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.

Considering Sun Safety Policies in the United States.

As they are collectively the most common malignancies, the personal and systemic burden of skin cancers represent a significant public health concern in the United States. Ultraviolet radiation from the sun as well as from artificial sources such as tanning beds is a carcinogen well-known to increase the risk of developing skin cancer in individuals. Public health policies can help mitigate these risks. In this perspectives article, we review sunscreen and sunglasses standards, tanning bed utilization, and workplace sun protection guidelines in the US and provide focused examples for improvement from Australia and the United Kingdom where skin cancer is a well-documented public health concern. These comparative examples can inform interventions in the US that have the potential to modify exposure to risk factors associated with skin cancer.

Factors affecting outcomes of second intent healing of nasal defects after Mohs micrographic surgery.

Reconstruction of nasal defects secondary to Mohs micrographic surgery (MMS) presents particular challenges related to the complex topography, skin quality, tissue laxity, and functional and aesthetic concerns of the region. Factors affecting outcomes resulting from second intent healing (SIH) on the nose have not been well described. The purpose of the study was to identify factors impacting outcomes of SIH for nasal tumors following MMS. Retrospective analysis was performed of all nasal lesions treated with MMS followed by SIH from a single surgical center over a 1.5-year period. Ninety-six cases were included. Chart review was performed, and data were collected including age, gender, nasal site, tumor type, defect size, depth, and number of MMS stages. Pre- and post-operative follow-up photographs were available for all cases. All five authors evaluated the photographs using the modified Manchester scar scale. Analysis was then conducted to identify features associated with good outcomes. Of the 96 tumors, 39 lesions (40.6%) were located on the nasal tip (including supratip), 32 (33.3%) on the ala/alar groove, 17 (17.7%) on the sidewall, and 8 (8.3%) on the dorsum. The average defect size was 0.83 cm2 (diameter of 1.06 cm ± 0.4). Defect diameter and defect depth were the factors that significantly impacted scar outcome (p < 0.001) in multivariate analysis. No significant functional deficits were reported. This retrospective study suggests that nasal defects with area less than 0.83 cm2 (or 1.06 cm diameter) and depth of defect not extending beyond the superficial fat healed well by SIH regardless of location on the nose.

Artificial intelligence in the detection of skin cancer.

Recent advances in artificial intelligence (AI) in dermatology have demonstrated the potential to improve the accuracy of skin cancer detection. These capabilities may augment current diagnostic processes and improve the approach to the management of skin cancer. To explain this technology, we discuss fundamental terminology, potential benefits, and limitations of AI, and commercial applications relevant to dermatologists. A clear understanding of the technology may help to reduce physician concerns about AI and promote its use in the clinical setting. Ultimately, the development and validation of AI technologies, their approval by regulatory agencies, and widespread adoption by dermatologists and other clinicians may enhance patient care. Technology-augmented detection of skin cancer has the potential to improve quality of life, reduce health care costs by reducing unnecessary procedures, and promote greater access to high-quality skin assessment. Dermatologists play a critical role in the responsible development and deployment of AI capabilities applied to skin cancer.

Guidelines of care for the management of actinic keratosis: Executive summary.

BACKGROUND: Actinic keratoses (AK) are rough scaly patches that arise on chronically ultraviolet-exposed skin and can progress to keratinocyte carcinoma. Treatment options for AK include topical medications, photodynamic therapy, cryosurgery, and laser ablation. OBJECTIVE: This executive summary provides a synopsis of the 18 evidence-based recommendations for the treatment of AK detailed in the Guidelines of Care for the Management of Actinic Keratosis. METHODS: A multidisciplinary workgroup conducted a systematic review to address 5 clinical questions on the management of AKs and applied the Grading of Recommendations Assessment, Development and Evaluation approach for assessing the certainty of the evidence and formulating and grading clinical recommendations. Graded recommendations were voted on to achieve consensus. RESULTS: Analysis of the evidence resulted in 18 recommendations, suggesting there are several effective treatments available for AK. LIMITATIONS: The analysis informing the recommendations was based on the best available evidence at the time it was conducted. The results of future studies may necessitate a revision of current recommendations. CONCLUSIONS: Strong recommendations are presented for using ultraviolet protection, topical imiquimod, topical 5-fluorouracil, and cryosurgery. Conditional recommendations are presented for the use of photodynamic therapy and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

Dermatofibrosarcoma protuberans in pregnancy: a case series and review of the literature.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma, which has been reported in pregnancy. This case series reports the clinical and histopathological findings of DFSP in pregnancy. METHODS: Eighteen cases of DFSP, including six unreported cases and 12 cases from the literature, were identified. Age, anatomic location, tumor size, changes in tumor characteristics during pregnancy, histopathological features, and treatment were recorded. Follow-up data, when available, were noted. RESULTS: The average age of the cohort was 30.6 years (range 19-38). Ten tumors (55.6%) were located on the trunk, four (22.2%) on the head and neck, three (16.7%) on the extremities, and one (5.6%) in the genitalia. Most tumors demonstrated features of conventional DFSP (12/18, 66.7%), while the remaining were identified as DFSP with fibrosarcomatous (FS) change (3/18, 16.7%), atrophic DFSP (2/18, 11.1%), and myxoid DFSP (1/18, 5.6%). Treatment was reported in 17 cases, at least nine of which were treated postpartum. Ten patients were treated with excision, while seven underwent Mohs micrographic surgery. Three patients recurred on follow-up, one with local recurrence and two with distant metastasis. CONCLUSIONS: DFSP can undergo enlargement or change in size or color in pregnancy, possibly mediated by hormones. While the majority of cases in this series represented conventional DFSP, unusual clinical and histopathological variants were also present. Treatment in most cases can be safely delayed until after delivery, but recurrent or very large tumors may require treatment prepartum. Close monitoring for recurrence or metastasis is advised.

Guidelines of care for the management of actinic keratosis.

BACKGROUND: Actinic keratoses (AK) are rough scaly patches that arise on chronically ultraviolet-exposed skin and can progress to keratinocyte carcinoma. OBJECTIVE: This analysis examined the literature related to the management of AK to provide evidence-based recommendations for treatment. Grading, histologic classification, natural history, risk of progression, and dermatologic surveillance of AKs are also discussed. METHODS: A multidisciplinary Work Group conducted a systematic review to address 5 clinical questions on the management of AKs and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of the evidence and formulating and grading clinical recommendations. Graded recommendations were voted on to achieve consensus. RESULTS: Analysis of the evidence resulted in 18 recommendations. LIMITATIONS: This analysis is based on the best available evidence at the time it was conducted. The pragmatic decision to limit the literature review to English language randomized trials may have excluded data published in other languages or limited identification of relevant long-term follow-up data. CONCLUSIONS: Strong recommendations are made for using ultraviolet protection, topical imiquimod, topical 5-fluorouracil, and cryosurgery. Conditional recommendations are made for the use of photodynamic therapy and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

A Histopathologic Scoring System for Perineural Invasion Correlates With Adverse Outcomes in Patients With Cutaneous Squamous Cell Carcinoma.

BACKGROUND: Perineural invasion (PNI) is a known risk factor for recurrence, metastasis, and death in cutaneous squamous cell carcinoma (cSCC). Current staging systems include PNI, but none define its extent or severity. OBJECTIVE: To identify histopathologic features of cSCC with PNI that may be associated with adverse outcomes. MATERIALS AND METHODS: This is a retrospective cohort study that included 45 patients with cSCC and PNI treated with surgical excision. Histopathologic slides were analyzed for 5 features of PNI: largest affected nerve diameter, number of nerves affected, depth of nerve involvement, intra- versus extratumoral PNI, and focal versus circumferential PNI. RESULTS: The median largest affected nerve diameter was 0.13 mm, and the median number of nerve structures involved was 4. After a median follow-up time of 24 months, 6 patients developed adverse outcomes, including 2 local recurrences, 4 metastases, and 2 tumor-related deaths. Univariate logistic regression analysis revealed that nerve diameter and number of affected nerves were significantly associated with adverse outcome. A composite PNI score, calculated from 5 histopathologic features, was the strongest predictor of adverse outcome (p = .020). CONCLUSION: Histopathologic features of PNI can be quantified with a composite PNI score that is significantly associated with adverse outcomes in cSCC.

Association of Treatment Facility Characteristics With Overall Survival After Mohs Micrographic Surgery for T1a-T2a Invasive Melanoma.

Importance: Early-stage melanoma, among the most common cancers in the US, is typically treated with wide local excision. However, recent advances in immunohistochemistry have led to an increasing number of these cases being excised via Mohs micrographic surgery (MMS). Although studies of resections for other cancers have reported that facility-level factors are associated with patient outcomes, it is not yet established how these factors may affect outcomes for patients treated with Mohs micrographic surgery. Objective: To evaluate the association of treatment center academic affiliation and case volume with long-term patient survival after MMS for T1a-T2a invasive melanoma. Design, Setting, and Participants: In a retrospective cohort study, 4062 adults with nonmetastatic, T1a-T2a melanoma diagnosed from 2004 to 2014 and treated with MMS in the National Cancer Database (NCDB) were identified. The NCDB includes all reportable cases from Commission on Cancer-accredited facilities and is estimated to capture approximately 50% of all incident melanomas in the US. Multivariable survival analyses were conducted using Cox proportional hazards models. Data analysis was conducted from February 27 to August 18, 2020. Exposures: Treatment facility characteristics. Main Outcomes and Measures: Overall survival. Results: The study population included 4062 patients (2213 [54.5%] men; median [SD] age, 60 [16.3] years) treated at 462 centers. Sixty-two centers were top decile-volume facilities (TDVFs), which treated 1757 patients (61.9%). Most TDVFs were academic institutions (37 of 62 [59.7%]). On multivariable analysis, treatment at an academic center was associated with a nearly 30% reduction in hazard of death (hazard ratio, 0.730; 95% CI, 0.596-0.895). In a separate analysis, treatment at TDVFs was also associated with improved survival (hazard ratio, 0.795; 95% CI, 0.648-0.977). Conclusions and Relevance: In this cohort study, treatment of patients with T1a-T2a invasive melanoma excised with MMS at academic and top decile-volume (≥8 cases per year) facilities was associated with improved long-term survival compared with those excised by MMS at nonacademic and low-volume facilities. Identification and protocolization of the practices of these facilities may help to reduce survival differences between centers.

Predicting outcomes following second intent healing of periocular surgical defects.

BACKGROUND: Traditionally, second intent healing (SIH) in the periocular region is reserved for small and/or concave defects, particularly those located on the medial canthus. AIM: The purpose of this study was to identify factors impacting outcomes of SIH for periocular tumors following Mohs micrographic surgery (MMS). METHODS: Retrospective analysis was performed of all periocular lesions treated with MMS followed by SIH from a single academic surgical center over a 5-year period. Data regarding tumor characteristics and follow-up was recorded. The modified Manchester scale was utilized to evaluate scar outcomes. RESULTS: Of the 39 tumors included, 14 (35.9%) were located on the lower eyelid, 12 (30.8%) on the upper eyelid, 6 (15.4%) on the lateral canthus, and 7 (17.9%) on the medial canthus. Involvement of the eyelid margin was seen in 11 (28.2%) of cases. The average defect diameter and area were 1.3 cm and 1.04 cm-squared. Twenty-three cases (59.0%) healed with optimal results. Larger defects were significantly associated with poorer outcomes of SIH (odds ratio 0.205, p = 0.017 by multivariate analysis). Anatomic location, involvement of the lid margin, age, and follow-up interval were not significant factors; however, medial canthus defects were least likely to heal with optimal results. On average, medial canthal lesions were larger in size (mean diameter 1.76 cm, mean area 1.97 cm-squared). CONCLUSIONS: This retrospective study suggests that periorbital defects in all locations with area less than 1.04 cm2 heal well by SIH. In this cohort, larger lesions on the medial canthus healed with worse outcomes.

Photodynamic therapy for cutaneous squamous cell carcinoma in situ: Impact of anatomic location, tumor diameter, and incubation time on effectiveness.

BACKGROUND: Photodynamic therapy (PDT) has been reported as a treatment for cutaneous squamous cell carcinoma in situ (SCCis), but only limited data are available on the effectiveness of PDT with aminolevulinic acid (ALA-PDT). OBJECTIVE: To review the outcomes of SCCis treated with ALA-PDT and examine factors associated with response. METHODS: A retrospective review identified 58 patients with 68 primary SCCis lesions treated with ALA-PDT and blue light illumination. Patient demographics, lesion features, treatment details, clinical response, and subsequent recurrence were extracted from medical record reviews. RESULTS: On completion of PDT the initial complete response rate was 77.9% and was not associated with the number of PDT treatments. On multivariate analysis factors associated with response were location on the face, tumor diameter <2 cm, and longer ALA incubation time. Lesions treated with a maximum incubation time of <3 hours had a 53.3% response compared with 84.9% for longer incubation. Subsequent recurrence of SCCis was noted in 7 of 53 cases (13.2%) at a median time of 11.7 months. LIMITATIONS: This was a retrospective study performed at a single institution without systematic follow-up. CONCLUSIONS: ALA-PDT may be an effective treatment for selected cases of SCCis. Effectiveness is impacted by anatomic location, tumor diameter, and ALA incubation time.

Optical Spectroscopy as a Method for Skin Cancer Risk Assessment.

Skin cancer is the most prevalent cancer, and its assessment remains a challenge for physicians. This study reports the application of an optical sensing method, elastic scattering spectroscopy (ESS), coupled with a classifier that was developed with machine learning, to assist in the discrimination of skin lesions that are concerning for malignancy. The method requires no special skin preparation, is non-invasive, easy to administer with minimal training, and allows rapid lesion classification. This novel approach was tested for all common forms of skin cancer. ESS spectra from a total of 1307 lesions were analyzed in a multi-center, non-randomized clinical trial. The classification algorithm was developed on a 950-lesion training dataset, and its diagnostic performance was evaluated against a 357-lesion testing dataset that was independent of the training dataset. The observed sensitivity was 100% (14/14) for melanoma and 94% (105/112) for non-melanoma skin cancer. The overall observed specificity was 36% (84/231). ESS has potential, as an adjunctive assessment tool, to assist physicians to differentiate between common benign and malignant skin lesions.

Cutaneous immunohistochemical staining pattern of p53ß isoforms.

p53 is considered the guardian of the genome and as such has numerous functions. The TP53 gene is the most commonly mutated gene in cancer, and yet the exact biological significance of such mutations remains unclear. There are at least 12 different isoforms of p53, and the complexity of the p53 pathway may be in part related to these isoforms. Prior research has often not teased out what isoforms of p53 are being studied, and there is evidence in the literature that p53 isoforms are expressed differently. In this paper, we document the staining pattern of p53ß isoforms in the skin and correlate it with mutational status in a subgroup of squamous proliferations of the skin. p53ß isoforms are present in the cytoplasm of the differentiated layer of the epidermis and hair follicles (granular layer, infundibular and isthmus-catagen). p53ß isoforms are diffusely expressed within the cytoplasm of well-differentiated squamous tumours with tetramerisation (C-terminal) domain mutations in TP53 Our results lend support to p53ß isoforms being a marker of differentiation in keratinocytes.

Transparency and Dermatologic Device Approval by the US Food and Drug Administration.

Importance: The US Food and Drug Administration approves Class III medical devices via the premarket approval pathway, often requiring clinical data on safety and efficacy. Manufacturers can submit incremental device changes via supplemental applications, which are not subjected to such vetting measures and can cause understudied changes that lead to drift from a device's original design. Objectives: To characterize the postapproval changes to Class III dermatologic devices and to evaluate inconsistencies in the use of the premarket approval pathway. Design, Setting, and Participants: This study was a cross-sectional retrospective cohort analysis of a public US Food and Drug Administration database for premarket approval of devices. Included were dermatologic devices approved by the US Food and Drug Administration between January 1, 1980, and November 1, 2016, through the premarket pathway for device approval. Main Outcomes and Measures: Original devices were identified, and their supplements were characterized chronologically, by review track, and by modification category. Results: The 27 dermatologic devices studied consisted of 14 injectables, 11 photodynamic therapies, a dermal replacement matrix, and a diagnostic imaging instrument. Supplemental applications are increasingly used: the data-requiring panel-track pathway was the least common approach (2.8% [16 of 562 supplements]), while the 30-day track, which does not require clinical data, was most frequently used (42.5% [239 of 562 supplements]). Four devices (14.8%) underwent low-risk recalls (Class II or Class III), and 10 devices (37.0%) were voluntarily withdrawn. Conclusions and Relevance: As manufacturers make increasing use of supplemental applications, minor device changes may occur without supporting clinical data, which could pose a safety risk to patients.