RESUMO
BACKGROUND: Mohs micrographic surgery (MMS) is a promising treatment modality for melanoma in situ (MIS). However, variations in surgical technique limit the generalizability of existing data and may impede future study of MMS in clinical trials. METHODS: A modified Delphi method was selected to establish consensus on optimal MMS techniques for treating MIS in future clinical trials. The Delphi method was selected due to the limited current data, the wide range of techniques used in the field, and the intention to establish a standardized technique for future clinical trials. A literature review and interviews with experienced MMS surgeons were performed to identify dimensions of the MMS technique for MIS that (1) likely impacted costs or outcomes of the procedure, and (2) showed significant variability between surgeons. A total of 8 dimensions of technical variation were selected. The Delphi process consisted of 2 rounds of voting and commentary, during which 44 expert Mohs surgeons across the United States rated their agreement with specific recommendations using a Likert scale. RESULTS: Five of eight recommendations achieved consensus in Round 1. All 3 of the remaining recommendations achieved consensus in Round 2. Techniques achieving consensus in Round 1 included the use of a starting peripheral margin of ≤5 mm, application of immunohistochemistry, frozen tissue processing, and resecting to the depth of subcutaneous fat. Consensus on the use of Wood's lamp, dermatoscope, and negative tissue controls was established in Round 2. CONCLUSIONS: This study generated 8 consensus recommendations intended to offer guidance for Mohs surgeons treating MIS. The adoption of these recommendations will promote standardization to facilitate comparisons of aggregate data in multicenter clinical trials.
RESUMO
BACKGROUND: Although current guidelines recommend a 5 mm surgical margin for the excision of melanoma in situ (MIS), increasing evidence has shown this may be suboptimal to achieve tumor clearance. OBJECTIVE: To evaluate margins required for optimal cure rates with excision of MIS on the head and neck and investigate tumor and/or patient factors in those requiring >5 mm margins to achieve tumor clearance. METHODS: A retrospective chart review was performed on 846 (807 primary and 39 recurrent) MIS cases on the head and neck treated in the authors' dermatologic surgery department over a 126-month (10.5 year) period. RESULTS: Sixty-two percent were cleared with 5 mm margins. A total of 15 mm margins were required to achieve a 97% clearance rate. Difference in clearance rate between margin thresholds was significant (P < .001). Tumor location on the cheek and larger preoperative size correlated with requiring >5 mm margins to achieve tumor clearance (P = .006 and P = .001, respectively). LIMITATIONS: This is a single-center retrospective study which relies on accurate documentation of clinical data. CONCLUSION: This study demonstrates that MIS on the head and neck often requires margins >5 mm margins to achieve tumor clearance. When Mohs micrographic surgery is not possible, excision margins of ≥10 mm are likely necessary for head and neck tumors.
Assuntos
Neoplasias de Cabeça e Pescoço , Margens de Excisão , Melanoma , Cirurgia de Mohs , Neoplasias Cutâneas , Humanos , Cirurgia de Mohs/métodos , Estudos Retrospectivos , Melanoma/cirurgia , Melanoma/patologia , Neoplasias Cutâneas/cirurgia , Neoplasias Cutâneas/patologia , Feminino , Masculino , Neoplasias de Cabeça e Pescoço/cirurgia , Neoplasias de Cabeça e Pescoço/patologia , Pessoa de Meia-Idade , Idoso , Adulto , Idoso de 80 Anos ou mais , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/prevenção & controle , Resultado do TratamentoRESUMO
BACKGROUND: Currently, there are limited reviews in the dermatology literature on how to approach reconstruction of nasal lining in full-thickness nasal defects resulting from Mohs micrographic surgery. Given variable training and experience, dermatologic surgeons may seek additional references to help reconstruct certain advanced defects. We sought to synthesize literature from dermatologic surgery, plastic surgery, and otolaryngology to review repair options and considerations for repair of nasal lining defects. OBJECTIVE: To present a comprehensive literature review of repair options for nasal lining reconstruction and discuss advantages, disadvantages, specific anatomic considerations, and techniques to execute such options. MATERIALS AND METHODS: Articles from several different reconstructive specialties including dermatologic/Mohs surgery, otolaryngology, and plastic and reconstructive surgery were reviewed. Instructive images were compiled to illustrate several techniques, with additional medical illustration recreations included to help showcase important reconstructive approaches. RESULTS: A comprehensive descriptive review of nasal lining repair options for the reconstructive surgeon. CONCLUSION: Advanced tumors can result in full-thickness nasal defects, and this review describes various reconstructive options for reconstruction based on the extent of the defect.
Assuntos
Otolaringologia , Procedimentos de Cirurgia Plástica , Cirurgiões , Humanos , Cirurgia de Mohs/efeitos adversos , Nariz/cirurgiaRESUMO
A 7-year-old girl with a history of Langerhans cell histiocytosis (LCH), in remission, presented with the sudden appearance of multiple, agminated nevi. Skin biopsy revealed a benign junctional nevus, without recurrence of LCH. Subsequent immunohistochemical testing of both the skin and iliac wing biopsies demonstrated a BRAF V600E mutation. MAPK pathway mutations have been implicated in both LCH and nevogenesis.
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Histiocitose de Células de Langerhans , Nevo Pigmentado , Nevo , Neoplasias Cutâneas , Criança , Feminino , Histiocitose de Células de Langerhans/complicações , Histiocitose de Células de Langerhans/diagnóstico , Humanos , Mutação , Recidiva Local de Neoplasia , Proteínas Proto-Oncogênicas B-raf/genéticaRESUMO
BACKGROUND: The use of cardiac implantable electronic devices (CIEDs) has expanded dramatically over the past decade, but net clinical benefit has been curtailed by increasing infectious complications. In particular, CIED-related infectious endocarditis (IE) is a serious condition with significant morbidity and mortality. METHODS: We performed a single-center, retrospective study between July 2006 and February 2011 with CIED-related IE, defined by either lead vegetations detected on echocardiography or by fulfilling Duke criteria for definite endocarditis. Clinical parameters and outcomes were detailed by electronic medical record review and vital status was confirmed by the Social Security Death Index. RESULTS: Eighty patients (median age 67, interquartile range 56-75, 58 M/22 F) were diagnosed with CIED-related IE. Overall mortality was 36% with a median time to death of 95 days from presentation. Over half (52%) of the deaths were infection related with a median time to death of 29 days. Multivariate analysis showed methicillin-resistant Staphylococcus aureus (MRSA) infection (odds ratio [OR] 0.158; 95% confidence interval [CI], 0.047-0.534; P = .003) and concomitant valve endocarditis (OR 0.141, CI 0.041-0.491, P = .002) independently predicted mortality. CONCLUSION: In this contemporary series, all-cause mortality in patients with CIED-related IE was high with a short time to death from onset of infection. MRSA and concomitant valve infection were the most powerful independent predictors of mortality.
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Desfibriladores Implantáveis/efeitos adversos , Endocardite Bacteriana/etiologia , Marca-Passo Artificial/efeitos adversos , Infecções Relacionadas à Prótese/etiologia , Idoso , Feminino , Humanos , Masculino , Staphylococcus aureus Resistente à Meticilina , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/terapia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
This case report describes symmetrically distributed red to violaceous fine telangiectasias in a lacelike pattern on the dorsal feet and ankles.