Use of Talimogene Laherparepvec to Treat Cutaneous Squamous Cell Carcinoma in a Renal Transplant Patient.

A 66-year-old female with a history of two renal transplants due to recurrent thrombotic thrombocytopenic purpura presented to clinic with multiple lesions identified to be non-metastatic cutaneous squamous cell carcinoma (CSCC). The patient previously underwent multiple Mohs procedures and radiation therapy treatment but continued to develop CSCC lesions with increasing frequency. After discussing multiple treatment options, it was elected to pursue treatment with Talimogene laherparepvec (T-VEC) given the systemic immune responses it can cause, with low theoretical risk of graft rejection. After starting intratumoral T-VEC injections, treated lesions began to decrease in size, and a reduction in the rate of new CSCC lesions was observed. Treatment was held due to unrelated renal complications during which time new CSCCs developed. Patient was restarted on T-VEC therapy with no recurrent renal issues. Upon reinitiating treatment, injected and non-injected lesions showed reduction in size, and the development of new lesions again ceased. One injected lesion was resected via Mohs micrographic surgery due to its size and discomfort. On sectioning, this demonstrated an exuberant lymphocytic perivascular infiltrate which was consistent with treatment response to T-VEC, with little active tumor. With high rates of non-melanoma skin cancer in renal transplant patients, their transplant status significantly limits treatment options, specifically with regards to anti-PD-1 therapy. This case suggests T-VEC can generate local and systemic immune responses in the setting of immunosuppression and that T-VEC may be a beneficial therapeutic option for transplant patients with CSCC.

Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal.

BACKGROUND: This is a continued examination of 10 years of prospectively collected Florida in-office adverse event data and new comparable data from mandatory Alabama in-office adverse event data reporting. OBJECTIVE: To determine which office surgical procedures have resulted in reported complications. METHODS: This study is a compilation of mandatory reporting of office surgical complications by Florida and Alabama physicians to a central agency. Reports resulting in death or a hospital transfer were further investigated over the telephone or on-line to determine the reporting physician's board certification status, hospital privilege status, and office accreditation status. RESULTS: In 10 years in Florida, there were 46 deaths and 263 procedure-related complications and hospital transfers; 56.5% (26/46) of deaths and 49.8% (131/263) of hospital transfers were associated with non-medically necessary (cosmetic) procedures. The majority of deaths (67%) and hospital transfers (74%) related to non-medically necessary (cosmetic) procedures were from procedures performed on patients under general anesthesia. Liposuction and liposuction with abdominoplasty or other cosmetic procedure resulted in 10 deaths and 34 hospital transfers. Thirty-eight percent of offices reporting adverse events were accredited by an independent accrediting agency, 93% of physicians were board certified, and 98% of physicians had hospital privileges. The most common specialty of physicians reporting adverse events was plastic surgery (45% of all reported complications). Dermatologists reported four total complications (no deaths) and accounted for 1.3% of all complications over the 10-year period. In 6 years in Alabama, there were three deaths and 49 procedure-related complications and hospital transfers; 42% (22/52) of hospital transfers and no deaths were associated with non-medically necessary (cosmetic) procedures. The majority of hospital transfers related to cosmetic procedures (86%) were from procedures performed on patients under general anesthesia. Liposuction accounted for no deaths and two hospital transfers. Seventy-one percent of offices reporting adverse events were accredited by an independent accrediting agency, and 100% of physicians were board-certified. Plastic surgery was the most common specialty represented in adverse event reporting (42.3% of all reported complications). Dermatologists reported one complication (no deaths) and accounted for 1.9% of all complications over the 6-year period. CONCLUSIONS: Continued analysis reveals that medically necessary office surgery does not represent an emergent hazard to patients. The data obtained from 10 and 6 years of adverse event reporting in Florida and Alabama, respectively, are comparable and consistent. Medically necessary surgical procedures performed in the office setting by dermatologists have an exceedingly low complication rate, and complications that arose were largely unexpected, isolated, and possibly unpreventable. Cosmetic procedures performed in offices by dermatologists under local and dilute local anesthesia yielded no reported complications. Complications from cosmetic procedures accounted for nearly half of all reported incidents in Florida and Alabama, and in both states, plastic surgeons were most represented in adverse event reports. Liposuction performed under general anesthesia requires further investigation because deaths from this procedure continue to occur despite the ability to use dilute local anesthesia for this procedure. Requiring physician board certification and physician hospital privileges does not seem to increase safety of patients undergoing surgical procedures in the office setting. Mandatory reporting of adverse events in the office setting should continue to be championed. Reporting of delayed deaths after hospital outpatient and ambulatory surgery center procedures should be implemented. All data should be made available for scientific analysis after protecting patient confidentiality.

Current progress of immunostains in Mohs micrographic surgery: a review.

Mohs micrographic surgery is often considered the treatment of choice for a variety of skin malignancies. In recent years, the application of immunostaining techniques has facilitated the successful removal of a number of common and less common cutaneous malignancies, including basal cell carcinoma, squamous cell carcinoma, malignant melanoma, dermatofibrosarcoma protuberans, microcystic adnexal carcinoma, sebaceous carcinoma, atypical fibroxanthoma, extramammary Paget's disease, and even sarcomas. Immunostains highlight the tumor cells and allow the Mohs surgeons to pinpoint and eliminate the residual tumor at the surgical margin. It is especially helpful when a tumor presents with subtle or nonspecific histologic features or when a tumor is masked in a pocket of dense inflammation. However, the cost, the labor, and the time consumption are of concern to many of our peers, as are the diversity of antigens, which may overwhelm some. This article serves as a review of the literature on current uses of immunostaining in Mohs micrographic surgery and as a summary of their realistic applications in the dermatologic surgeon's practice. We conclude that immunohistochemical technique has played an important role in Mohs surgery advancement. With greater use and more cost-effective staining methods, we believe that the use of immunostains in a Mohs practice will become routine.

Periocular squamous cell carcinoma.

BACKGROUND: We present a case report of periocular squamous cell carcinoma and a review of the literature with emphasis on early diagnosis, proper follow-up and management, reconstructive options, and new immunomodulatory therapies. OBJECTIVE: The objective is to guide the dermatologist and the dermatologic surgeon in proper management and continued care of patients with periocular squamous cell carcinoma in light of its propensity for perineural involvement and regional lymphatic metastases. MATERIALS AND METHODS: A MEDLINE, Ovid, and PubMed search was conducted for recent relevant articles pertaining to "periocular,""periorbital,""squamous cell" carcinoma, and their "surgery""treatment" modalities. CONCLUSIONS: Periocular squamous cell carcinoma is an aggressive tumor, characterized by perineural involvement and an overall rate of regional lymph node metastases reported to range from 10% to as high as 20% to 25%. Increased vigilance must be undertaken when treating these high-risk tumors. Mohs micrographic surgery or excision with frozen section analysis is the standard of care for periocular squamous cell carcinoma. Multiple options exist for the reconstruction of the postoperative defect that allow for excellent function and cosmesis. Finally, research into new immunomodulators will hopefully lead to an increased understanding of the aggressive nature of periocular squamous cell carcinoma and potential aid in the treatment of the tumor.