SOX10 commonly stains scar in Mohs sections.

Sox10 immunostaining is used for the diagnosis and margin evaluation of melanocytic lesions. Sox10 was initially thought not to stain fibrohistiocytic processes. Consequently, it was believed to reliably distinguish desmoplastic melanoma from scar. However, recent data from formalin sections suggest Sox10 is less specific than previously thought. In this report, we demonstrate that Sox10-stained Mohs sections commonly show strong, fractional staining of scar. When using Sox10 with frozen section immunohistochemistry, Mohs practitioners should recognize the potential of this marker to stain scar to avoid overdiagnosis of desmoplastic melanoma.

Dual Immunostaining With SOX10 and AE1/AE3 to Confirm Perineural Invasion on Mohs Sections

Perineural invasion (PNI) is associated with high risk keratinocyte carcinomas. Identification of PNI during Mohs surgery is important for staging and post-adjuvant treatment decisions but can be challenging. To confirm or exclude PNI suspected on hematoxylin and eosin sections, we performed immunohistochemical double staining on Mohs frozen sections. Neural marker SOX10 and pan-cytokeratin marker AE1/AE3 were combined in a simultaneous assay using species-specific (mouse and rabbit) antibodies and horseradish peroxidase and alkaline phosphatase detection systems. Of 23 Mohs cases with suspected PNI, 18 were confirmed to have definitive nerve involvement by tumor using double staining. Double staining frozen tissue is feasible and can be beneficial for real time confirmation of PNI during Mohs. J Drugs Dermatol. 2019;18(3):262-264.

Dermatologists perform the majority of cutaneous reconstructions in the Medicare population: numbers and trends from 2004 to 2009.

BACKGROUND: Dermatologists are experts in skin cancer treatment. Their experience with cutaneous reconstruction may be underrecognized. OBJECTIVE: We sought to determine the percentage of skin reconstruction claims submitted to Medicare by dermatologists relative to other specialists. METHODS: The Medicare Physician Supplier Procedure Master File from 2004 to 2009 was accessed to determine the proportion of layered closures, grafts, and flaps by specialty. RESULTS: In 2009, dermatologic surgeons' (DS) claims accounted for 60.8% of intermediate closures, 75.1% of complex repairs, 55.5% of local tissue rearrangements, and 57.5% of full-thickness skin grafts in the Medicare population. DS billed for the majority of skin reconstructions except simple repairs, split-thickness skin grafts, and interpolation flaps. DS claims represented far more reconstructions of aesthetically important regions of the head and neck-including ears, eyes, nose, and lips-than other fields including plastic surgery and otolaryngology. Over the study period, DS increased the percentage of skin reconstructions in nearly every category relative to other specialists. LIMITATIONS: This analysis is limited to the Medicare population and addresses claim volumes only. Cosmetic outcomes or appropriateness of closure selection or coding cannot be addressed. CONCLUSIONS: DS perform the highest volumes of repairs in the Medicare population. DS play a primary role in routine and advanced cutaneous reconstructive surgery, especially of aesthetically important regions.

Sentinel lymph node biopsy for melanoma in pregnant women.

BACKGROUND: The incidence of melanoma is rising in young women of childbearing age. Melanoma diagnosed during pregnancy presents unique challenges. This study was conducted to determine the effect of sentinel lymph node biopsy (SLNB) for melanoma on maternal and fetal outcomes in pregnant women. METHODS: A prospective melanoma database was retrospectively queried for women diagnosed with melanoma during or immediately before pregnancy as well as SLNB in pregnant women. The outcomes of SLNB for the mothers and fetuses were evaluated. RESULTS: Fifteen pregnant women underwent wide local excision (WLE) and SLNB for melanoma from 1997 to 2012. The median gestational age was 20 weeks. More than half of the women noticed changes in the primary melanoma lesion during the pregnancy. The median Breslow thickness was 1.00 mm. Lymphatic mapping and SLNB were performed with some combination of radiocolloid or vital blue dye without adverse effects. Three patients had micrometastatic disease and underwent a completion lymphadenectomy. Sixteen children were born at a median gestational age of 39 weeks. The median 1- and 5-minute Apgar scores were 8 and 9, respectively. At a median follow-up of 54.4, months none of the patients had experienced recurrence, and all children were healthy and free of melanoma. CONCLUSIONS: In this series of pregnant women with melanoma, SLNB was performed safely during pregnancy without adverse effects to the mothers and fetuses. We recommend that clinicians explain the risks and benefits of the SLNB procedure to pregnant women so an informed decision can be made about the procedure.

Scars after second intention healing.

Second intention healing (SIH) is useful for many defects after skin cancer removal. SIH decreases intraoperative morbidity and reduces procedure costs. Granulating wounds are rarely infected, have minimal pain or bleeding, and care is simple. Location is the key determinant in cosmetic outcomes of SIH. Concavities of the face including the medial canthus and conchal bowl often heal imperceptibly. Defects on convex surfaces such as the nasal tip and malar cheek can heal poorly with depressed scars. Flat areas of the cheeks, forehead, and chin heal favorably but cosmesis can be unpredictable. These regions are often described by NEET (concavities of the nose, eyes, ears, and temple), NOCH (convexities of nose, oral lips, cheek, chin, and helix), and FAIR (flat areas of the forehead, antihelix of the ear, eyelids, and rest of the nose, lips, and cheeks). We review the limited literature describing SIH based on regional anatomy of the face. Complications of SIH include exuberant granulation tissue, hypopigmented or telangiectatic scars, and distortion of free lid margins. SIH should be an integral part of the surgeon's reconstructive algorithm after skin cancer removal.

Mohs micrographic surgery utilization in the Medicare population, 2009.

BACKGROUND: Mohs micrographic surgery (MMS) is the criterion standard treatment for high-risk skin cancers. Few data on current MMS Utilization are available. OBJECTIVE: To better understand current trends in MMS use in the Medicare population. METHODS AND MATERIALS: The 2009 Medicare Limited Data Set Standard Analytic File (LDSSAF), carrier claims, 5% sample and the Physician Supplier Procedure Master File (PSPMF) 100% summary were analyzed. RESULTS: In 2009, 558,447 Medicare MMS cases were performed, with an average of 1.75 stages per case. In the 5% claims sample, 0.3% and 1.3% of MMS cases were performed for melanoma and carcinoma in situ, respectively. Total annual volume predictions for 1,777 providers showed a left-shifted curve. 65.8% of LDSSAF cases had same-day MMS repairs: 48.7% of repairs were complex, 9.8% intermediate, 32.4% flaps, and 7.4% full-thickness skin grafts. CONCLUSIONS: The 5% LDSSAF is highly predictive of total claim volumes and is useful for modeling practice trends. There is wide variation in MMS provider annual case volume. These data reflect only Medicare Part B enrollees in 2009; 5% LDDSAF extrapolations are predictions based on sampling.

No end in sight: the skin cancer epidemic continues.

The incidence of nonmelanoma skin cancer (NMSC) continues to increase. Multiple reports from the United States and Europe suggest we are in the midst of an epidemic. European studies show substantial NMSC incidence increases during the last 2 decades. In the United States, a recent analysis of Medicare Claims data showed that procedures performed for NMSC nearly doubled from 1994 to 2006. From these data, the total number of new NMSC in 2006 was estimated to be 3,507,693. Procedure data for 2006-2008 from the 5% Medicare Claims sample dataset corroborate the reported trajectory of incidence increase. Destructions, excisions, and Mohs procedures for NMSC have increased by 2.6% per year during the last 2 years. On the basis of this current rate of increase, the annual incidence of NMSC in the United States in 2008 would be nearly 3.69 million. Recognizing the NMSC epidemic is critical as the incidence-and cost-will continue to increase.

JAAD grand rounds quiz*: Dusky intertriginous plaques and acral erythema after bone marrow transplant.

LEARNING OBJECTIVES: At the conclusion of this learning activity, physician participants should be able to assess their own diagnostic and patient management skills and use the results of this exercise to help determine personal learning needs that can be addressed through subsequent CME involvement. Instructions for claiming CME credit appear in the front advertising section. See last page of Contents for page number. INSTRUCTIONS: In answering each question, refer to the specific directions provided. Because it is often necessary to provide information occurring later in a series that give away answers to earlier questions, please answer the questions in each series in sequence.

Novel screening assay performance in pediatric celiac disease and adult dermatitis herpetiformis.

OBJECTIVES: : Several serologic assays are commercially available to aid in the diagnosis of gluten-sensitive enteropathy (GSE). Our objective in this study was to assess the performance of a novel combined antigen-screening assay for GSE. PATIENTS AND METHODS: : Deidentified sera from 111 pediatric patients suspected of having celiac disease (CD), 130 adults diagnosed with dermatitis herpetiformis (DH), and 77 pediatric and 49 adult normal controls were included in the study. Sera from 10 patients submitted to our laboratory for GSE testing with IgA deficiency and IgG antibodies against 1 or more of the traditional serologic markers associated with GSE were also included. All sera were screened for antibodies (IgA and IgG) against tissue transglutaminase (tTG) and deamidated gliadin peptides (DGP) by enzyme immunoassay (EIA) in a single test well. In addition, all sera were assessed for each individual marker and isotype using separate EIAs. RESULTS: : The IgA/IgG anti-tTG/DGP EIA screen was 92.6% sensitive and 94.3% specific in pediatric CD and detected 1 patient (Marsh 3c) who was IgA anti-tTG negative; this patient was not IgA deficient (<7.0 mg/dL). All 10 IgA-deficient sera gave positive results by the tTG/DGP EIA screen. Sensitivity and specificity of the tTG/DGP EIA screen in retrospective and prospective DH were 65% and 100% versus 62% and 100%, respectively. CONCLUSIONS: : The new IgA/IgG anti-tTG/DGP EIA screen was slightly more sensitive than IgA anti-tTG alone in pediatric CD. This novel screening assay may allow the current recommendation of measuring total serum IgA in suspected GSE patients to be eliminated.