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.

The role of imaging in the prevention of wrong-site surgery in dermatology.

Wrong-site surgery in dermatology often results from inaccurate identification of a skin cancer biopsy site. Factors making biopsy-site identification difficult include background actinic damage, delays from biopsy to surgery, and lack of photographic documentation. While other methods exist for biopsy-site identification, photography is the most helpful tool available. Although modern technology has made high-quality photographic equipment ubiquitous and easy to use, photography for biopsy-site identification continues to be underutilized. The authors recommend that photographic documentation of biopsy sites become the standard of care.

Resident rounds part III: plaque on left areola of an African-American woman.

Basal cell carcinoma (BCC) is the most common cutaneous malignancy, and usually presents on sun-exposed areas of the skin. Unsurprisingly, BCC appearing on the nipple-areola complex (NAC) is rare, and even more so in females and dark skin types. BCC of the NAC is more aggressive than other locations, thus diagnosis and treatment are imperative. We present a case of an African American female with a lichenified, scaly plaque on her left areola that was unresponsive to clobetasol. After biopsy, the lesion was identified as pigmented BCC of the NAC. The patient denied surgical treatment and was treated with topical 5-fluorouracil. The BCC initially resolved but recurred at 22 month follow-up. We plan to treat the recurrence with Mohs surgery.

Not all basal cell carcinomas are created equal: a case of a fatal BCC.

Basal cell carcinoma is one of the most common malignancies in the world. It is usually a low-grade malignancy, but may invade deeper structures and metastasize in less than 0.1 percent of cases. Giant basal cell carcinoma is a rare, much more aggressive subtype greater than 5 cm in diameter. In the article, the authors present a case of a neglected giant basal cell carcinoma that resulted in death and provide a brief update on the literature.

Epidermolysis bullosa nevus-like lesions in a pediatric patient with pyoderma gangrenosum.

Epidermolysis bullosa-associated nevi are recently described dysplastic nevi found in patients with epidermolysis bullosa. These lesions display clinical features of unusual nevi suggestive of malignancy but thus far cases with malignant transformation have not been reported. We describe a case of epidermolysis bullosa-type nevi developing in a child with pyoderma gangrenosum. The nevi in our patient were found in areas previously affected by pyoderma gangrenosum and were clinically concerning for malignancy. However, they were only moderately atypical on light and confocal microscopy. This case demonstrates that pediatric patients with cutaneous inflammation, bullae formation, or both, are at risk for developing unusual nevi at previous sites of skin involvement. Considering the absence of malignant change in these nevi, we suggest that close observation can be employed in cases where this diagnosis can be confirmed both clinically and microscopically.

Skin metastases from lung cancer.

Cutaneous metastases from the lung are rare but must be ruled out in patients with suspicious skin lesions and history of smoking or lung cancer. All histological types of lung cancer may metastasize to the skin and clinical lesions are variable. The percentage of patients with lung cancer that develop cutaneous metastases ranges from 1 to 12 percent. In 20-60 percent of cases the skin lesions present before or synchronously with the diagnosis of the primary tumor. Skin lesions are often described as nodular, mobile or fixed, hard or flexible, single or multiple, and painless. Histologically, cutaneous metastases from the lung are frequently moderately or poorly differentiated. IHC markers that may be useful in these cases are anti-thyroid transcription factor (TTF) and CK7/20. Treatment of solitary cutaneous metastases usually includes surgery alone or combined with chemotherapy, and/or radiation. If multiple cutaneous lesions or internal metastases exist, chemotherapy is the primary option. Cutaneous metastases and their primaries in the lung are usually incurable and suggest an unfortunate prognosis. Poor prognostic indicators include non-resectable or small-cell primary tumors, multiple cutaneous metastases, or other distant metastases. Mean survival is usually about 5-6 months.