Oliver J. Wisco

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: A report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

AAD/ACMS/ASDSA/ASMS 2012 Appropriate Use Criteria for Mohs Micrographic Surgery: A Report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery

&NA; The appropriate use criteria process synthesizes evidence‐based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California–Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

The great imitator revisited: the spectrum of atypical cutaneous manifestations of secondary syphilis

Syphilis is a well‐known sexually transmitted infection infamous for its protean cutaneous manifestations. Over the last decade, the rate of infection in the USA has risen, particularly among human immunodeficiency virus (HIV)‐infected individuals and certain ethnic groups. Although the primary chancre developing at the site of inoculation usually has typical and well‐characterized features, cutaneous manifestations of secondary syphilis span a wide spectrum and mimic those of other dermatoses. This may be particularly evident in patients with HIV. Such deviations from the expected typical papulosquamous eruption may present a diagnostic challenge and delay diagnosis and therapy. Given the increasing incidence of syphilis among the immunosuppressed patient population, recognition of atypical cutaneous manifestations is critical for adequate management. We review a range of cutaneous manifestations of secondary syphilis and the skin diseases it may mimic.

Identifying and defining complications of dermatologic surgery to be tracked in the American College of Mohs Surgery (ACMS) Registry.

BACKGROUND In recent years, increasing emphasis has been placed on value-based health care delivery. Dermatology must develop performance measures to judge the quality of services provided. The implementation of a national complication registry is one such method of tracking surgical outcomes and monitoring the safety of the specialty. OBJECTIVE The purpose of this study was to define critical outcome measures to be included in the complications registry of the American College of Mohs Surgery (ACMS). METHODS A Delphi process was used to reach consensus on the complications to be recorded. RESULTS Four major and one minor complications were selected: death, bleeding requiring additional intervention, functional loss attributable to surgery, hospitalization for an operative complication, and surgical site infection. LIMITATIONS This article addresses only one aspect of registry development: identifying and defining surgical complications. CONCLUSION The ACMS Registry aims to gather data to monitor the safety and value of dermatologic surgery. Determining and defining the outcomes to be included in the registry is an important foundation toward this endeavor.

The Helix Jelly Roll Flap

&NA; The authors have indicated no significant interest with commercial supporters.

Letter: Embryologic Fusion Planes: A Plea for More Precise Analysis

Authors frequently publish the generally held belief that fusion planes promote, direct, or limit tumor spread, at least for basal cell and squamous cell carcinoma. However, the only well-supported connection between abnormal growths and embryologic fusion exists for various clefts, cysts, and sinus tracts linked to incomplete or abnormal fusion. Surprisingly, in light of seemingly overwhelming support for the fusion plane/cancer link, in the absence of chronic inflammation, the incidence of cancer formation within these proven fusion-derived abnormalities is vanishingly small.

Low-grade myxofibrosarcoma presenting at the site of prior high-grade disease*

Myxofibrosarcoma is one of the most common soft tissue sarcomas occurring in older adults. It can arise de novo or can be radiation induced, and the term myxofibrosarcoma was originally devised to encompass a spectrum of myxoid tumors with characteristics similar to malignant fibrous histiocytoma (MFH). Confusion exists, however, regarding the distinction between microscopic grade and characteristics of myxofibrosarcoma and MFH. Correct classification is vital to prognosis, as the degree of myxoid change is inversely related to the incidence of metastasis. We present a case of a 76‐year‐old man with a history of high‐grade MFH of the left lower extremity, status post excision and radiation therapy, who presented 2 years later with a regional metastatic recurrence of high‐grade MFH to the left groin as well as new nodules adjacent to and within his prior excision and radiation site. These new nodules were determined to represent low‐grade myxofibrosarcoma. These new low‐grade lesions either represent a low‐grade recurrence of high‐grade sarcoma or a new, radiation‐induced soft tissue sarcoma occurring at the same site. Radiotherapy, however, is an unlikely cause; specific postradiation sarcoma criteria have not been fulfilled. This article discusses both the nosology and histopathological spectrum of these important soft tissue sarcomas, their aggressive and recurrent nature and their association with radiation therapy.

Concomitant Merkel Cell Carcinoma and Basal Cell Carcinoma Presenting as a Solitary Nodule

We report a case of a concomitant basal cell carcinoma (BCC) and Merkel cell carcinoma (MCC) presenting as a solitary tumor. Despite the rarity of MCC in general, the tumor has been reported to occur synchronously with numerous malignancies, including chronic lymphocytic leukemia, dermatofibrosarcoma protuberans, melanoma, squamous cell carcinoma (SCC), and sebaceous carcinoma. There is also a report of a large, ill-defined, ulcerated MCC containing foci of SCC and BCC. To our knowledge, this is only the second report of concomitant BCC and MCC and the only case identified in a single, clearly defined tumor.

When an M is a V: Vector Analysis Calls for Redesign of the M-Plasty

&NA; The authors have indicated no significant interest with commercial supporters.