imperative for risk stratification and treatment planning. Depending on the type of tumor, size of tumor, location, staging, and grading, treatment modalities vary and may include topical chemotherapy, surgical excision, Mohs micrographic surgery, laser excision or ablation, systemic chemotherapy, and radiotherapy.

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.

Atypical fibroxanthoma: a review of the literature.

BACKGROUND: Atypical fibroxanthoma (AFX) is an uncommon superficial fibrohistiocytic tumor. It was originally described as a low-grade dermal tumor of atypical spindle cells, but this view has changed, and it is generally considered to be a tumor of intermediate malignant potential. OBJECTIVE: To review the current literature on AFX pertaining to epidemiology, pathogenesis and etiology, clinical presentation, histology, immunohistochemistry, prognosis and follow-up, and treatment. MATERIALS AND METHODS: Extensive literature review was conducted using OVID Medline and Pubmed searching for articles relating to AFX. RESULTS: AFX typically presents as a red or pink papule or nodule on the head or neck of an elderly man. The pathogenesis is most commonly related to ultraviolet radiation. It can clinically mimic other cutaneous malignancies and histologically can mimic squamous cell carcinoma, desmoplastic melanoma, and undifferentiated pleomorphic sarcoma. Immunohistochemistry is important in making the distinction. The prognosis is generally excellent, although there are rare cases of metastatic disease. There is a higher cure rate with Mohs' micrographic surgery than with wide local excision. CONCLUSIONS People with AFX generally have had significant ultraviolet radiation exposure. They should be examined at least every 6 months for recurrence, metastasis, and the development of additional skin cancers.

Prospective evaluation of surgical site infection rate among patients with Mohs micrographic surgery without the use of prophylactic antibiotics.

BACKGROUND: Antibiotics may be indiscriminately given to patients undergoing Mohs micrographic surgery (MMS) for the prevention of surgical site infections, despite a low risk of infection in these patients. OBJECTIVE: We sought to evaluate the rate of wound infections among patients undergoing MMS without the use of prophylactic antibiotics. METHODS: We prospectively evaluated 1000 consecutive patients undergoing MMS for nonmelanoma skin cancer or modified MMS/"slow Mohs" for lentigo maligna melanoma in situ. RESULTS: The overall wound infection rate among 1000 patients with 1115 tumors was 0.7% (8/1115 tumors). Five (62.5%) of 8 infections occurred on the nose with an overall 1.7% (5/302) nose infection rate. Seven (87.5%) of 8 infections occurred after flap reconstruction with an overall 2.4% (7/296) flap closure infection rate. Four (50%) of 8 infections occurred in patients requiring more than one Mohs stage for tumor clearance with a 0.8% (4/487) overall infection rate in cases requiring multiple Mohs stages. Two (25%) of 8 infections had cultures positive for oxacillin-resistant Staphylococcus aureus. No wound infections occurred in cases involving the lips or ears, skin-graft closures, or below-knee or modified MMS procedures. LIMITATIONS: This was a prospective single institution uncontrolled study. CONCLUSION: Rates of infections among patients undergoing MMS or modified MMS are exceedingly low. Indiscriminate use of antibiotics increases patient risk to adverse drug reactions and antibiotic resistance. Administration of antibiotics to patients undergoing MMS should be on a case-by-case basis according to the known risk factors combined with clinical judgment.

Tanning and cutaneous malignancy.

BACKGROUND: Exposure to ultraviolet radiation (UVR) results in a darkening of the skin known as tanning. Recently, it has been shown that tanning is a response to UVR-induced DNA damage and represents the skin's efforts to protect itself against further injury. Despite the link between UVR and cutaneous malignancy, people continue to pursue tanning from natural and artificial sources. This trend is reflected in the exponential rise in skin cancer incidence. OBJECTIVE: The objective of this study was to review our current understanding of the factors controlling the tanning response and the relationship to cutaneous carcinogenesis, as well as the impact that the multibillion dollar tanning industry has had on the practice of dermatology. MATERIALS AND METHODS: Extensive literature review was conducted in subjects related to tanning and the relationship to cutaneous malignancy. RESULTS: Our knowledge of tanning and its effects on the skin has increased tremendously. It is clear that tanning contributes to the development of skin cancer. Despite this information, the incidence of skin cancer continues to increase exponentially. CONCLUSIONS: Skin cancer poses a major public health concern and tanning remains the most modifiable risk factor in its etiology. Social, economic, and legislative issues have become tightly intertwined with the complex nature of human behavior in the continued pursuit of an activity that clearly has detrimental effects on one's health.

Special concern about squamous cell carcinoma of the scalp in organ transplant recipients.

BACKGROUND: Several risk factors are generally accepted to portend more aggressive behavior of cutaneous squamous cell carcinoma. These include tumor size, tumor depth, histologic subtype, location on the lip or ear, tumor arising in scar, recurrent tumor, and tumor demonstrating perineural invasion. Organ transplant recipients can have significant morbidity and mortality from squamous cell carcinoma. OBSERVATIONS: Four organ transplant recipients developed metastatic disease from squamous cell carcinoma of the scalp. CONCLUSIONS: Squamous cell carcinoma of the scalp in organ transplant recipients should be considered a high-risk tumor because of its anatomic location. Margin-controlled tumor extirpation, sentinel lymph node biopsy, and adjuvant radiation therapy should all be considered in the organ transplant recipient population.

Decreasing the pain of local anesthesia: a prospective, double-blind comparison of buffered, premixed 1% lidocaine with epinephrine versus 1% lidocaine freshly mixed with epinephrine.

BACKGROUND: Local anesthetics are acidic and cause pain on infiltration into the skin. Two methods are commonly used by dermatologists to raise the pH of lidocaine with epinephrine: buffering with sodium bicarbonate or freshly mixing lidocaine with epinephrine on the day of use. OBJECTIVE: Our purpose was to compare the pain induced by infiltration of the skin with 1% lidocaine with epinephrine 1:100,000 buffered with sodium bicarbonate (buffered) versus 1% lidocaine freshly mixed with epinephrine (fresh). METHODS: Sixty volunteers were recruited for this prospective, double-blind study. Each subject received an intradermal injection of the buffered solution and the fresh solution. Immediately after each injection subjects rated the pain of infiltration on a 100-mm visual analog scale. The pain scores for the anesthetic solutions were compared using the paired t test. RESULTS: The pain score for the buffered solution was 18.3 +/- 20.3, and the pain score for the fresh solution was 23.5 +/- 19.1 (P = .0543). Sixty-five percent of subjects felt the fresh solution was more painful than the buffered solution. LIMITATIONS: The results did not reach statistical significance. CONCLUSION: In this small study, buffered lidocaine with epinephrine caused less pain on infiltration into the skin than lidocaine freshly mixed with epinephrine, but the results were not statistically significant.

Imiquimod for the treatment of skin cancer.

Imiquimod is a topically applied immunomodulator. Although initially approved for genital and perianal warts, dermatologists have prescribed this compound for many neoplastic and nonneoplastic skin conditions. The US Food and Drug Administration recently approved imiquimod for the treatment of actinic keratoses. This article reviews the literature on imiquimod in the treatment of cutaneous malignancies.

PKK suppresses tumor growth and is decreased in squamous cell carcinoma of the skin.

Non-melanoma skin cancer represents the most common cancer in the United States. Squamous cell carcinoma (SCC) of the skin is a subtype of NMSC that shows a greater potential for invasion and metastasis. The current study identifies the protein kinase C-associated kinase (PKK), which is also known as the receptor-interacting protein kinase 4, as a suppressor of tumor growth in SCC of the skin. We show that expression of PKK is decreased in human SCC of the skin compared with normal skin. Further, suppression of PKK in human keratinocytes leads to increased cell proliferation. The use of RNA interference to reduce PKK expression in keratinocytes leads to an increase in S phase and in proteins that promote cell cycle progression. Consistent with the results obtained from cell culture, there is a marked increased tumorigenesis after PKK knockdown in a xenotransplant model and in soft agar assays. The loss of tumor suppression involves the NF-κB and p63 pathways. NF-κB is inhibited through inhibition of inhibitor of NF-κB kinase function and there is increased nuclear TP63 activity after PKK knockdown. This study opens new avenues both in the discovery of disease pathogenesis and for potential treatments.

Building the minority faculty development pipeline.

The shortage of faculty in dental education is well documented, but the data also show a shortage of minorities in postgraduate programs, which develop future faculty. In the last ten years, ADEA's effort to address minority issues in dental education has made some progress. In addition, examples of pipelines for minority faculty development that have shown some success include: a partnership between Harlem Hospital and Columbia University School of Dentistry and Oral Surgery in which the school dedicates one position in its postgraduate training programs to an individual participating in the Harlem Hospital General Practice Residency program; a partnership between the National Dental Association Foundation and Colgate-Palmolive Company, which provides scholarships for advanced dental education study; and the Bronx Lebanon Hospital Center Department of Dentistry, which enrolls underrepresented minorities in its General Practice Residency Program, a new Pediatric Dentistry Residency Program, and a unique program providing hands-on experience in HIV/AIDS health care policy and AIDS development management. Critical elements in the relative success of these programs are environment, selection criteria, mentoring, networking, and finance. The true measure of the outcomes is still to be seen.

Office management of melanoma patients.

As the incidence of melanoma continues to increase, so does the role of the dermatologist as both medical and surgical oncologist for these patients. The dermatologist holds a key role in all phases of care, including prevention, diagnosis, treatment, and follow-up. The dermatologist is best trained to complete a full and thorough skin examination and is best able to recognize a melanoma in its early stages of growth. Dermatologists have a unique opportunity to prevent melanoma through appropriate patient education concerning sun protection, self skin examinations, and the ABCDEs of melanoma recognition (ie, asymmetry, border irregularity, color variations, dimension and evolution). The dermatologist is well trained to obtain an appropriate full-thickness skin biopsy and is knowledgeable to interpret the pathologist report and understand the significance of the various histologic prognostic indexes. Most patients present with localized disease and with thinner Breslow depth and thus can be skillfully treated in an outpatient setting under local anesthesia by a dermatologist.

Actinic keratoses: a comprehensive update.

Actinic keratoses are common intra-epidermal neoplasms that lie on a continuum with squamous cell carcinoma. Tightly linked to ultraviolet irradiation, they occur in areas of chronic sun exposure, and early treatment of these lesions may prevent their progression to invasive disease. A large variety of effective treatment modalities exist, and the optimal therapeutic choice is dependent on a variety of patient- and physician-associated variables. Many established and more recent approaches are discussed in this review with a focus on efficacy and administration techniques. Several previously experimental options, such as imiquimod and photodynamic therapy, have become incorporated as first-line options for the treatment of actinic keratoses, while combination treatment strategies have been gaining in popularity. The goal of all therapies is to ultimately limit the morbidity and mortality of squamous cell carcinoma. (J Clin Aesthetic Dermatol. 2009;2(7):43-48.).

Metastasizing atypical fibroxanthoma (cutaneous malignant histiocytoma): report of five cases.

BACKGROUND: Atypical fibroxanthoma (AFX) is an unusual malignant fibrohistiocytic tumor of sun-damaged skin. When first described, it was felt to be a reactive tumor of low malignant potential. More recently, it has been shown to be a tumor of intermediate malignant potential. OBJECTIVE: To describe five cases of metastatic AFX. RESULTS: Five patients ranging in age from 65 to 85 years old presented with metastatic AFX. Three of the five cases presented with regional lymph node disease. Also, three of the five cases had other aggressive cutaneous malignancies. LN-2 (CD74) staining was positive in three of five primary tumors and two of five metastatic tumors. CONCLUSION: The metastatic potential of AFX may be underestimated. LN-2 staining may be a useful marker in identifying more aggressive tumor behavior.

Guidelines for the management of squamous cell carcinoma in organ transplant recipients.

BACKGROUND: Solid-organ transplant recipients have a high incidence of cutaneous squamous cell carcinoma (SCC) and often develop multiple and aggressive tumors. There are few published studies or reviews, which provide guidance to the clinician in the treatment of these patients. OBJECTIVE: The objective was to develop useful clinical guidelines for the treatment of skin cancer in organ transplant recipients (OTRs). METHODS: The members of the Guidelines Committee of the International Transplant-Skin Cancer Collaborative (ITSCC) carried out a computerized search utilizing the databases of the National Library of Medicine for reports in the literature on SCC in OTRs. These reports were collectively examined by the group and combined with experiences from the members' clinical practices in the development of the guidelines. RESULTS: More than 300 articles relating to SCC in OTRs were reviewed. In general, reports concerning the prevention and treatment of SCC in OTRs are of individual cases or small case series. They are retrospective in nature, statistically nonrigorous, and lack the complete epidemiologic data necessary to derive definitive conclusions. Combining these studies and collective clinical experience, however, is at present the best available method for devising guidelines for the treatment of SCC in OTRs. CONCLUSION: Guidelines developed for the treatment of skin cancer in OTRs, supported by the best available data and collective clinical experience, may assist in the management of OTRs with SCC. The development of clinical pathways and complete documentation with rigorous prospective study is necessary to improve and refine future guideline development.