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.

Factors associated with skin cancer in lung transplant recipients: A single-center experience.

BACKGROUND: Skin cancer is common after solid organ transplantation, but few have investigated it after lung transplant (LTx). OBJECTIVE: We assessed incidence and predictors of non-melanoma skin cancer (NMSC) post-LTx. METHODS: We studied patients who underwent LTx at our center from 2012 to 2015. RESULTS: Of 287 patients, mean age was 59.6 ± 11 years, 170 (59.2%) were men, and 231 (80.5%) were white. Seventy-six (26.5%) developed NMSC over a median follow-up of 32 months (IQR, 23-45). Of those with NMSC, 37% developed subsequent skin cancer of the same type. Independent predictors of decreased odds of NMSC and squamous cell carcinoma (SCC) were non-white race (P = .002; P = .003) and body mass index >30 kg/m2 compared with underweight patients (P = .001, P = .009). Patients with skin cancer pre-LTx had higher risk of post-LTx skin cancer (P = .02). Voriconazole use ≥100 days was associated with increased risk of SCC (P = .03), but not increased risk of basal cell carcinoma. Out of 76, 4 (5.3%) died from skin cancer. LIMITATIONS: Retrospective, single-center study. CONCLUSION: Squamous cell carcinoma risk post-LTx may increase with prolonged voriconazole use in white patients with pre-LTx history of skin cancer, whereas excess body weight may be protective from NMSC. Regular pre- and post-LTx skin cancer screenings and guidelines are warranted.

Factors associated with advanced-stage Merkel cell carcinoma at initial diagnosis and the use of radiation therapy: Results from the National Cancer Database.

BACKGROUND: The stage of disease at initial diagnosis and the use of radiation therapy (RT) are important determinants of survival in patients with Merkel cell carcinoma (MCC). OBJECTIVE: To define factors that are associated with advanced-stage MCC at the time of initial diagnosis and the use of RT. METHODS: Cross-sectional, retrospective analysis of patients with MCC registered in the National Cancer Database during the period from 2004 to 2013. RESULTS: A total of 11,917 patients were identified; 3152 and 4586 patients were excluded from the staging and RT analyses, respectively, because of lack of available data. African American ethnicity (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.06-2.10; P = .023), lack of medical insurance (OR, 2.15; 95% CI, 1.40-3.30; P < .001), Charlson-Deyo comorbidity score of at least 1 (OR, 1.21; 95% CI, 1.09-1.34; P < .001), residence more than 26 miles from a treatment facility (OR, 1.18; 95% CI, 1.03-1.35; P = .015), tumor located on the lower limb/hip (OR, 1.59; 95% CI, 1.42-1.78; P < .001) or trunk (OR, 2.05; 95% CI, 1.81-2.33; P < .001), and poorly (OR, 2.57; 95% CI, 1.13-5.82; P = .024) or undifferentiated (OR, 3.11; 95% CI, 1.36-7.15; P = .007) tumor histology predicted advanced-stage MCC at the time of initial diagnosis. The use of RT was associated with Native American ethnicity (OR, 5.04; 95% CI, 1.10-22.99; P = .037), tumor size between 1.5 and 2.7 cm (OR, 1.27; 95% CI, 1.10-1.47; P = .001), electing not to have surgery (OR, 2.77; 95% CI, 1.90-4.03; P < .001), positive postsurgical margins (OR, 1.39; 95% CI, 1.18-1.63; P < .001), and receiving treatment at a comprehensive cancer program (OR, 1.25; 95% CI, 1.03-1.50; P = .020). LIMITATIONS: Retrospective design limits generalizability of the results, and precise details of RT regimens utilized were not available. CONCLUSIONS: A number of factors are associated with advanced-stage MCC at initial diagnosis and the use of RT. Health care models should account for these factors, and efforts should be directed toward improving those that are modifiable.

Survival in patients with primary dermatofibrosarcoma protuberans: National Cancer Database analysis.

BACKGROUND: The predictors of mortality, second surgery, and postoperative radiation therapy for treating dermatofibrosarcoma protuberans (DFSP) are not well described. OBJECTIVE: We sought to determine the impact of patient demographics, tumor characteristics, and treatment site and modality on survival after primary DFSP. METHODS: A retrospective analysis of data from the National Cancer Database was performed for patients diagnosed with DFSP during 2003-2012. RESULTS: A total of 5249 cases were identified. Of these, 3.1% of patients died during an average of 51.4 months of follow-up. After adjusting for relevant factors, lack of insurance, Medicaid and Medicare insurance, anaplastic histology, and positive postoperative margins all predicted mortality, while treatment at an Integrated Network Cancer Program predicted survival (P < .05). Higher odds of postoperative radiation therapy were directly associated with large tumor size, anaplastic and poorly differentiated histology, and positive postoperative margins and inversely associated with treatment at high volume facilities, and non-head and neck tumors. Higher second surgery rates were associated with Hispanic ethnicity, and lower rates were associated with female sex. LIMITATIONS: Survival data was not cancer-specific. CONCLUSION: Better understanding of factors affecting survival outcomes might help improve management of DFSP and delineate other potential causes of increased morbidity and mortality.

Melanoma of the Face and Mohs Micrographic Surgery: Nationwide Mortality Data Analysis.

BACKGROUND: Although Mohs micrographic surgery (MMS), narrow margin excision (NME), and wide margin excision (WME) are commonly used to treat melanoma of the face, there is a paucity of data comparing mortality outcomes for each method. OBJECTIVE: To determine the association between surgical method used to treat cutaneous melanoma of the face and patient survival. MATERIALS AND METHODS: A retrospective review of Surveillance, Epidemiology, and End Results registries for patients diagnosed with melanoma of the face between 2003 and 2012 was conducted. RESULTS: The authors query resulted in 43,443 records. Patients with melanoma were more likely to undergo NME (57.79%) than WME (27.86%) or MMS (14.36%). Overall 5-year risk of death was higher with WME (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.00-1.23; p = .043) and NME (HR, 1.10; 95% CI, 1.00-1.20; p = .046) relative to MMS after adjusting for patient demographics, residence socioeconomic factors, and tumor characteristics. No statistically significant difference in melanoma-specific mortality was found between different surgical methods on multivariate analysis. CONCLUSION: Patients with melanoma of the face treated with MMS had similar melanoma-specific mortality or overall survival outcome as patients treated by other surgical modalities.

The Use of a Fresh-Tissue Cadaver Model for the Instruction of Dermatological Procedures: A Laboratory Study for Training Medical Students.

BACKGROUND: A realistic model for the instruction of basic dermatologic procedural skills was developed, while simultaneously increasing medical student exposure to the field of dermatology. OBJECTIVE: The primary purpose of the authors' study was to evaluate the utilization of a fresh-tissue cadaver model (FTCM) as a method for the instruction of common dermatologic procedures. The authors' secondary aim was to assess students' perceived clinical skills and overall perception of the field of dermatology after the lab. METHODS: Nineteen first- and second-year medical students were pre- and post-tested on their ability to perform punch and excisional biopsies on a fresh-tissue cadaver. Students were then surveyed on their experience. RESULTS: Assessment of the cognitive knowledge gain and technical skills revealed a statistically significant improvement in all categories (p < .001). An analysis of the survey demonstrated that 78.9% were more interested in selecting dermatology as a career and 63.2% of participants were more likely to refer their future patients to a Mohs surgeon. CONCLUSION: An FTCM is a viable method for the instruction and training of dermatologic procedures. In addition, the authors conclude that an FTCM provides realistic instruction for common dermatologic procedures and enhances medical students' early exposure and interest in the field of dermatology.

Depletion of deoxyribonucleotide pools is an endogenous source of DNA damage in cells undergoing oncogene-induced senescence.

In normal human cells, oncogene-induced senescence (OIS) depends on induction of DNA damage response. Oxidative stress and hyperreplication of genomic DNA have been proposed as major causes of DNA damage in OIS cells. Here, we report that down-regulation of deoxyribonucleoside pools is another endogenous source of DNA damage in normal human fibroblasts (NHFs) undergoing HRAS(G12V)-induced senescence. NHF-HRAS(G12V) cells underexpressed thymidylate synthase (TS) and ribonucleotide reductase (RR), two enzymes required for the entire de novo deoxyribonucleotide biosynthesis, and possessed low dNTP levels. Chromatin at the promoters of the genes encoding TS and RR was enriched with retinoblastoma tumor suppressor protein and histone H3 tri-methylated at lysine 9. Importantly, ectopic coexpression of TS and RR or addition of deoxyribonucleosides substantially suppressed DNA damage, senescence-associated phenotypes, and proliferation arrest in two types of NHF-expressing HRAS(G12V). Reciprocally, short hairpin RNA-mediated suppression of TS and RR caused DNA damage and senescence in NHFs, although less efficiently than HRAS(G12V). However, overexpression of TS and RR in quiescent NHFs did not overcome proliferation arrest, suggesting that unlike quiescence, OIS requires depletion of dNTP pools and activated DNA replication. Our data identify a previously unknown role of deoxyribonucleotides in regulation of OIS.

A prospective study of pain control by a 2-step irradiance schedule during topical photodynamic therapy of nonmelanoma skin cancer.

BACKGROUND: Topical photodynamic therapy (PDT) for selected nonmelanoma skin cancer using 5-aminolevulinic acid (ALA) or methyl aminolevulinate (MAL) has yielded high long-term complete response rates with very good cosmesis. Pain during light activation of the photosensitizer can be a serious adverse event. A 2-step irradiance protocol has previously been shown to minimize ALA-PDT pain. OBJECTIVE: To determine the irradiance-dependent pain threshold for MAL-PDT, to adapt the 2-step protocol to a light-emitting diode (LED) light source, and assess clinical response. METHODS: In this prospective study, 25 superficial basal cell carcinoma (sBCC) received an initial irradiance by laser at 40 or 50 mW/cm², or LED at 35 mW/cm² followed by an irradiance at 70 mW/cm² for a total of 75 J/cm². Pain levels were recorded for both irradiance steps. Efficacy was assessed at 6, 12, or 24 months. RESULTS: Pain was mild in the 40/70 mW/cm² laser cohort. Three instances of irradiance-limiting pain occurred at 50/70 mW/cm². Pain was minimal in the 35/70 mW/cm² LED cohort. Clinical response rates were 80% in the 50/70 mW/cm² laser cohort and 90% in the 35/70 mW/cm² LED cohort. CONCLUSION: Topical PDT can be effectively delivered to sBCC with minimal treatment-related pain by a 2-step irradiance protocol.

Giant keratoacanthoma: case report and review of the English literature.

The giant keratoacanthoma (KA) is a rare variant of KA with a maximum size exceeding 2-3 cm. Like other forms of KA, it has a tendency to spontaneously regress but can cause significant anatomic damage. A 69-year-old male presented to our hospital with a giant KA of the nose that showed complete pathological regression by the time of surgery. Pathology showed dermal scar with keratin granulomas extending through the nasal wall to the respiratory mucosa. A total of 57 similar cases from the English literature were reviewed for comparison. Few provide similar details of histological regression. Literature cases occurred predominately in males (74.1%) with a mean age of 59 years. Head tumors were most common (70.7%) and most were treated by surgery (34.5%) or a combination of surgery and radiotherapy (24.1%). Other treatment modalities reported include methotrexate, 5-fluorouracil, and interferon.

The palliative role of lasers in the treatment of melanoma.

Melanoma, accounting for a significant proportion of skin cancer-related deaths, has variable survival outcomes based on the stage at diagnosis and treatment efficacy. Traditional treatments, while effective, pose risks of scarring and systemic side effects. Laser therapy offers an emerging non-surgical alternative, with CO2 lasers particularly showing promise in palliative care.A comprehensive search was conducted using PubMed, focusing on laser therapy for melanoma treatment. The search included studies on both stand-alone and adjunct laser therapies, with inclusion criteria requiring peer-reviewed articles detailing treatment outcomes for primary, recurrent, or metastatic melanoma.The literature shows that laser therapy for melanoma falls into four major types when categorized by laser medium: solid-state, diode, pulse-dye, and gas (CO2). Data on solid-state lasers for melanoma are limited and their use remains controversial. However, one study with high-energy pulsed neodymium lasers reported a 5-year survival of 82.9% with minimal adverse effects for primary melanoma. CO2 laser therapy has been effective for palliative treatment, with one study showing 54.8% of patients with recurrent melanoma surviving 5.4 years post-ablation. For metastatic melanoma, numerous studies have shown that CO2 laser therapy can provide symptomatic relief and disease control. Combination therapies using lasers and immune-based therapies have demonstrated enhanced outcomes and immune activation, highlighting the potential of laser therapies in melanoma management.While traditional treatments remain the standard for primary melanoma, laser therapies, particularly CO2 laser ablation, show substantial promise in palliative care for metastatic melanoma. Careful patient selection and assessment are crucial for achieving positive outcomes.

Elastic Scattering Spectroscopy on Patient-Selected Lesions Concerning for Skin Cancer.

BACKGROUND: Access to dermatologists is limited in parts of the US, making primary care clinicians (PCCs) integral for early detection of skin cancers. A handheld device using elastic scattering spectroscopy (ESS) was developed to aid PCCs in their clinical assessment of skin lesions. METHODS: In this prospective study, 3 PCCs evaluated skin lesions reported by patients as concerning and scanned each lesion with the handheld ESS device. The comparison was pathology results or a 3-dermatologist panel examining high resolution dermatoscopic and clinical images. PCCs reported their diagnosis, management decision, and confidence level for each lesion. Evaluation of results included sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and Area Under the Curve (AUC). RESULTS: A total of 155 patients and 178 lesions were included in the final analysis. The most commonly patient-reported concerning feature was "new or changing lesion" (91.6%). Device diagnostic sensitivity and specificity were 90.0% and 60.7%, respectively, based on biopsy result or dermatologist panel reference standard; comparatively, PCC sensitivity was 40.0% and 84.8% specificity without the use of the device. Device NPV was 98.9%, and device PPV was 13.6%. The device recommended patient referral to dermatology with 88.2% concordance with the dermatologist panel. AUC for the device and PCCs were 0.815 and 0.643, respectively. CONCLUSIONS: The use of the ESS device by PCCs can improve diagnostic and management sensitivity for select malignant skin lesions by correctly classifying most benign lesions of patient concern. This may increase skin cancer detection while improving access to specialist care.

Primary signet-ring cell carcinoma of the axilla.

Primary cutaneous histiocytoid or signet-ring cell carcinoma represents an extremely rare adnexal neoplasm that most frequently presents on the eyelid but more rarely may present in the axilla. As this tumor can resemble metastatic carcinoma with signet-ring cells, especially lobular carcinoma of the breast, it can often present a diagnostic challenge. We present a case of cutaneous signet-ring cell carcinoma presenting in the axilla and outline the challenges of diagnosing this rare malignancy.

A retrospective review of pain control by a two-step irradiance schedule during topical ALA-photodynamic therapy of non-melanoma skin cancer.

BACKGROUND AND OBJECTIVE: Photodynamic therapy (PDT) with topical δ-aminolevulinic acid (ALA) of non-melanoma skin cancers is often associated with treatment-limiting pain. A previous study on basal cell carcinomas (BCCs) at Roswell Park Cancer Institute evaluated a two-step irradiance scheme as a means of minimizing pain, preserving outcomes, and limiting treatment time. We used an initial low irradiance until 90% of the protoporphyrin IX was photobleached, followed by a high irradiance interval until the prescribed fluence was delivered. Success of this pilot investigation motivated integration of the protocol into routine practice. Here, we present a retrospective review of recent clinical experience in a broad patient population. STUDY DESIGN/MATERIALS AND METHODS: This was a retrospective review of an existing dermatology database. Fourteen caucasion patients-nine men and five women, ages 18-80, with a total of 51 superficial and 73 nodular BCCs, and three Bowen's disease lesions-were included. ALA was applied to each lesion for approximately 4 hours. Lesions received an initial irradiance of 30-50 mW/cm(2) for 20 J/cm(2) , followed by 150 mW/cm(2) for a total fluence of 200-300 J/cm(2) . Pain was assessed using a visual analog scale (VAS). Clinical outcome was determined at 6-12 months. RESULTS: Median VAS scores were 1.0 for both irradiances. Five of 127 lesions required pain control with 1% xylocaine. Pain was strongly influenced by lesion location but not by lesion type, number, or size. Complete responses were achieved in 84.1% of BCCs, which compares favorably with reported results for single ALA-PDT treatments. Two of three Bowen's disease lesions showed a complete response. Complete responses for nodular BCCs were 37%, which are also within the range of reported outcomes. CONCLUSIONS: A two-step irradiance protocol in ALA-PDT effectively minimizes pain, maintains excellent clinical outcomes in superficial lesions, and adds minimal treatment time.