RESUMEN
BACKGROUND: Mohs surgery of eyelid skin cancers requires detailed knowledge of anatomy for precise surgery and accurate evaluation of histology. OBJECTIVE: To review the histology of the peritarsal eyelid using frozen sections as encountered intraoperatively by Mohs surgeons. METHODS: The authors review the literature describing the anatomy and histology of the peritarsal eyelid from the lens of a Mohs surgeon. Histology from select Mohs cases is used to frame the discussion of the microanatomy of this region. RESULTS: The peritarsal eyelids contain a unique mixture of skin, muscle, tarsus, glandular tissue, and conjunctiva. The histologic appearance of many of these structures differs from skin found outside of this anatomic region. Tumors of the eyelid and periocular region may mimic normal histologic structures found within the peritarsal eyelid. CONCLUSION: The peritarsal eyelids have unique anatomy and associated histologic structures. Knowledge of the detailed histoanatomy is required for confident execution of Mohs surgery in this anatomic region.
Asunto(s)
Neoplasias de los Párpados , Párpados , Secciones por Congelación , Cirugía de Mohs , Humanos , Párpados/anatomía & histología , Neoplasias de los Párpados/cirugía , Neoplasias de los Párpados/patología , Neoplasias Cutáneas/patología , Neoplasias Cutáneas/cirugíaAsunto(s)
Carcinoma Basocelular , Carcinoma de Células Escamosas , Enfermedades de la Uña , Neoplasias Cutáneas , Humanos , Carcinoma de Células Escamosas/cirugía , Carcinoma de Células Escamosas/patología , Neoplasias Cutáneas/cirugía , Neoplasias Cutáneas/patología , Cirugía de Mohs , Uñas/cirugía , Uñas/patología , Enfermedades de la Uña/cirugía , Enfermedades de la Uña/patología , Recurrencia Local de Neoplasia/epidemiología , Recurrencia Local de Neoplasia/cirugía , Estudios Retrospectivos , Carcinoma Basocelular/cirugíaAsunto(s)
Carcinoma de Células de Merkel , Neoplasias Cutáneas , Humanos , Carcinoma de Células de Merkel/epidemiología , Carcinoma de Células de Merkel/cirugía , Carcinoma de Células de Merkel/patología , Neoplasias Cutáneas/epidemiología , Neoplasias Cutáneas/cirugía , Neoplasias Cutáneas/patología , Estadificación de Neoplasias , Programa de VERFRESUMEN
BACKGROUND: Mohs micrographic surgery may be discontinued with positive margins as an anticipated strategy for multidisciplinary care or as an unanticipated occurrence. Management of primary tumors has not been compared after anticipated versus unanticipated incomplete Mohs micrographic surgery (iMMS). OBJECTIVE: To compare rates and timing of adjuvant surgery after iMMS and final margin status when iMMS is anticipated versus unanticipated. Secondary outcomes were preoperative and intraoperative clinicopathologic factors associated with iMMS. METHODS: Cases of iMMS of keratinocyte carcinomas at a tertiary academic center between 2005 and 2022 were classified as anticipated (preoperative assembly of multidisciplinary teams) or unanticipated (ad hoc management of positive margins). Rate, timing, and final margin status of adjuvant surgery was compared between anticipated and unanticipated iMMS cohorts using χ2/Fisher exact test for categorical variables and t-test for continuous variables. RESULTS: Of 127 iMMS cases, 51.2% (65/127) were anticipated. Anticipated iMMS cases were more likely to undergo additional resection (98.5% vs 72.6%, p < .001), with fewer delays (3.9 vs 13.2 days, p < .001) and higher rates of final margin clearance (84.6% vs 59.7%, p < .001). CONCLUSION: When iMMS is anticipated as part of multidisciplinary care, patients are more likely to undergo additional resection, with fewer delays to next surgery and higher final margin clearance rates.
Asunto(s)
Carcinoma Basocelular , Neoplasias Cutáneas , Humanos , Neoplasias Cutáneas/cirugía , Neoplasias Cutáneas/patología , Cirugía de Mohs , Tiempo de Tratamiento , Resultado del Tratamiento , Carcinoma Basocelular/cirugía , Carcinoma Basocelular/patología , Márgenes de Escisión , Estudios RetrospectivosRESUMEN
Importance: Patient preferences for pain medications after Mohs micrographic surgery are important to understand and have not been fully studied. Objective: To evaluate patient preferences for pain management with only over-the-counter medications (OTCs) or OTCs plus opioids after Mohs micrographic surgery given varying levels of theoretical pain and opioid addiction risk. Design, Setting, and Participants: This prospective discrete choice experiment was conducted in a single academic medical center from August 2021 to April 2022 among patients undergoing Mohs surgery and their accompanying support persons (≥18 years). A prospective survey was administered to all participants using the Conjointly platform. Data were analyzed from May 2022 to February 2023. Main outcome and measure: The primary outcome was the pain level at which half of the respondents chose OTCs plus opioids equally to only OTCs for pain management. This pain threshold was determined for varying opioid addiction risk profiles (low, 0%; low-moderate, 2%; moderate-high, 6%; high, 12%) and measured via a discrete choice experiment and linear interpolation of associated parameters (pain levels and risk of addiction). Results: Of the 295 respondents (mean [SD] age, 64.6 [13.1] years; 174 [59%] were female; race and ethnicity were not considered) who completed the discrete choice experiment, 101 (34%) stated that they would never consider opioids for pain management regardless of the pain level experienced, and 147 (50%) expressed concern regarding possible opioid addiction. Across all scenarios, 224 respondents (76%) preferred only OTCs vs OTCs plus opioids after Mohs surgery for pain control. When the theoretical risk of addiction was low (0%), half of the respondents expressed a preference for OTCs plus opioids given pain levels of 6.5 on a 10-point scale (90% CI, 5.7-7.5). At higher opioid addiction risk profiles (2%, 6%, 12%), an equal preference for OTCs plus opioids and only OTCs was not achieved. In these scenarios, patients favored only OTCs despite experiencing high levels of pain. Conclusion and relevance: The findings of this prospective discrete choice experiment indicate that the perceived risk of opioid addiction affects the patient's choice of pain medications after Mohs surgery. It is important to engage patients undergoing Mohs surgery in shared decision-making discussions to determine the optimal pain control plan for each individual. These findings may encourage future research on the risks associated with long-term opioid use after Mohs surgery.
Asunto(s)
Trastornos Relacionados con Opioides , Manejo del Dolor , Humanos , Femenino , Persona de Mediana Edad , Masculino , Analgésicos Opioides/uso terapéutico , Cirugía de Mohs/efectos adversos , Prioridad del Paciente , Estudios Prospectivos , Dolor/tratamiento farmacológico , Trastornos Relacionados con Opioides/tratamiento farmacológicoRESUMEN
Merkel cell carcinoma (MCC) is a neuroendocrine carcinoma that typically presents as a rapidly enlarging violaceous papulonodule on sun-damaged skin in elderly patients. MCC has high rates of local recurrence, metastasis, and poor survival. Treatment of the primary tumor involves surgical excision with possible adjuvant radiation therapy, whereas regional nodal disease is treated with some combination of lymph node dissection and radiation therapy. Immune checkpoint inhibitors, such as avelumab and pembrolizumab, are first-line agents for metastatic MCC. Monitoring for recurrence can be aided by Merkel cell polyomavirus oncoprotein antibody titers.
Asunto(s)
Carcinoma de Células de Merkel , Poliomavirus de Células de Merkel , Neoplasias Cutáneas , Humanos , Anciano , Carcinoma de Células de Merkel/patología , Neoplasias Cutáneas/patología , Escisión del Ganglio LinfáticoRESUMEN
Patients with immunosuppressive conditions experience an increased frequency and severity of cutaneous malignancies. This article highlights management of keratinocyte carcinoma, melanoma, Merkel cell carcinoma, and Kaposi sarcoma in the setting of lymphoproliferative disorders, acquired immunodeficiencies, and organ transplantation. Advances in the safety of organ transplant recipient immunosuppression, early identification of risk factors, and new targeted therapies are improving skin cancer outcomes in immunocompromised populations.
Asunto(s)
Carcinoma de Células de Merkel , Neoplasias Cutáneas , Humanos , Huésped Inmunocomprometido , Piel/patología , Neoplasias Cutáneas/patología , Carcinoma de Células de Merkel/terapia , Terapia de Inmunosupresión/efectos adversosAsunto(s)
Carcinoma de Células de Merkel , Ganglio Linfático Centinela , Neoplasias Cutáneas , Humanos , Biopsia del Ganglio Linfático Centinela , Carcinoma de Células de Merkel/patología , Neoplasias Cutáneas/patología , Metástasis Linfática/patología , Ganglios Linfáticos/patología , Ganglio Linfático Centinela/patología , Escisión del Ganglio Linfático , Estadificación de NeoplasiasAsunto(s)
Melanoma , Neoplasias Cutáneas , Humanos , Cirugía de Mohs , Márgenes de Escisión , Melanoma/cirugía , Neoplasias Cutáneas/cirugía , Recurrencia Local de Neoplasia/epidemiología , Recurrencia Local de Neoplasia/prevención & control , Recurrencia Local de Neoplasia/cirugía , Estudios RetrospectivosAsunto(s)
Analgésicos Opioides , Prescripción Electrónica , Analgésicos Opioides/uso terapéutico , Prescripciones de Medicamentos , Humanos , Cirugía de Mohs/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Pautas de la Práctica en Medicina , PrescripcionesRESUMEN
BACKGROUND: Mohs micrographic surgery (MMS) for cutaneous melanoma is becoming more prevalent, but surgical technique varies. OBJECTIVE: To define variations in published techniques for MMS for melanoma. METHODS AND MATERIALS: A systematic review was performed of PubMed, EMBASE, and Scopus databases to identify all articles describing surgical techniques for MMS for melanoma. Technical details were recorded for the preoperative, intraoperative, and postoperative phases of MMS. RESULTS: Twenty-four articles were included. Mohs surgeons vary in how they assess clinical margins, how wide a margin they excise on the first MMS layer, and how they process tissue to determine tumor stage and margin clearance during MMS for melanoma. CONCLUSION: Mohs micrographic surgery for melanoma is performed with varied surgical techniques. To establish best practices, additional research is necessary to determine how different techniques affect outcomes.
Asunto(s)
Melanoma/cirugía , Cirugía de Mohs/métodos , Neoplasias Cutáneas/cirugía , HumanosRESUMEN
IMPORTANCE: To curtail the opioid epidemic, physicians have been advised to limit opioid prescriptions. OBJECTIVE: To characterize the frequency and changes over time (2009-2020) of opioid prescriptions following Mohs micrographic surgery. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study using Optum Clinformatics DataMart (Optum CDM), a nationally representative insurance claims database, included patients aged 18 years and older who had Mohs micrographic surgery insurance claims in the Optum CDM database from 2009 to 2020. Data were analyzed from November 11, 2020, to March 30, 2021. EXPOSURES: Opioid prescription following Mohs surgery. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of patients who underwent Mohs surgery and obtained an opioid prescription within 2 days of surgery. Secondary outcomes included type and opioid quantity prescribed. RESULTS: Among 358â¯012 patients with Mohs micrographic surgery claims (mean [SD] age, 69 [13] years; 205â¯609 [57.4%] were men), the proportion of patients obtaining an opioid prescription after Mohs micrographic surgery increased from 2009 (34.6%) to 2011 (39.6%). This proportion then declined each year, reaching a low of 11.7% in 2020 (27.9% absolute decrease from 2011 to 2020). Hydrocodone, codeine, oxycodone, and tramadol were the 4 most commonly prescribed opioids. By 2020, hydrocodone was obtained less (2009: 47.5%; 2011: 67.1%; 2020: 45.4%; 21.7% absolute decrease from 2011 to 2020) and tramadol was obtained more (2009: 1.6%; 2020: 27.9%; 26.3% absolute increase from 2009 to 2020). CONCLUSIONS AND RELEVANCE: In this cross-sectional study of Mohs micrographic surgery claims, patients obtained fewer postsurgery opioid prescriptions over the study period, suggesting responsiveness of patients and dermatologic surgeons to public health concerns regarding the opioid epidemic. During this decline, prescriptions for hydrocodone decreased and tramadol increased.
Asunto(s)
Analgésicos Opioides , Cirugía de Mohs , Adolescente , Anciano , Analgésicos Opioides/uso terapéutico , Estudios Transversales , Prescripciones de Medicamentos , Humanos , Masculino , Pautas de la Práctica en MedicinaRESUMEN
BACKGROUND: Sentinel lymph node biopsy (SLNB) has not been studied for invasive melanomas treated with Mohs micrographic surgery using frozen-section MART-1 immunohistochemical stains (MMS-IHC). The primary objective of this study was to assess the accuracy and compliance with National Comprehensive Cancer Network (NCCN) guidelines for SLNB in a cohort of patients who had invasive melanoma treated with MMS-IHC. METHODS: This retrospective cohort study included all patients who had primary, invasive, cutaneous melanomas treated with MMS-IHC at a single academic center between March 2006 and April 2018. The primary outcomes were the rates of documenting discussion and performing SLNB in patients who were eligible based on NCCN guidelines. Secondary outcomes were the rate of identifying the sentinel lymph node and the percentage of positive lymph nodes. RESULTS: In total, 667 primary, invasive, cutaneous melanomas (American Joint Committee on Cancer T1a-T4b) were treated with MMS-IHC. The median patient age was 69 years (range, 25-101 years). Ninety-two percent of tumors were located on specialty sites (head and/or neck, hands and/or feet, pretibial leg). Discussion of SLNB was documented for 162 of 176 (92%) SLNB-eligible patients, including 127 of 127 (100%) who had melanomas with a Breslow depth >1 mm. SLNB was performed in 109 of 176 (62%) SLNB-eligible patients, including 102 of 158 melanomas (65%) that met NCCN criteria to discuss and offer SLNB and 7 of 18 melanomas (39%) that met criteria to discuss and consider SLNB. The sentinel lymph node was successfully identified in 98 of 109 patients (90%) and was positive in 6 of those 98 patients (6%). CONCLUSIONS: Combining SLNB and MMS-IHC allows full pathologic staging and confirmation of clear microscopic margins before reconstruction of specialty site invasive melanomas. SLNB can be performed accurately and in compliance with consensus guidelines in patients with melanoma using MMS-IHC.
Asunto(s)
Melanoma , Ganglio Linfático Centinela , Neoplasias Cutáneas , Adulto , Anciano , Anciano de 80 o más Años , Humanos , Melanoma/patología , Melanoma/cirugía , Persona de Mediana Edad , Cirugía de Mohs , Estudios Retrospectivos , Ganglio Linfático Centinela/patología , Ganglio Linfático Centinela/cirugía , Biopsia del Ganglio Linfático Centinela , Neoplasias Cutáneas/patología , Neoplasias Cutáneas/cirugíaRESUMEN
Nail unit melanoma is an uncommon form of melanoma with worse prognosis compared with nonacral cutaneous melanoma. Nail unit melanoma is often diagnosed at a late stage. Clinical and dermoscopic features may suggest a diagnosis of nail unit melanoma, but confirmation requires histologic analysis. Like the clinical diagnosis, histopathologic diagnosis of nail unit melanoma is also difficult. The surgical management of nail unit melanoma has evolved from aggressive amputations to digit-sparing approaches. This article reviews the clinical presentation, diagnosis, and surgical treatment of nail unit melanoma to promote early diagnosis and rational surgery.
Asunto(s)
Melanoma , Enfermedades de la Uña , Neoplasias Cutáneas , Humanos , Melanoma/diagnóstico por imagen , Melanoma/cirugía , Enfermedades de la Uña/diagnóstico por imagen , Enfermedades de la Uña/cirugía , Uñas/cirugía , Pronóstico , Neoplasias Cutáneas/diagnóstico por imagen , Neoplasias Cutáneas/cirugíaAsunto(s)
Materiales Biocompatibles/administración & dosificación , Melanoma/cirugía , Repitelización , Neoplasias Cutáneas/cirugía , Herida Quirúrgica/terapia , Anciano , Anciano de 80 o más Años , Materiales Biocompatibles/química , Durapatita/química , Femenino , Gelatina/química , Miel , Humanos , Leptospermum/química , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Plaque psoriasis is a chronic inflammatory disease driven by the proliferation of T cells and the production of several immunomodulators such as tumor necrosis factor (TNF) α. Tumor necrosis factor α plays a key role in multiple inflammatory conditions, including psoriatic arthritis, rheumatoid arthritis, and hidradenitis suppurativa. We present a patient with plaque psoriasis and sickle cell disease who began treatment with the TNF-α inhibitor adalimumab. With this treatment, the patient had improvement in both psoriasis and sickle cell disease symptoms. Tumor necrosis factor α inhibitors may be the drug of choice in patients with both psoriasis and sickle cell disease.