Jeremy R. Etzkorn

Low recurrence rates for in situ and invasive melanomas using Mohs micrographic surgery with melanoma antigen recognized by T cells 1 (MART-1) immunostaining: Tissue processing methodology to optimize pathologic staging and margin assessment

BACKGROUND Various methods of tissue processing have been used to treat melanoma with Mohs micrographic surgery (MMS). OBJECTIVE We describe a method of treating melanoma with MMS that combines breadloaf frozen sectioning of the central debulking excision with complete peripheral and deep microscopic margin evaluation, allowing detection of upstaging and comprehensive pathologic margin assessment before reconstruction. METHODS We conducted a retrospective cohort study evaluating for local recurrence and upstaging in 614 invasive or in situ melanomas in 577 patients treated with this MMS tissue processing methodology using frozen sections with melanoma antigen recognized by T cells 1 (MART-1) immunostaining. Follow-up was available in 597 melanomas in 563 patients. RESULTS Local recurrence was identified in 0.34% (2/597) lesions with a mean follow-up time of 1026 days (2.8 years). Upstaging occurred in 34 of 614 lesions (5.5%), of which 97% (33/34) were detected by the Mohs surgeon before reconstruction. LIMITATIONS Limitations include retrospective study, intermediate follow-up time, and that the recurrence status of 39.6% of patients was self-reported. CONCLUSION Treating melanoma with MMS that combines breadloaf sectioning of the central debulking excision with complete peripheral and deep microscopic margin evaluation permits identification of upstaging and consideration of sentinel lymph node biopsy before definitive reconstruction and achieves low local recurrence rates compared with conventional excision.

Topical and intralesional treatment of nonmelanoma skin cancer: efficacy and cost comparisons.

Background Topical chemotherapy, topical immunomodulators, or intralesional chemotherapy may be used to treat nonmelanoma skin cancer (NMSC). Objectives To review the cost and efficacy of topical and intralesional therapies for NMSC. Methods Literature search assessing the efficacy of NMSC treatment with topical imiquimod, topical 5‐flourouracil (5FU) intralesional 5FU, methotrexate, bleomycin, and interferon (IFN). Single‐lesion case reports were excluded. Aggregate cure rates and the estimated cost of treatment (including excision and repair of recurrent lesions) for a sample 1‐cm lesion on an extremity were calculated. Results Cure rates ranged from 65% to 100% for topical imiquimod and 61% to 92% for 5FU. For intralesional agents, cure rates varied considerably according to medication used and NMSC subtype treated. Keratoacanthomas had high cure rates with intralesional agents: 98% for 5FU, 91% for methotrexate, 100% for bleomycin, 100% for IFN alpha (&agr;)‐2, 83% for IFN &agr;‐2a, and 100% for IFN &agr;‐2b. Estimated costs (excluding medication cost) ranged from

Clinical and pathologic factors associated with subclinical spread of invasive melanoma

205 (intralesional methotrexate for keratoacanthoma) to

Patient and Physician Assessment of Surgical Scars: A Systematic Review

1,174 (IFN &agr;‐2a for superficial basal cell carcinoma). Conclusion Nonsurgical management of NMSC remains a viable and relatively cost effective treatment option in select cases. Providers should consider the relative efficacy and cost of each medication when using nonsurgical modalities.

Clinical factors associated with subclinical spread of in situ melanoma

Background Indications to treat invasive melanoma with Mohs micrographic surgery (MMS) or analogous techniques with exhaustive microscopic margin assessment have not been defined. Objective Identify clinical and histologic factors associated with subclinical spread of invasive melanoma. Methods This retrospective, cross‐sectional study evaluated 216 invasive melanomas treated with MMS and melanoma antigen recognized by T cells 1 immunostaining. Logistic regression models were used to correlate clinicopathologic risk factors with subclinical spread and construct a count prediction model. Results Risk factors associated with subclinical spread by multivariate analysis included tumor localization on the head and neck (OR 3.28, 95% confidence interval [CI] 1.16‐9.32), history of previous treatment (OR 4.18, 95% CI 1.42‐12.32), age ≥65 (OR 4.45, 95% CI 1.29‐15.39), and ≥1 mitoses/mm2 (OR 2.63, 95% CI 1.01‐6.83). Tumor thickness and histologic subtype were not associated with subclinical spread. The probability of subclinical spread increased per number of risk factors, ranging from 9.22% (95% CI 2.57%‐15.86%) with 1 factor to 80.32% (95% CI 68.13%‐92.51%) with 5 factors. Limitations This study was conducted at a single academic institution with a small study population using a retrospective study design that was subject to potential referral bias. Conclusion Clinical and histologic factors identify invasive melanomas that are at increased risk for subclinical spread and might benefit from MMS or analogous techniques prior to reconstruction.

Risk factors for positive or equivocal margins after wide local excision of 1345 cutaneous melanomas

Importance Surgical scarring affects patients by distracting the gaze of onlookers, disrupting social interactions, and impairing psychosocial health. Patient and physician agreement regarding ideal scar characteristics is important in developing congruent expectations after surgery. Objective To summarize published studies assessing patient and physician ratings of surgical scars, rates of patient and physician agreement in scar assessment, and elements of cutaneous scar assessment that differ between patients and physicians. Evidence Review A literature search of Ovid/Medline, PubMed, and EMBASE was conducted from January 1, 1972, to August 1, 2015. Prospective studies comparing scars from different surgical techniques using at least 1 physician-reported and patient-reported scar measure were included. Strength of studies was graded according to the Oxford Centre for Evidence-Based Medicine guidelines. Findings The review identified 29 studies comprising 4485 patients. Of the 29 included studies, 20 (69%) were randomized clinical trials (RCTs), 5 (17%) were prospective, nonrandomized studies, and 4 (14%) were descriptive studies. Disagreement between patients and physician evaluation of scars occurred in 28% (8 of 29) studies, with only patients rating scar difference in 75% (6 of 8) of these cases. Patients were more likely to value scar depth while physicians were more likely to value scar pigmentation and relief. Conclusions and Relevance Methodologically rigorous studies that include clinician- and patient-reported scar outcomes are uncommon. Studies that incorporate subjective and objective scar grading reveal disagreement between patients and clinicians. Of the incision and wound closure techniques assessed, few affected patient- and clinician-reported outcomes, but the evidence remains weak and future studies are recommended.

Patient-reported quality of life and psychosocial health prior to skin cancer treatment – A cross-sectional study

Background Subclinical spread of in situ melanoma occurs at a wide frequency, ranging from 12% to 71%. Objective To identify clinical factors associated with subclinical spread of in situ melanoma. Methods We used a retrospective, cross‐sectional study of 674 consecutive in situ melanomas to examine 627 patients treated with Mohs surgery and melanoma antigen recognized by T cells 1 immunostaining. The presence of subclinical spread was correlated with clinical characteristics. Univariate and multivariate logistic regression analyses were performed to generate odds ratios (ORs) and 95% confidence intervals (CIs). Results Both univariate and multivariate analyses demonstrated significantly increased odds for subclinical spread of in situ melanomas when they were located on the head or neck, at acral sites, or on the pretibial leg (OR 1.97, 95% CI 1.41‐3.40); in persons with a history of prior treatment (OR 2.77, 95% CI 1.74‐4.420); melanomas of preoperative size >1 cm (OR 1.74, 95% CI 1.23‐2.46, P = .002); or in persons ≥60 years old (OR 1.47, 95% CI 1.01‐2.13, P = .042). A count prediction model demonstrated that the risk for subclinical spread increased with the number of clinical risk factors. Limitation We used a single‐site, retrospective study design. Conclusion Clarifying the risk factors for subclinical spread might help to refine triage of in situ melanomas to the appropriate surgical techniques for margin assessment prior to reconstruction.

Local Fasciocutaneous Sliding Flaps for Soft-Tissue Defects of the Dorsum of the Hand

Background Positive or equivocal margins after wide local excision (WLE) complicate surgical management of cutaneous melanoma. Objective To identify the frequency of and risk factors for positive or equivocal margins after WLE of cutaneous melanoma. Methods Retrospective, single‐center, cross‐sectional study of 1345 consecutive melanomas treated with WLE. Results The overall frequency of positive or equivocal margins was 4.2% (56/1345), ranging from 2.2% to 22.6%, depending on the size of the surgical margins, patient characteristics, biopsy history, and the clinicopathology of the melanoma. In descending order, independent risk factors associated with the greatest odds for positive or equivocal margins after multivariate analysis were noncompliance with recommended surgical margins (odds ratio [OR] 5.57, P = .002); anatomic location on the head, neck, hands, feet, genitals, or pretibial leg (OR 5.07, P < .001); histologic regression (OR 2.78, P = .007); in situ melanoma (OR 2.27, P = .011); multiple biopsies at the tumor site before WLE (OR 1.92 [per biopsy], P = .004); and increasing age (OR 1.049 [per year], P < .001). Limitations This was a single‐site, retrospective observational study. Conclusions Clinicopathologic factors, especially location in cosmetically or functionally sensitive areas and noncompliance with recommended surgical margins, identified melanomas at increased risk for positive or equivocal margins after WLE.

Utilization patterns and survival outcomes after wide local excision or Mohs micrographic surgery for Merkel cell carcinoma in the United States, 2004-2009

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Patient quality of life fluctuates before and after Mohs micrographic surgery: A longitudinal assessment of the patient experience

IMPORTANCE Appropriate coverage of defects that expose tendon, joints, and/or neurovascular structures is necessary to preserve optimal hand function. Local, random-pattern flaps and skin grafts may be inadequate because of the hands finite skin reservoir or the presence of a poorly vascularized and mobile wound bed. Described herein is a novel method of dorsal hand reconstruction. OBSERVATIONS A fasciocutaneous sliding flap and the underlying vascular anatomy of the dorsal hand are described. The flap takes advantage of the distinct fascial layers of the hand by raising the skin and fascia with bilevel undermining. CONCLUSIONS AND RELEVANCE The proposed single-stage, bilevel undermined fasciocutaneous sliding flap based on the perforating vessels running through fascial septae recruits pliable, easily mobilized skin, preserves neurosensory innervation, and facilitates early hand mobilization with reduced postoperative care. This flap, and its proposed variations, are ideal for use when paratenon is exposed and immobilizing the hand would be necessary for graft survival or when tension at the wound precludes reconstruction with primary closure or a traditional flap.