FOR PHYSICIANS
Journal Club
Led by Dr. Ian Maher — a Professor, Director of Dermatology, and Mohs Fellowship Director at the University of Minnesota — the American College of Mohs Surgery's Virtual Journal Club meets each month to discuss the best new literature related to dermatologic surgery.
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October 2024
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- Article 1 take home points:
- RT+cemiplimab significantly improved PFS vs. cemiplimab alone in patients with la/mCSCC
- Further research needed to validate data from real-world studies
- Article 2 take home points:
- Save this article and study it before boards.
- Article 3 take home points:
- Skin grafts provide a versatile, reliable, and simple approach for reconstructing scalp defects
- FTSG can be used on exposed calvarium
- FTSG has increased graft take and decreased wound complications on exposed calvarium and intact pericranium vs. STSG
- Risk factors affecting outcomes: Grafting exposed bone, larger graft sizes, previous exposure to head and neck radiation, and immunosuppression
- Similar to study of Jiang et al analyzing FTSG on LE wounds after Mohs where 72/80 cases (90%) had full graft survival, 6/80 (7.5%) had partial failure, and 2/80 (2.5%) had complete failure. Complications included infections in 9/80 (11%) cases and hematoma formation in 2/80 (2.5%).
- Article 4 take home points:
- TXA safely reduced postoperative ecchymosis and edema
- Clinical superiority suggested with IV dosing
- Improved Early-Postoperative Experience
- Lower levels of postoperative edema and ecchymosis
- Faster recovery time
- Enhance patient satisfaction
- Intraoperative hemostasis
- Helps control bleeding during surgery
- Ensures a clear surgical field
- No adverse effects
- IV doses 1000mg
Dr. Igor Kapetanovic (University of Minnesota), Dr. Ian Maher (University of Minnesota), Dr. Adam Mattox (University of Minnesota), and Dr. Kathryn Shahwan (Ohio State University) present the best dermatologic surgery relevant literature from the October Journals.:
- Article 1: Previous radiotherapy increases the efficacy of cemiplimab in the treatment of locally advanced and metastatic cutaneous squamous cell carcinoma: A retrospective analysis
- Article 2: Histologic Hitchhikers: A Review of Common Exogenous Artifacts Encountered During Mohs Micrographic Surgery
- Article 3: Full-thickness versus split-thickness skin graft reconstruction of scalp defects with and without calvarium exposure
- Article 4: Effects of Preoperative Intravenous Versus Subcutaneous Tranexamic Acid on Postoperative Periorbital Ecchymosis and Edema Following Upper Eyelid Blepharoplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled, Comparative Study
September 2024
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- Article 1 take home points:
- Findings suggest that a running SQ may result in a less noticeable scar when compared to a running HM at 3 months.
- Superior observer and patient overall opinion scores
- However, there were no significant differences in patient or observer POSAS scores
- The decision of suture technique should remain dependent on surgeon and patient preference.
- Maybe deep layer quality is a more significant contributor
- Findings suggest that a running SQ may result in a less noticeable scar when compared to a running HM at 3 months.
- Article 2 take home points:
- Patients diagnosed with AFX/PDS had an increased risk of developing subsequent SC when compared to the general population, especially SCC and BD and to a lesser extent BCC.
- Might reflect the similar pathogenesis of SCC/BD and AFX/PDS.
- Emphasizes the importance of proper instruction on UV-protection, self-examination and routine total body skin examination in patients with AFX/PDS, particularly in those with a history of SC.
- Article 3 take home points:
- There is no evidence that prior WLE meaningfully impacts SLNB in terms of false-negative findings or recurrence.
- There is mixed anecdotal data on the impact of large rotation flaps on SLNB accuracy.
- Further trials needed to evaluate this notion, especially with larger rotation flaps on the trunk.
- Article 4 take home points:
- NIT is given more selectively to clinical stage III patients with more advanced N category disease
- Despite significant differences in N category between groups there was no difference in OS observed at 3 years
- In subgroup analysis, NIT was associated with a survival advantage among N2/N3 patients
- The national data support the continued usage and study of NIT approaches in patients with high-risk resectable melanoma
- Article 5 take home points:
- SRT/eBT may very well have role in the skin cancer armamentarium
- They themselves are cheaper than traditional radiotherapy, can be offered in outpatient settings, and may offer a good alternative for non-surgical candidates
- However, in practice they are commonly bundled with codes of questionable value to patient care (e.g. ultrasound, hyperthermia, etc.)
- There is a limited amount of healthcare resources and a small number of individuals are going to make life tougher for the rest of us.
Dr. Igor Kapetanovic (University of Minnesota) and Dr. Adam Mattox (University of Minnesota) present the best dermatologic surgery relevant literature from the September Journals.:
- Article 1: Aesthetic outcome of running subcuticular suture versus running horizontal mattress suture in closure of linear wounds of the trunk and extremities: A randomized evaluator-blinded split-wound comparative effectiveness trial
- Article 2: The risk of subsequent skin cancer in patients with atypical fibroxanthoma or pleomorphic dermal sarcoma compared to the general population
- Article 3: Wide Local Excision Before Sentinel Lymph Node Biopsy in Melanoma
- Article 4: Sequencing of Immunotherapy and Outcomes in Operable Clinical Stage III Melanoma: A National Cohort Study
- Article 5: Volume and distribution of radiotherapy performed by dermatologists from 2016 to 2021: A national Medicare trend analysis
August 2024
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- Article 1 take home points:
- MMS seems to be the best active management strategy
- Lowest rate of recurrence or persistence in this review
- Majority of DTE on the face
- Frozen histology helpful in cases where BCC and MAC cannot be ruled out.
- Larger-scale studies necessary to improve understanding on outcomes of DTEs
- MMS seems to be the best active management strategy
- Article 2 take home points:
- BWM is a viable technique for nasal reconstruction after Mohs
- Can achieve definitive coverage in soft-tissue defects much larger than previously described.
- The use of ADM as an adequate departure from the traditional algorithm for nasal reconstruction.
- Patient selection important, must be accepting of a granulating wound scar.
- Helps to preserve future autologous reconstruction options
- Promotes tissue scaffolding that can facilitate reepithelization by secondary intent, or accept a subsequent skin graft, even in defects with exposed cartilage.
- Plan ahead as insurance coverage in the outpatient setting is varibale.
- BWM is a viable technique for nasal reconstruction after Mohs
- Article 3 take home points:
- AI applications currently being assessed for integration into MMS and dermatologic surgery for NMSC have the potential to improve the accuracy of tumor detection and enhance surgical planning
- Extent of these benefits is contingent upon the specific AI models, their integration into clinical workflows, and the quality of the underlying data sets.
- Methodological transparency of AI needed (disclosure of inclusion criteria of data sets, clear descriptions of the diversity and representativeness of this data with acknowledgement of potential biases, and a thorough assessment of performance metrics)
- Further research is warranted to establish standardized protocols and validate these findings across diverse clinical environments
- Article 4 take home points:
- Mohs surgeons steadily integrating IHC into clinical practice across all regions
- Adoption rates higher in the Northeast but volume greatest in the South and West
- Significantly higher utilization rates among ACMS members, recipients of MDS certification, and those in academics likely highlights the importance of formalized training and exposures in improving IHC comfort
- Recent IHC trends may permit approximation of future IHC adoption rates and further encourage training and educational experiences to drive comfort and proficiency among Mohs surgeons
Dr. Igor Kapetanovic (University of Minnesota) and Dr. Adam Mattox (University of Minnesota) present the best dermatologic surgery relevant literature from the August Journals.:
- Article 1: A Systematic Review of the Epidemiology, Clinical Characteristics, Treatment, and Outcomes for Desmoplastic Trichoepithelioma: Underscoring Mohs Micrographic Surgery in Management
- Article 2: Reconstructing Nasal Defects With Acellular Dermal Matrix After Mohs Micrographic Surgery: A 12-year Experience
- Article 3: Artificial Intelligence for Mohs and Dermatologic Surgery: A Systematic Review and Meta-Analysis
- Article 4: Growing Adoption of Immunohistochemistry by Mohs Micrographic Surgeons: A National Medicare Trend Analysis
July 2024
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- Article 1 take home points:
- Longer course based on ID literature showing lower bacterial counts with longer courses
- Could be useful in very compliant patients
- Article 2 take home points:
- MRI most common modality for detecting perineural spread, with high sensitivity
- CT most common for detecting bony invasion with high specificity and relatively high sensitivity
- US, PET-CT, and CT most commonly used to detect NM
- All perform reasonably well, but CT has the highest sensitivity and specificity
- US: low-risk and cost-effective, but highly operator dependent and less able to detect deeper nodes
- Imaging for DM is poorly studied
- Overall, imaging in CSCC appears to change management and improve outcomes
- Additional research is needed to develop practice guidelines
- Article 3 take home points:
- Watchful waiting for SCCIS with a clinically resolved biopsy site has a local recurrence rate of 4%
- Exercise caution in solid organ transplant recipients, tumors on the head/neck (especially vermilion lip or ear), and with positive deep biopsy margins
- Article 4 take home points:
- Local recurrence of invasive melanoma is significantly lower after MMS and staged excision with IHC as opposed to without IHC
- No statistical difference between IHC and H&E in regards to nodal or distal recurrence and disease-specific mortality
- Efforts should be made to implement IHC with MMS to improve patient outcomes and decrease local recurrence
- Prospective studies with uniform reporting and long-term follow-up needed
Dr. Ian Maher (University of Minnesota), Dr. Katie Shahwan (The Ohio State University) and Dr. Andrea Tan (The Ohio State University) present the best dermatologic surgery relevant literature from the July Journals.:
- Article 1: The Effect of Preoperative Chlorhexidine Gluconate Cleanse on Lower Extremity Surgical Site Infections: A Retrospective Cohort Study
- Article 2: Use of Imaging in Cutaneous Squamous Cell Carcinoma to Detect High-Risk Tumor Features, Nodal Metastasis, and Distant Metastasis: A Systematic Review
- Article 3: Oncologic Outcomes for Squamous Cell Carcinoma In Situ With a Clinically Resolved Biopsy Site Managed by Watchful Waiting
- Article 4: Intraoperative Immunohistochemistry During Mohs Micrographic Surgery and Staged Excision Decreases Local Recurrence Rates for Invasive Cutaneous Melanoma: A Systematic Review and Meta-Analysis
June 2024
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- Article 1 take home points:
- This doesn't count settlements which are the vast majority
- Consistent with previous studies risk points are:
- Being a male dermatologist
- Doing cosmetic procedures
- Doctors who are well liked by their patients are FAR less likely to be sued
- Article 2 take home points:
- MIS on head and neck requires larger margins to achieve clearance
- Cheek associated with larger subclinical spread
- Reinforces previous data
- Subtle differences expected with single center studies
- Article 3 take home points:
- Peer comparison and intervention can influence outliers
- Still relatively sticky. Not much movement.
- 0.16 stages/case improvement in outliers
- Also reduced stages in non-outliers
- Gross savings in inliers ~4x that in outliers.
- Even these marginal gains resulted in big $$ savings
- $80m over three-year period
- Article 4 take home points:
- Significant risk of SCC metastases for SOTR within 2 years of index SCC
- Holds with previous risk factors
- Clinical finding of ulceration also associated with risk
- Combination of ulceration and high stage had additive negative effect
- Identifies patients who should be monitored closely
- Potential area for study of interventions to improve outcomes for these patients
Dr. Ian Maher (University of Minnesota) presents the best dermatologic surgery relevant literature from the June Journals.:
- Article 1: Retrospective Analysis of US Litigations Involving Dermatologists From 2011 to 2022
- Article 2: Excision margins for melanoma in situ on the head and neck-A single-center 10-year retrospective review of treatment with Mohs micrographic surgery
- Article 3: 5-Year Follow-Up of a Physician Performance Feedback Report Intervention to Reduce Overuse and Excess Cost: A National Cohort Study
- Article 4: Cumulative incidence and risk factors for cutaneous squamous cell carcinoma metastases in organ transplant recipients: The Skin Care in Organ Transplant Patients in Europe-International Transplant Skin Cancer Collaborative metastases study, a prospective multicenter study
May 2024
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- Article 1 take home points:
- Updated staging during MMS is important
- Central debulks for cSCC >= 2 cm, poor diff, IS patients
- Upstaging during MMS occurs more commonly in SOC tumors
- Greater subclinical extension, results in more MMS layers
- No difference in rate of high-risk features in SOC cSCC
- Updated staging during MMS is important
- Article 2 take home points:
- Subq TXA without waiting period significantly decreases post-op ecchymosis in eyelid surgery but not intra-op bleeding
- The effect of TXA on non-ecchymosis bleeding complications are unknown
- Local TXA + 15 minute waiting period may reduce intra-op bleeding
- AEs/complications are extremely rare with subq TXA
- Subq TXA without waiting period significantly decreases post-op ecchymosis in eyelid surgery but not intra-op bleeding
- Article 3 take home points:
- Large lip repairs can be safely and effectively done under local anesthesia
- Complication rate ~8% actually low for literature averages
- Durable in smokers
- Durable to radiation
- Design keys flap width = defect height. Spilling past MLF > making the flap too narrow
- Really only need full thickness to ~oral commissure then just incise to prefascial plane ergo no risk of motor nerve injury
- Article 4 take home points:
- While a nicely presented article with rational approach, Dr. Demer's concerns about use of SRT for skin cancer treatment in the US persist
- Despite careful pt/tumor selection: recurrence rate 10%+ at 10 years
- Cost-effectiveness significantly overestimated
- If performed, consider: low risk tumor, elderly patient, non-surgical candidate, careful counseling, and hypofractionated course without image guidance
- Article 5 take home points:
- In otherwise immunocompetent patients with non-inflamed skin, prophylactic antibiotics may not be necessary
- There are no RCTs assessing the efficacy of antibiotic prophylaxis for prevention of bacteremia, IE, or PJI.
- Data is limited to small case series and prospective studies, many of which were published several decades ago.
- There is a need for further research and updated guidelines.
Dr. Anderson (University of Minnesota), Dr. Demer (Mayo Clinic College of Medicine and Science), Dr. Mattox (University of Minnesota), and Dr. Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the May Journals.:
- Article 1: Tumor size associated with upstaged cutaneous squamous cell carcinoma in patients with skin of color
- Article 2: Effect of Tranexamic Acid on Intra- and Postoperative Bleeding in Eyelid Surgery: A Prospective, Randomized, Multicenter, Double-Masked, Control Trial
- Article 3: Reconstruction of Broad Lower Lip Defects Using Karapandzic-Type Flaps
- Article 4: Superficial X-ray in the treatment of nonaggressive basal and squamous cell carcinoma in the elderly: A 22-year retrospective analysis
- Article 5: Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review
April 2024
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- Article 1 take home points:
- Discordance in interpretation of IS and variance of IS/VS diagnosis suggest that reviewing IS and VS is something that is reasonable to consider.
- The nastier something is on vertical sections the more likely you are to have to chase it on layers
- Learners like more information
- We’re always challenged to review each slide without bias
- Article 2 take home points:
- Staph aureus and Pseudomonas aeruginosa are the most common isolates and can occur in clinically infected or non-clinically infected wounds. Supports that these bacteria can be colonizers in some.
- Exception - MRSA was seen in only clinically infected wounds.
- Some clinically infected wounds just grew normal flora.
- Authors recommend that culture be collected if a wound is clinically infected, but not treat with oral antibiotics initially unless clinical concern for cellulitis. Authors suggest topical antibiotics (mupirocin and gentamicin) until culture data has returned.
- Article 3 take home points:
- Overall, patient-centered communication skills, referral to the surgeon by the patient’s physician or family and friends, and staff members who made a favorable impression were some of the most notable factors associated with patients’ confidence.
- Identifying characteristics that foster confidence can provide ways to strengthen patient–physician relationships (and health outcomes).
- Article 4 take home points:
- If you’re already doing CK-7 for EMPD, the protocol is the same for Sebaceous Carcinoma.
- Knowing the tumor’s CK-7 staining pattern on the original biopsy can help you determine its utility in each case.
- If CK-7 is not available on the biopsy tissue, a sharp debulk could be used as control tissue.
- Staining and lack of staining may aid in confirming positive and negative margins.
- Article 5 take home points:
- Mail vs mail + phone call had similar level of patients’ sense of preparedness
- Higher satisfaction ratings if additional pre-op phone call but satisfaction still high without phone call
- If it’s vital that patient has a driver home, might be worth while to have phone call in addition to mailed materials
Dr. Laura Archibald (University of Minnesota), Dr. Adam Mattox (University of Minnesota), and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the April Journals.:
- Article 1: Using Initial Biopsies and Vertical Sections to Improve Trainees' Confidence in Performing Mohs Surgery
- Article 2: Bacterial Organisms Colonizing Mohs Surgical Wounds Healing by Second Intention on the Lower Extremities: A Prospective, Controlled Study
- Article 3: Factors Influencing Patients' Confidence in Their Mohs Surgeons
- Article 4: Utility of Intraoperative Cytokeratin-7 Immunostaining During Mohs Micrographic Surgery for Sebaceous Carcinoma
- Article 5: A Comparison of Preoperative Telephone Call Versus Mailed Educational Materials on Patient-Reported Outcomes in Mohs Micrographic Surgery
March 2024
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- Article 1 take home points:
- mBCC is rare
- Consider salvage surgery + radiation for nodal mets
- 50% chance of CR
- For distant mets Hhi and immunotherapy are the first options in that order
- Long course
- Remission is unlikely
- Article 2 take home points:
- Useful tool for counseling patients
- Good reminder of MCC risk factors for those that have to take exams
- Article 3 take home points:
- Upstaging of cutaneous melanoma during MMS occurs at a low rate (2.3%)
- Authors say unclear why their rate is lower than previously published literature. Possibly earlier detection of melanoma, more accurate initial biopsies, or expedited surgery.
- Majority of those upstaged had either base transected or positive peripheral margin on original biopsy.
- No statistically significant demographic or tumor-specific risk factors for upstaging were identified.
- Upstaging of cutaneous melanoma during MMS occurs at a low rate (2.3%)
- Article 4 take home points:
- No significant difference in scar outcomes when comparing sutures vs sutures + cyanoacrylate
- No difference in rates of adverse events
- Not statistically significant but patients tended to prefer wound care on the cyanoacrylate side
- Article 5 take home points:
- Injection of a mixture of bleomycin and triamcinolone seems to be an effective therapy for treatment-resistant keloids. About 80% of patients had an excellent response.
- Very low recurrence rate (3.3%) at 6 months
- One-third of patients each experienced ulceration, hyperpigmentation, post-operative pain, and/or infection
Dr. Laura Archibald (University of Minnesota) and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the March Journals.:
- Article 1: A multicenter real-world analysis of risk factors, therapeutics, and outcomes of patients with metastatic basal cell carcinoma
- Article 2: Merkel cell carcinoma recurrence risk estimation is improved by integrating factors beyond cancer stage: A multivariable model and web-based calculator
- Article 3: Pathologic Upstaging of Cutaneous Melanoma After Mohs Micrographic Surgery
- Article 4: Aesthetic outcome of intermediate closure versus intermediate closure followed by 2-octyl cyanoacrylate: A randomized evaluator-blinded split-wound comparative effectiveness trial
- Article 5: The Combined Application of Bleomycin and Triamcinolone for Treating Refractory Keloids
February 2024
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- Article 1 take home points:
- Our current staging systems can be used to predict poor outcomes for non-head and neck CSCC
- Its performance is on-par with what is seen for head and neck CSCC
- Our current staging systems can be used to predict poor outcomes for non-head and neck CSCC
- Article 2 take home points:
- Delay of PORT is associated with increased LRR, usually outside radiation field
- Each week is a 20% increase in the rate of LRR
- Starting PORT within 8 weeks (ideally 2-3 weeks) reduces rate of LRR and DSD
- Delay of PORT is associated with increased LRR, usually outside radiation field
- Article 3 take home points:
- N/A
- Article 4 take home points:
- N/A
Dr. Aatman Shah and Dr. Kyle Rismiller present the best dermatologic surgery relevant literature from the February Journals.:
- Article 1: Performance of Staging Systems for Non-Head and Neck Cutaneous Squamous Cell Carcinoma
- Article 2: Increased risk of recurrence and disease-specific death following delayed postoperative radiation for Merkel cell carcinoma
- Article 3: Temporoparietal Fasciocutaneous Island Flap for Forehead and Anterior Scalp Reconstruction
- Article 4: Anatomic Location Influences Duration of Local Lidocaine Anesthesia in Dermatologic Surgery
January 2024
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- Article 1 take home points:
- Excision of SCCIS with 5 mm margin has very high cure rates
- Rate of clearance with 4 weeks of 5-FU was 85% (c/w past literature)
- Non-inferiority studies need to be big to achieve a useful margin of non-inferiority
- Topical 5-FU remains a reasonable treatment options for low risk tumors in patients willing to accept a lower cure rate to avoid surgery
- Doing this with 2 groups would have improved the non-inferiority margin (also would have made a positive study less likely)
- Article 2 take home points:
- NOAC monotherapy does not have an increased bleeding risk
- Combo therapy does
- Supports continuation of therapy
- ~1/1000 risk of serious event if discontinue anticoagulation
- Potential tailoring of regiment should be done in consultation with prescribing doctor
- Article 3 take home points:
- CAPABLE survey offers a succinct, practical method to assess multiple aspects of the postoperative patient experience
- Incorporation of the CAPABLE survey in Mohs surgical centers has the potential to improve patient experience and satisfaction
- Article 4 take home points:
- Both STSG and SIH can be great options for defects on the cartilaginous ear.
- Favorable scar outcomes, minimal complications, well-tolerated
- Patients who underwent STSG had increased pain in the first 3 days after surgery but had faster healing time compared to SIH
- For majority of patients with STSG, pain still only mild to moderate
- Both STSG and SIH can be great options for defects on the cartilaginous ear.
Dr. Ian Maher and Dr. Laura Archibald present the best dermatologic surgery relevant literature from the January Journals.:
- Article 1: Surgical excision versus topical 5% 5-fluorouracil and photodynamic therapy in treatment of Bowen's disease: A multicenter randomized controlled trial
- Article 2: Postoperative Bleeding Complications Associated With Novel Oral Anticoagulants in Mohs Micrographic Surgery
- Article 3: CAPABLE: A Scoring System Utilizing Patient-Reported Measures to Evaluate Patient Experience After Mohs Surgery
- Article 4: Assessment of Pain, Healing Time, and Postoperative Complications in the Healing of Auricular Defects After Secondary Intent Healing Versus Split Thickness Skin Graft Placement
December 2023
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- Article 1 take home points:
- TXA seems to be promising in reducing post-op bleeding
- MOST data demonstrates its safety even with IV administration
- Likely any risks would be mitigated by subcutaneous administration
- This is something to keep an eye on
- Article 2 take home points:
- Builds on earlier work of BWH
- Extensive PNI predicts prognosis better and improves staging system
- Lack of large caliber invasion NOT reassuring in the setting of extensive PNI
- Useful for informing adjuvant treatment in the setting of emerging information
- Extensiveness is still a little in the eye of the beholder
- Article 3 take home points:
- Local infiltration and tissue destruction ongoing.
- Consider clearing the invasive tumor with Mohs and alternative non-surgical treatment for the lower risk lesions at the periphery.
- Analogous to SCC with AK at the periphery.
- Same-day frozen biopsy of all lesions in an anatomic zone.
- Reduced office visits
- Allows histology-driven surgical decision making
- Limit complications of adjacent tumors
- Article 4 take home points:
- Cases of anticipated incomplete Mohs were more likely to have patients undergo additional resection, have fewer delays to next surgery, and a higher overall chance of clear final margin
- Preoperative features to support multidisciplinary discussion
- Large size
- Focal neurologic symptoms (pain, paresthesia, weakness)
- Clinically immobile
- Authors note further data in this area is warranted
Dr. Ian Maher, Dr. Adam Mattox and Dr. Laura Archibald present the best dermatologic surgery relevant literature from the December Journals.:
- Article 1: Tranexamic Acid Prevention of Hemorrhagic Complications Following Interpolated Flap Repair: A Single-Center, Retrospective, Cohort Study
- Article 2: Extensive Perineural Invasion vs Nerve Caliber to Assess Cutaneous Squamous Cell Carcinoma Prognosis
- Article 3: An Institutional Experience of a Tertiary Referral Center in Surgically Managing Patients With Gorlin Syndrome
- Article 4: Anticipated Versus Unanticipated Incomplete Mohs Micrographic Surgery for Keratinocyte Carcinomas: Impact on Treatment Delays and Final Margin Status
November 2023
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- Article 1 take home points:
- MIA model for SLNB positivity seems to be a good model (73.3% predicted accuracy in NCDB patients) for patients with <20% predicted risk of SLNB positivity and likely overestimates risk if >20% predicted risk
- Future research on how the MIA model compares to the MSKCC model in large cohorts would be useful
- Article 2 take home points:
- Diazepam had an early and sustained statistically significant reduction in anxiety compared to placebo
- Gabapentin had a significant reduction compared to placebo but only at early time point
- May be useful in patients with CI to benzodiazepine or in cases when a short procedure length is anticipated
- Melatonin a/w worse patient satisfaction compared to placebo, possibly due to sedative effects rather than anxiolytic
- Data supports the safety of these medications
- Article 3 take home points:
- GN infections may only be more edematous or painful than no growth.
- Overall lack of identifiable risk factors and insidious presentation suggest it's reasonable to have a low threshold to culture wounds
- Especially with edema or pain
- Empiric GN coverage not recommended.
- Article 4 take home points:
- Screening for AFX/PDS duration is >= 4 years
- AFX q12 months
- PDS q6 months x3yr; then q12m
- All visits should include PET/CT scanning.
- If high risk factors present consider screening more frequently
- Invasion beyond subcutis, PNI, intravascular invasion
- This article unable to recommend margins, but it seems complete margin analysis may help reduce risk of relapse in AFX.
- Article 5 take home points:
- Day of surgery
- Lower satisfaction with
- 3 or more stages
- Increased perioperative anxiety?
- Procedure extending past the lunch hour
- Patient hunger, staff turn over, delays?
- 3 or more stages
- Increased satisfaction with
- Early arrival
- Lower satisfaction with
- 3 months post op
- Lower satisfaction
- 3 or more Mohs layers
- Surgical site on the extremities
- Longer healing on lower extremities
- Larger pre- & post-operative
- Lower satisfaction
- Day of surgery
Dr. Laura Archibald, Dr. Adam Mattox and Dr. Daniel Knabel present the best dermatologic surgery relevant literature from the November Journals.:
- Article 1: External validation of the Melanoma Institute Australia Sentinel Node Metastasis Risk Prediction Tool using the National Cancer Database
- Article 2: Efficacy and Safety of Anxiolytics in Mohs Micrographic Surgery: A Randomized, Double-Blinded, Placebo-Controlled Trial
- Article 3: Clinical Characteristics of Gram-Negative Surgical Site Infections in Patients Treated With Mohs Micrographic Surgery: A Retrospective Analysis
- Article 4: Atypical fibroxanthoma and pleomorphic dermal sarcoma: Local recurrence and metastasis in a nationwide population-based cohort of 1118 patients
- Article 5: Predictors of patient satisfaction with Mohs micrographic surgery at time of surgery and 3 months postsurgery: A prospective cohort study
October 2023
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- Article 1 take home points:
- Histologic margin status of <3.0mm may predict disease relapse (27.2% recurrence vs. 2.6% recurrence with margin >=3.0mm)
- This correlates with a clinical margin of ~6.5mm
- Authors postulate that this could be related to skip lesions within LMM lesions
- Progression may occur years to decades after initial treatment and patients should be followed closely
- Further studies integrating tumor molecular profiles can aid in further risk stratifying patients in both positive and negative margin scenarios given the number of positive margins that did not progress
- Histologic margin status of <3.0mm may predict disease relapse (27.2% recurrence vs. 2.6% recurrence with margin >=3.0mm)
- Article 2 take home points:
- Pathologic margin control at the 5-year and 10-year survival periods appears superior in the NCDB database
- T1 and T2 tumors
- Academic centers with better outcomes with MCC
- Thoughts to ponder:
- Is this overall survival conclusion valid without localized disease/regional recurrence data?
- Pathologic margin control at the 5-year and 10-year survival periods appears superior in the NCDB database
- Article 3 take home points:
- Study suggests aRT is associated with not only local and regional LN recurrence-free survival but also disease-specific survival
- However, due to retrospective nature, aRT group were significantly younger and more frequently underwent SLNB
- Study spanned 20 years involving various aRT protocols and low rate of SLNB
- Additional prospective studies are needed to clarify the impact of aRT on MCC outcomes
- Article 4 take home points:
- N/A
- Article 5 take home points:
- N/A
Dr. Bryan Carroll (Northwestern University), Dr. Kevin Savage (PGY IV, University of Pittsburg), Dr. Lauren Crow (MSDO Fellow, University of Pittsburg), Dr. Melissa Pugliano-Mauro (University of Pittsburgh), Dr. Jake Wang, (Case Western Reserve University), and Dr. Scott Mahlber (Case Western Reserve University) present the best dermatologic surgery relevant literature from the October Journals.:
- Article 1: Histologic margin status is a predictor of relapse in lentigo maligna melanoma
- Article 2: Overall Survival After Mohs Surgery for Early-Stage Merkel Cell Carcinoma
- Article 3: Impact of adjuvant radiation therapy on survival and recurrence in patients with stage I-III Merkel cell carcinoma: A retrospective study of 312 patients
- Article 4: N/A
- Article 5: Debating Sentinel Lymph Node Biopsy for Melanoma in the Modern Adjuvant Era
September 2023
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- Article 1 take home points:
- DFSP is a low-grade tumor with in general a good prognosis and survival rate
- Tumor size (>= 10 cm), grade III (poorly diff, undifferentiated): RF for survival
- Tumor depth may not be an independent RF for survival
- Article 2 take home points:
- MMS complete peripheral and deep margin assessment, recurrence 1% vs CE 10% (in face)
- Patients with > Breslow, scalp, worse prognosis
- RCTs are needed to compare CE vs MMS
- Article 3 take home points:
- OTR significantly higher risk of 2nd CSCCs, metastasis, and DSD
- Did not control for T stage
- Most deaths were non-CSCC related
- Most CSCC deaths were not due to mets
- OTR significantly higher risk of 2nd CSCCs, metastasis, and DSD
- Article 4 take home points:
- Twizzler technique incrementally reduces tension through creep and load cycling
- Useful tool for high tension primary closures on the scalp
- Article 5 take home points:
- Nomogram risk calculator useful tool for informed discussion with MCC patients
- Not meant to take the place of SLNB
- But can help inform risk when SLNB not possible, non-diagnostic, or potentially false negative
Dr. Kathryn Shahwan and her fellow present the best dermatologic surgery relevant literature from the September Journals.:
- Article 1: Survival Outcomes and Prognostic Factors of Dermatofibrosarcoma Protuberans: A Population-Based Retrospective Cohort Analysis
- Article 2: Outcomes of invasive melanoma of the head and neck treated with Mohs micrographic surgery - A multicenter study
- Article 3: Rates of Second Tumor, Metastasis, and Death From Cutaneous Squamous Cell Carcinoma in Patients With and Without Transplant-Associated Immunosuppression
- Article 4: Reconstruction of High-Tension Scalp Defects by the Twizzler Technique: A Retrospective Case Series
- Article 5: Online risk calculator and nomogram for predicting sentinel lymph node positivity in Merkel cell carcinoma
August 2023
Click for meeting recording and notes
- Article 1 take home points:
- Globe sparing surgery remains a reasonable tool for preserving critical functions in patients with advanced periocular BCC
- Clinical signs of recurrence are often highly nonspecific
- Recurrent status predisposes to further recurrence
- Recurrences often occur LATE
- Vismodegib is a viable alternative to radiation with lower ocular risks but risk of non-response
- Prolonged close follow up with imaging is critical
- Article 2 take home points:
- Poor prognostic features are more common in SCCs in OTRs compared to general population
- SCCs on arms/hands: PNI and poor differentiation were over 4x more frequent in OTRs
- SCCs on H/N and trunk/LE: Poor differentiation was over 3x more frequent in OTRs
- Results reinforce the need for early detection of SCCs in OTRs and intensive surveillance over time
- Limitation
- No central review of SCC pathology
- Poor prognostic features are more common in SCCs in OTRs compared to general population
- Article 3 take home points:
- ED+C continues to be a reasonable treatment option for low risk tumors
- Is the recurrence rate really that low?
- Data quality always a problem with retrospective recurrence studies
- Early in this study period they probably weren't using photos as freely as we are now.
- Lack of standard technique - though results are good so...
- Article 4 take home points:
- For clinically and pathologically node-negative patients, no overall or MCC-specific survival difference for MMS compared to WLE
- MMS has advantage of tissue sparing
- Limitations:
- Retrospective database study, exact margin used not available, data on use of immunostains and immunosuppression status not available, recurrence rates not available
- SLNB associated with improved OS and DSS
- Significantly less patients got SLNB in MMS group vs WLE group
- "MMS should be considered for treatment of MCC as long as SLNB can be performed before surgical resection."
- Article 5 take home points:
- N/A
Dr. Ian Maher and Dr. Laura Archibald will present the best dermatologic surgery relevant literature from the August Journals.:
- Article 1: Recurrence Following Globe Sparing Excision for Basal Cell Carcinoma with Anterior Orbital Invasion
- Article 2: High-risk Prognostic Tumor Features of Squamous Cell Carcinomas in Organ Transplant Recipients Compared With the General Population
- Article 3: Electrodesiccation and Curettage for Squamous Cell Carcinoma in Situ: The Effect of Anatomic Location on Local Recurrence
- Article 4: No difference in survival for primary cutaneous Merkel cell carcinoma after Mohs micrographic surgery and wide local excision
- Article 5: Trends in Residency Academic Productivity of Ophthalmic Plastic and Reconstructive Surgery Fellows Between 2012 and 2019
July 2023
Click for meeting recording and notes
- Article 1 take home points:
- Slightly more than half of MMS for melanoma on head and neck
- No survival difference between groups.
- Kind of a glass half full/half empty thing
- Wide margin had a higher Breslow depth (0.7 vs. 0.4)
- More higher stage patients in wide margin group
- No survival disadvantage for narrow margins in on average a T1 population
- Detractors might say that the lack of difference was due to taking wider margins in higher risk tumors
- Article 2 take home points:
- Complication definitions have to be the same for everybody
- We all need to be using the same definition
- That definition needs to align with other specialties doing the same work
- There have been previous efforts within Mohs to make a standard definition
- Knowledge of that definition is a major gap
- A lot of respondents seemed to be using an inappropriately short horizon for SSI.
- Complication definitions have to be the same for everybody
- Article 3 take home points:
- MCC treatment in a facility with academic affiliation and high case volume seems to improve survival.
- Care regionalization helps improve outcomes in some malignancy.
- Care regionalization may help improve MCC outcomes
- More data on disease specific survival and local recurrence needed.
- Potential benefits and feasibility of MCC care regionalization studies needed.
- Article 4 take home points:
- In this cohort, digital pathology decreased operative time and improved accuracy of Mohs surgery
- Limitations:
- Retrospective, single institution
- Relatively small cohort (80 patients)
- Not generalizable
- Article 5 take home points:
- In this cohort, pain level did not significantly increase with subsequent Mohs stages
- Vast majority of patients (~90%) reported only mild to moderate levels of intraoperative pain, supporting the use of Mohs surgery in the outpatient setting as a well-tolerated procedure
- Limitations:
- Pain is an inherently subjective measure
Dr. Ian Maher (University of Minnesota), Dr. Adam Mattox (University of Minnesota), and Dr. Laura Archibald (Fellow, University of Minnesota), present the best dermatologic surgery relevant literature from the July Journals.:
- Article 1: No Survival Benefit With Wide Margin Mohs Micrographic Surgery for Melanoma: A National Cancer Database Analysis
- Article 2: Results of a National Survey on the Definition of Surgical Site Infections After Mohs Micrographic Surgery
- Article 3: The impact of facility characteristics on Merkel cell carcinoma outcomes: A retrospective cohort study
- Article 4: Mohs Micrographic Surgery With Digital Pathology Improves Surgical Quality and Efficiency: A Retrospective Cohort Study
- Article 5: Pain of local anesthetic injection of lidocaine during subsequent stages of Mohs micrographic surgery: A multicenter prospective cohort study
June 2023
Click for meeting recording and notes
- Article 1 take home points:
- Bony Invasion is not well defined.
- Management of periosteum involvement is variable
- Referral for superficial cranioplasty is most common
- Superficial Cranioplasty seems to have the most evidence supporting
- Consider Tumor Boarding T3-T4 tumors
- Article 2 take home points:
- PDT seems more effective resolving AKs
- SCC prevention undetermined
- Excellent cosmetic outcomes and patient preference.
- More common and severe adverse effects
- AE's resolve
- Protocols can be manipulated to lessen adverse effects
- PDT seems more effective resolving AKs
- Article 3 take home points:
- Mohs Surgeons Dominate!
- Cutaneous reconstructions at CFS sites broadly
- All recon categories, except interpolation flaps
- With increasing lead from 2013-2019
- Interpolations: "you can do it"
- Tell your friends!
- Mohs Surgeons Dominate!
- Article 4 take home points:
- N/A
Dr. Adam Mattox (University of Minnesota), Dr. Addison Demer (Mayo) and Dr. Daniel Knabel (Medical College of Wisconsin), present the best dermatologic surgery relevant literature from the June Journals.:
- Article 1: Management of Scalp Squamous Cell Carcinoma Involving Bone: A Survey of the American College of Mohs Surgery
- Article 2: Efficacy and Safety of Photodynamic Therapy for the Treatment of Actinic Keratoses: A Meta-Analysis Update of Randomized Controlled Trials
- Article 3: Mohs Surgeons Dominate Cutaneous Reconstructions in Cosmetically and Functionally Sensitive Sites: Medicare Trends From 2013 to 2019
- Article 4: Association of Excision Margin Size With Local Recurrence and Survival in Patients With T1a Melanoma at Critical Structures
May 2023
No Journal Club meeting reviewing May 2023 literature.
April 2023
Click for meeting recording and notes
- Article 1 take home points:
- We need to prescribe fewer opiates
- Many patients do not take their full course ergo excess can be diverted
- Effective non-addicting alternatives are available
- Legislation is effective, but do we want that level of administrative encroachment
- Article 2 take home points:
- Studies show efficacy of resurfacing laser for improving scar appearance as early as day 0
- No difference in appearance at day 0 vs. day 14 for fractional ablative resurfacing
- Question of early vs. delayed scar treatment remains
- Article 3 take home points:
- Baseline US and PET can be used to detect regional MCC prior to SLNB
- But why? Would you trust it?
- Baseline US w/ FNA is not a substitute for SLNB in those with localized MCC
- FN rate of >30%
- In those with negative imaging, ~25% were upstaged with SLNB
- PET may be useful in those w/ stage III MCC to detect distant dz
- Baseline US and PET can be used to detect regional MCC prior to SLNB
- Article 4 take home points:
- MMS patients with eligible melanomas significantly less likely to have SLNB
- Across all T stages
- Even in matched cohort analysis
- Further studies needed to explore root cause
- MMS patients with eligible melanomas significantly less likely to have SLNB
- Article 5 take home points:
- SLNB added net benefit at treatment thresholds of 30% or higher, at which adjuvant therapy is typically given
- Persisted across T stages and age ranges
- Prognostic value of SLNB is clinically meaningful
- SLNB added net benefit at treatment thresholds of 30% or higher, at which adjuvant therapy is typically given
Dr. Kyle Rismiller (University of Minnesota Fellow), Dr. Katie Shahwan (Altru Health System) and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the April Journals.:
- Article 1: Association of a Statewide Opioid Legislation with Opioid Prescribing Patterns in Facial Plastic and Reconstructive Procedures
- Article 2: Early Fractional Ablative Laser for Skin Cancer Excision Scars: A Randomized Split-Scar Study
- Article 3: Baseline ultrasound and FDG-PET/CT imaging in Merkel cell carcinoma
- Article 4: Differences in sentinel lymph node biopsy utilization in eligible melanoma patients treated with Mohs micrographic surgery or wide local excision: A population-based logistic regression model and survival analysis
- Article 5: Sentinel lymph node biopsy status improves adjuvant therapy decision-making in patients with clinical stage IIB/C melanoma: A population-based analysis
March 2023
Click for meeting recording and notes
- Article 1 take home points:
- Both procedures were equally efficacious, had minimal complications, and showed no recurrence at 6 months and 1 year.
- Both with variable pros/cons
- Both procedures were equally efficacious, had minimal complications, and showed no recurrence at 6 months and 1 year.
- Article 2 take home points:
- Education level was not statistically significantly associated with health care literacy
- Increased age was associated with lower health care literacy
- Article 3 take home points:
- Understanding processing needs for special tissue types are important for successfully running a Mohs lab
- Additionally, these are easy things to write questions about.
- Very high yield
- This article is an excellent, concise resource for adipose processing.
- Article 4 take home points:
- Tough area to repair
- Seems to be a good option for small defects in this area
- Does not require grafting of donor site or immobilization like many flaps on the finger
- Can survive over bare nail plate or tendon unlike graft
- Always good to have options
Dr. Laurin Council (Washington University in St. Louis), Dr. Addison Demer (Mayo Clinic), and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the March Journals:
- Article 1: Surgical Matricectomy Versus Phenolization in the Treatment of Ingrown Toenails: A Randomized Controlled Trial
- Article 2: Predictors of Low Health Care Literacy in Mohs Micrographic Surgery Patients
- Article 3: Optimal Preparation of Adipose Tissue in Frozen Sections for Mohs Micrographic Surgery
- Article 4: Long-necked reading man flap for distal dorsal finger defect reconstruction
February 2023
Click for meeting recording and notes
- Article 1 take home points:
- Risk factors for poor outcomes in SCC are well established
- Event though established in small testing subset they are widely extrapolable
- We still don't REALLY know what to do to improve outcomes
- Prospective randomized trials on the use of adjuvant radiation, neoadjuvant PD-1, etc. are needed to define care pathways for high-risk patients.
- Article 2 take home points:
- Dermatologists' visual dx of BCC is very accurate
- Shave removal has some advantages over shave and ED+C for the rare instances when we are wrong
- Shave removal of low-risk BCCs in low-risk areas produced histological clearance ~75% of the time
- Reasonable option for patients looking to minimize trips
- N.B. intention matters. 2mm clinical margin was taken on these shaves. Larger or smaller margins would influence results.
- Authors report no clinical recurrences
- Article 3 take home points:
- In-office treatments such as photodynamic therapy represent a cost-effective (low cost and high adherence) alternative to topical therapies with comparable efficacy.
- Treatment choice for AK should balance efficacy, adherence, cost, tolerability, individual risk of KC, and patient concerns and motivation.
- Article 4 take home points:
- Compliance with NCCN guideline of SLNB for MCC is increasing but remains low (~55%)
- Significantly lower than for SLNB rates for melanoma and breast cancer
- Lower compliance of SLNB with Mohs
- Head/neck location
- Requires 2 asynchronous surgeries
- Compliance with NCCN guideline of SLNB for MCC is increasing but remains low (~55%)
- Article 5 take home points:
- Complication rates following interpolated flap repair in outpatient setting are low
- Bleeding and infection are most common (4-5%), more frequent after 1st stage (3:1)
- Manageable in outpatient setting
Dr. Adam Mattox (University of Minnesota), Dr. Kyle Rismiller (University of Minnesota Fellow), and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the February Journals:
- Article 1: Association of Patient Risk Factors, Tumor Characteristics, and Treatment Modality With Poor Outcomes in Primary Cutaneous Squamous Cell Carcinoma: A Systematic Review and Meta-analysis
- Article 2: Deep Shave Removal of Suspected Basal Cell Carcinoma: A Prospective Study
- Article 3: Field Therapy for Actinic Keratosis: A Structured Review of the Literature on Efficacy, Cost, and Adherence
- Article 4: Sentinel lymph node biopsy in Merkel cell carcinoma: Rates and predictors of compliance with the National Comprehensive Cancer Network guidelines
- Article 5: Postoperative Complications After Interpolated Flap Repair for Mohs Defects of the Nose: A Multicenter Prospective Cohort Study
January 2023
Click for meeting recording and notes
- Article 1 take home points:
- Excellent outcomes with Mohs surgery alone in high risk SCC
- Superior to those reported in cohorts treated with wide local excision
- Adjuvant radiation and/or selective neck dissection may be unnecessary in patients with clear margins following Mohs surgery
- Favorable survival outcomes even after salvage therapy
- Excellent outcomes with Mohs surgery alone in high risk SCC
- Article 2 take home points:
- Fellowship-trained Mohs surgeons show 99.79% concordance with board-certified dermatopathologists in frozen section interpretation
- Article 3 take home points:
- High local control and low mortality with histologic PNI in BCC with both surgery and surgery + RT
- No statistically significant benefit with adjuvant RT compared to surgery alone
- Adjuvant RT unlikely to be of significant benefit in histologic PNI with clear margins
- Article 4 take home points:
- Local recurrence rates for EMPD were significantly lower following Mohs surgery vs. WLE
- 2.67x higher odds of recurrence after WLE than MMS
- 7.3% rate of recurrence with MMS vs. 26.3% with WLE
- Local recurrence rates for EMPD were significantly lower following Mohs surgery vs. WLE
- Article 5 take home points:
- In patients with T1a melanomas, risk factors significantly associated with SLNB positivity on multivariable analysis were:
- Age less than or equal to 42 years
- Mitotic rate less than or equal to 2/mm2
- LVI
- Head and neck location
- SLNB positivity significantly reduced survival in T1a melanomas
- 5-year disease specific survival: 90.7% vs. 99.5% (P<.0001)
- 5-year recurrence free survival: 81.4% vs. 95.6% (P<.0001)
- In patients with T1a melanomas, risk factors significantly associated with SLNB positivity on multivariable analysis were:
The best dermatologic surgery relevant literature from the January Journals is presented.:
- Article 1: Clinical outcomes of high-risk cutaneous squamous cell carcinomas treated with Mohs surgery alone: An analysis of local recurrence, regional nodal metastases, progression-free survival, and disease-specific death
- Article 2: Mohs micrographic surgery and dermatopathology concordance: An analysis of 1421 Mohs cases over 17 years
- Article 3: Surgery Alone (Without Adjuvant Radiation) Adequately Treats Histologic Perineural Basal Cell Carcinomas: A Systematic Review With Meta-Analysis
- Article 4: Local Recurrence Rates of Extramammary Paget Disease Are Lower After Mohs Micrographic Surgery Compared With Wide Local Excision: A Systematic Review and Meta-Analysis
- Article 5: Sentinel lymph node biopsy in patients with T1a cutaneous malignant melanoma: A multicenter cohort study
To view earlier recordings in the Journal Club archive, click the desired year below.
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