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.

Outcomes of Sentinel Lymph Node Biopsy for Primary Cutaneous Squamous Cell Carcinoma of the Head and Neck.

BACKGROUND: Limited data exist on sentinel lymph node biopsy (SLNB) for cutaneous squamous cell carcinoma (cSCC) of the head and neck. OBJECTIVE: To review the results of SLNB for patients with cSCC of the head and neck at the authors' institution. MATERIALS AND METHODS: A retrospective review was completed for patients who underwent SLNB for cSCC of the head and neck over 19 years. Patient demographics, immune status, tumor stage, total patients with positive SLNB, local recurrence, nodal recurrence, in-transit metastasis, and disease-specific death were recorded. RESULTS: Sixty patients underwent lymphoscintigraphy, and an SLN was identified in 58 patients. The mean follow-up was 3.2 years (range, 15 days-16 years). Four patients (6.9%) had a positive SLNB. All were Brigham and Women's Hospital (BWH) stage T2b tumors. Three of these patients were immunosuppressed, 3 patients underwent neck dissection, and 2 patients received adjuvant radiation. None developed local or regional recurrence. Of the 53 patients with a negative SLNB, there were 4 local recurrences, 2 in-transit metastases, and no nodal recurrences. CONCLUSION: Immunosuppressed patients with tumors BWH stage T2b or greater may be a reasonable cohort to focus future prospective studies on the utility of SLNB in cSCC of the head and neck.

Nasal Valve Insufficiency in Dermatologic Surgery.

BACKGROUND: Few publications have addressed nasal valve (NV) insufficiency as a complication of Mohs micrographic surgery. OBJECTIVE: To comprehensively review the literature and further characterize the causes, prevalence, evaluation, and management of NV insufficiency as it relates to cutaneous oncology. MATERIALS AND METHODS: A PubMed search was completed to identify articles related to the NV in the context of Mohs micrographic surgery, cutaneous oncology, and reconstruction. RESULTS: Nasal valve insufficiency may occur during tumor removal and/or reconstruction. Defect size larger than 1 cm; location on the ala, sidewall, or alar crease; lack of structural support; and poorly planned flaps are the main risk factors for NV insufficiency. Several surgical techniques have been described to avoid and correct this complication. CONCLUSION: Nasal valve insufficiency may be an underrecognized and underreported complication of Mohs micrographic surgery. Nasal valve insufficiency may be identified with relatively simple tests. Knowledge of NV anatomy and preoperative function assessment is essential. Recognition of this potential complication and awareness of its prevention and management may decrease morbidity in patients undergoing cutaneous surgery.

Safety of Oral Midazolam as a Perioperative Anxiolytic for Outpatient Dermatologic Procedures.

BACKGROUND: Perioperative anxiety can negatively impact patient satisfaction and can complicate outpatient dermatologic procedures. OBJECTIVE: Evaluate adverse events associated with oral midazolam as a perioperative anxiolytic during dermatologic surgery and assess whether an enhanced monitoring approach is associated with an increased detection rate. MATERIALS AND METHODS: Five hundred cases (250 before and after change in monitoring) where patients were administered oral midazolam between July 2015 and May 2017 were retrospectively reviewed. The number of procedures, type of procedures, dose in milligrams, number of doses, major and minor adverse events, and vital signs were recorded. RESULTS: The difference in number of treatment sites, types of procedures, and total dose administered was not significant. There were minor but significant differences in the mean change in blood pressure, heart rate, respiratory rate, and Richmond Agitation and Sedation Scale score before and after the procedure but not oxygen saturation. These vital sign changes were not clinically significant. There were zero major adverse events in both groups. There were 2 patients who became transiently hypoxic. CONCLUSION: Oral midazolam administration was not associated with major adverse events including in the more intensively monitored group. This supports its use as an anxiolytic for outpatient dermatologic procedures.

Opioid prescribing for acute postoperative pain after cutaneous surgery.

BACKGROUND: Little information is available to predict which patients require opioid analgesia following cutaneous surgery. When opioids are indicated, information regarding the optimal opioid agent selection and dosage is lacking. OBJECTIVE: To make recommendations for opioid prescription after cutaneous surgery. METHODS: A PubMed literature search was conducted to review the available literature. Recommendations are presented on the basis of available evidence and the opinion of the authors. RESULTS: Most patients undergoing cutaneous surgery do not require opioid analgesia. For those who do, the duration of pain warranting opioid analgesia is generally less than 36 hours. Opioid refill requests warrant a follow-up visit to ascertain the cause of ongoing pain after excisional procedures. LIMITATIONS: The recommendations are not based on prospective randomized trials. CONCLUSIONS: The presented recommendations for opioid prescription practice are derived from available evidence, recommendations, and expert opinion.

Patterns of failure following the excision of in-transit lesions in melanoma and the influence of excisional margins.

BACKGROUND AND OBJECTIVES: To describe the patterns of failure in patients with in-transit (IT) melanoma undergoing surgical excision. METHODS: A retrospective review of patients who underwent their first IT lesion(s) resection between May 2005 and September 2014. Cumulative incidence of local failure (new lesion within 2 cm of IT resection) was estimated. Associations between clinicopathologic characteristics, local failure, and any recurrence were analyzed. RESULTS: One hundred and thirty patients presented to our institution with IT disease over the study period and met the inclusion criteria. The 2-year cumulative incidence of local failure was 19.5%. Twenty-four patients developed disease within 2 cm of the resected IT disease; however, only eight were isolated local events. Cumulative incidence of local failure and of any disease differed with respect to less than 1 year disease-free interval (DFI) from primary melanoma to first IT event, and having greater than 1 IT lesion at presentation. Incidence of local failure was not found to differ with respect to gross margin greater than 5 mm, after adjusting for DFI and greater than 1 IT lesions. CONCLUSIONS: Patients with greater than 1 IT lesion and a DFI less than 1 year are at a higher risk of failure after surgical excision of a first IT event. Very few failures were isolated local disease within 2 cm of the IT resection scar, regardless of IT excision margin.

A new evidence-based risk stratification system for cutaneous squamous cell carcinoma into low, intermediate, and high risk groups with implications for management.

Most primary cutaneous squamous cell carcinomas are cured with surgery. A subset, however, may develop local and nodal metastasis that may eventuate in disease-specific; death. This subset has been variably termed high risk. Herein, we review; an emerging body of data on the risks of these outcomes and propose an evidence-based; risk stratification for low-, intermediate-, and high-risk tumors that takes into; account both tumor and patient characteristics. Finally, we discuss a framework for; management of these tumors on the basis of data, when available, and our; recommendations when data are sparse.

A Comparison of Mohs Micrographic Surgery and Wide Local Excision for Treatment of Dermatofibrosarcoma Protuberans With Long-Term Follow-up: The Mayo Clinic Experience.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a soft tissue tumor with slow infiltrative growth and local recurrence if inadequately excised. OBJECTIVE: To compare long-term outcomes after Mohs micrographic surgery (MMS) and wide local excision (WLE). MATERIALS AND METHODS: Records of patients with DFSP surgically treated with WLE or MMS from January 1955 through March 2012 were retrospectively reviewed. RESULTS: Mean follow-up for patients treated with MMS (n = 67) and WLE (n = 91) was 4.8 and 5.7 years, respectively. Twenty-eight patients (30.8%) with WLE had recurrence (mean, 4.4 years), whereas only 2 (3.0%) with MMS had recurrence (1.0 and 2.6 years). Recurrence-free survival rates at 1, 5, 10, and 15 years were significantly higher with MMS (p < .001). Mean preoperative lesion sizes were similar (5-6 cm) between the 2 groups, whereas mean (standard deviation) postoperative defect sizes were 10.7 (4.3) cm and 8.8 (5.5) cm for WLE and MMS, respectively (p = .004). Primary closure was used for 73% of MMS cases, whereas WLE more commonly used flaps, grafts, or other closures (52%). Two Mohs layers typically were required for margin control. CONCLUSION: Surgical excision with meticulous histologic evaluation of all surgical margins is needed for DFSP treatment to achieve long-term high cure rates and low morbidity.

Surgical Treatment and Outcomes of Patients With Extramammary Paget Disease: A Cohort Study.

BACKGROUND: Extramammary Paget disease (EMPD) is a rare intraepithelial adenocarcinoma occurring mainly in the anogenital region. Traditional management with wide local excision has shown high recurrence rates, thus Mohs micrographic surgery (MMS) has emerged as a promising treatment option. OBJECTIVE: To compare long-term outcomes after treatment with MMS or excision for primary EMPD. METHODS AND MATERIALS: Retrospective cohort review was conducted for 207 patients with EMPD treated at Mayo Clinic in Rochester, MN, between 1961 and 2012. RESULTS: Of the 25 patients treated with MMS, 19 primary tumors were included for outcome analysis, with an estimated 5-year recurrence-free survival rate of 91% (95% confidence interval [CI], 75-100) using Kaplan-Meier curve analysis. Of 158 patients treated with local excision, 124 were included for the analysis, with an estimated 5-year recurrence-free survival rate of 66% (95% CI, 56-78). The hazard ratio (HR) for association of treatment was 0.4 (95% CI, 0.10-1.65; p = .20). Estimated 5-year overall survival rates were 79% for MMS (95% CI, 61-100) and 68% for excision (95% CI, 59-78) (HR, 1.39 [95% CI, 0.69-2.82]; p = .36). CONCLUSION: Although treatment of primary EMPD with MMS versus excision did not show statistical difference, MMS demonstrated favorable long-term outcomes and was associated with a higher recurrence-free survival rate.

Comparison of MITF and Melan-A Immunohistochemistry During Mohs Surgery for Lentigo Maligna-Type Melanoma In Situ and Lentigo Maligna Melanoma.

BACKGROUND: Mohs micrographic surgery (MMS) with frozen section immunohistochemistry is a treatment option for malignant melanoma in situ (MMIS) and lentigo maligna melanoma (LMM). Melan-A is a cytoplasmic melanocyte immunostain useful on frozen sections but may lack specificity. Microphthalmia transcription factor (MITF) is a more specific nuclear melanocyte immunostain less frequently used in MMS. OBJECTIVE: To quantify melanocyte density in chronic sun-damaged skin (CSDS), negative margin, and tumor from patients undergoing MMS for MMIS and LMM using MITF and melan-A. METHODS: Sixteen patients with MMIS or LMM had frozen sections from CSDS, negative margin, and 12 tumor samples, stained with MITF and melan-A. Melanocyte counts were performed. RESULTS: Chronic sun-damaged skin mean melanocyte count (MMC) for MITF and melan-A was 9.8 and 13.7, respectively, (p < .001). Negative margin MMC for MITF and melan-A was 8.84 and 14.06, respectively, (p < .001). Tumor MMC for MITF and melan-A was 63.5 and 62.4, respectively. CONCLUSION: Although both MITF and melan-A facilitate the identification of tumor during MMS for MMIS and LMM, the apparent melanocyte density on tumor-free CSDS appears higher with melan-A than MITF. Microphthalmia transcription factor provides a crisp outline of melanocyte nuclei and is a useful alternative stain to melan-A for MMS of melanoma.

Increased incidence and recurrence rates of nonmelanoma skin cancer in patients with non-Hodgkin lymphoma: a Rochester Epidemiology Project population-based study in Minnesota.

BACKGROUND: Cutaneous malignancy is associated with worse outcomes in patients with chronic lymphocytic leukemia (CLL). OBJECTIVE: We sought to identify the incidence and recurrence rate of nonmelanoma skin cancer (NMSC) in patients with non-Hodgkin lymphoma (NHL). METHODS: NMSC incidence was calculated and Cox proportional hazards models were used to evaluate associations with risk of recurrence for patients with NHL between 1976 and 2005 who were in the Rochester Epidemiology Project research infrastructure. RESULTS: We identified 282 patients with CLL or small lymphocytic lymphoma and 435 with non-CLL NHL. The incidence of basal cell carcinoma and squamous cell carcinoma was 1829.3 (95% confidence interval [CI] 1306.7-2491.1) and 2224.9 (95% CI 1645.9-2941.6), respectively, in patients with CLL. The cumulative recurrence rate at 8 years after treatment with Mohs micrographic surgery was 8.3% (95% CI 0.0%-22.7%) for basal cell carcinoma and 13.4% (95% CI 0.0%-25.5%) for squamous cell carcinoma in patients with CLL. LIMITATIONS: This was a retrospective cohort study. CONCLUSIONS: After Mohs micrographic surgery and standard excision of NMSC, patients with NHL had a skin cancer recurrence rate that was higher than expected. Careful treatment and monitoring of patients with NHL and NMSC are warranted.

Consensus for Nonmelanoma Skin Cancer Treatment, Part II: Squamous Cell Carcinoma, Including a Cost Analysis of Treatment Methods.

BACKGROUND: Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer in the United States. Cutaneous squamous cell carcinoma has an estimated incidence of more than 700,000 new cases per year and a 5% risk of metastasis. OBJECTIVE: To provide clinicians with guidelines for the management of cSCC based on evidence from a comprehensive literature review and consensus among the authors. MATERIALS AND METHODS: The authors conducted an extensive review of the medical literature on treatment methods for cSCC, taking into consideration cure rates, recurrence and metastatic rates, aesthetic and functional outcomes, and cost effectiveness of the procedures. RESULTS: Surgical treatments provide the best outcomes for cSCC. Mohs micrographic surgery is a cost-effective procedure that affords the highest cure rate, maximal tissue preservation, and superior cosmetic outcomes. Nonsurgical methods may be used as a primary treatment for low-risk squamous cell carcinomas, but the cure rates are lower. CONCLUSION: The cure rate remains the most important consideration in choosing the treatment method, but additional factors, such as the patient's general medical condition, psychosocial circumstances, the location of the tumor and cost effectiveness of the therapy should be considered. Mohs micrographic surgery remains the preferred treatment for high-risk tumors and tumors located in cosmetically sensitive areas.

Complications With New Oral Anticoagulants Dabigatran and Rivaroxaban in Cutaneous Surgery.

BACKGROUND: Anticoagulant medications to date are not associated with increased risk of severe life-threatening complications during cutaneous surgery. Dabigatran and rivaroxaban are new orally administered anticoagulants that do not require laboratory monitoring and have no available specific antidotes, making perioperative management more complex. To the authors' knowledge, published data on the use of dabigatran or rivaroxaban in patients undergoing cutaneous surgery are limited. OBJECTIVE: The authors sought to study perioperative complications associated with dabigatran and rivaroxaban during cutaneous surgery. MATERIALS AND METHODS: Retrospective chart analysis was performed for all patients who underwent Mohs micrographic surgery or basic excision while taking dabigatran or rivaroxaban between January 1, 2010, and September 1, 2013, at Mayo Clinic, Rochester, MN. RESULTS: Twenty-seven patients taking dabigatran underwent 41 cutaneous surgeries, with only 1 mild bleeding complication observed that was remedied with a pressure dressing. Four patients on rivaroxaban underwent 5 cutaneous surgeries without complication. CONCLUSION: Because no patients on dabigatran or rivaroxaban experienced severe hemorrhagic complications during cutaneous surgery, a strategy of continuing these medically necessary medications during cutaneous surgery seems reasonable.

Upstaging From Melanoma in Situ to Invasive Melanoma on the Head and Neck After Complete Surgical Resection.

BACKGROUND: Melanoma in situ (MIS) diagnosed from a subtotal biopsy may be upstaged to invasive melanoma after resection. The frequency of this phenomenon is markedly variable. OBJECTIVE: To quantify the rate of upstaging MIS on the head and neck after resection at this institution, characterize the location of the invasive component relative to the clinically evident lesion, and determine the rate of upstaging with time. MATERIALS AND METHODS: The authors retrospectively reviewed clinical records of adult patients with a preoperative diagnosis of MIS on the head and neck from January 1994 to August 2012. Patient and tumor characteristics were recorded. RESULTS: In total, 624 patients met the inclusion criteria and 24 (4%) were upstaged after resection. Four patients had invasive disease beyond the clinically evident lesion. The annual percentage of upstaged lesions seemed to show an increasing trend with time. CONCLUSION: Upstaging of MIS on the head and neck occurs at a relatively low rate that may be increasing with time. Invasive components of lentigo maligna melanoma may exist beyond the clinically evident margins. Histological examination of the maximal amount of the surgical specimen is paramount for optimal staging and treatment of MIS.

Comparison of full-thickness skin grafts versus second-intention healing for Mohs defects of the helix.

BACKGROUND: Two repair options for Mohs defects of the helix include full-thickness skin grafting and second-intention healing. Limited long-term data exist comparing these 2 repair options. OBJECTIVE: To compare outcomes of full-thickness skin grafts (FTSG) versus second-intention wound healing for Mohs defects on the helix. METHODS: In this study, 29 second-intention and 18 FTSG repairs were evaluated using a visual analog scale (VAS). Patient questionnaires and retrospective chart analysis were used to assess secondary outcomes. RESULTS: The average second-intention VAS score was 82.1 (standard deviation [SD] = 7.6), and the average FTSG VAS score was 75.2 (SD = 16.7) (difference of 6.9, 95% confidence interval: -1.3 to 15.1, p = .061). A subsequent noninferiority test indicated that cosmetic outcome of second-intention healing was at least as good as that of FTSG in the authors' study (p < .001). Retrospective chart analysis revealed no significant difference in complications. Patient-reported outcomes were not significantly different. CONCLUSION: Mohs surgical defects of the helix left to heal by second-intention have comparable long-term cosmetic outcomes to those repaired by FTSG. There was no significant difference in complications, and patients were highly satisfied with both repair options.

Mohs micrographic surgery for the treatment of hidradenocarcinoma: the Mayo Clinic experience from 1993 to 2013.

BACKGROUND: Hidradenocarcinoma (HAC) is a rare malignant adnexal neoplasm with reported metastatic potential and undefined optimal treatment. OBJECTIVE: To review clinical characteristics and outcomes of patients with HAC treated with Mohs micrographic surgery (MMS). MATERIALS AND METHODS: The authors performed a retrospective chart review of patients with HAC treated by MMS at Mayo Clinic from 1993 to 2013, recording patient demographics, tumor characteristics, MMS stages to clearance, follow-up, recurrence, metastasis, and mortality. RESULTS: Ten patients underwent MMS for HAC more than 20 years. The average age was 62.8 years, with 6 females and 4 males. Occipital scalp was the most common location (40%), followed by extremities (30%) and face (20%). In 5 of 7 cases (71%), "cyst" was the working clinical diagnosis. The average preoperative lesion area was 3.18 cm, with an average of 1.5 MMS stages required for clearance. Mean postoperative follow-up was 7 years (range, 5-205 months). No tumors treated with MMS recurred, metastasized, or led to disease-related mortality. CONCLUSION: Mohs micrographic surgery seems to be a useful treatment modality for HAC. This is the largest reported series of HAC treated with MMS with long-term follow-up.

Leiomyosarcoma of the skin: clinical, histopathologic, and prognostic factors that influence outcomes.

BACKGROUND: Superficial leiomyosarcoma (LMS) is a rare tumor with important clinical, pathologic, and treatment features. Previous LMS studies have included few patients, included minimal follow-up, and typically combined the superficial and subfascial (deep) forms. OBJECTIVE: We sought to characterize clinical features, effectiveness of treatment approaches, and long-term outcomes for LMS stratified by depth of invasion. METHODS: In all, 71 cases of primary superficial LMS, 48 dermal and 23 subcutaneous (mean follow-up of 8 years), were examined and clinical, histopathologic, and treatment factors reported. RESULTS: Tumor size and subcutaneous classification correlated with greater likelihood of metastasis and death at 5 years. When superficial LMS metastasizes, other skin sites are the most common distant location. Treatment with wide local excision with minimum 1-cm margins showed statistically lower rates of recurrences and metastasis compared with excision with narrow surgical margins. Fourteen cases of Mohs micrographic surgery had no recurrences or metastases. Five cases of dermal LMS metastasized, 2 of which resulted in death. LIMITATIONS: This study is a retrospective review of a relatively small number of patients. CONCLUSION: LMS can metastasize and warrants surgical intervention and long-term follow-up. Wide local excision, and Mohs micrographic surgery in particular, appear to provide the best management approach for definitive treatment.

Ultrasound and fine-needle aspiration in dermatology, underuse of minimally invasive, efficient diagnostic tools.

BACKGROUND: Ultrasound imaging and ultrasound-guided fine-needle aspiration (FNA) are common procedures used to evaluate and sample cutaneous and subcutaneous tissue. Although ultrasound and FNA have been explored for individual neoplasms, lymph node involvement, and metastases, their use in day-to-day dermatology is not well defined. OBJECTIVE: To investigate the use and utility of ultrasound and FNA in the dermatologic surgery division of a large academic institution. METHODS: Retrospective case review of all ultrasound and FNA procedures ordered by a dermatologic surgeon over a 3-year period. RESULTS: Metastatic disease was suspected in 11 of 21 (52.4%) cases. Cytology confirmed the presence of metastatic disease in two of the 11 cases, and metastatic disease was identified in one additional case in which the diagnosis was not suspected at clinical presentation. Cytology revealed leukemia or lymphoma in three (14.3%) cases, two of which were new diagnoses. Sonographic imaging and cytology revealed a benign diagnosis in 16 (76.2%) cases, five of which were reactive lymph nodes. CONCLUSIONS: The results suggest that ultrasound and FNA are underused techniques that may play an important role in dermatology diagnostics and have the potential for expansion in day-to-day clinical practice.