Randall K. Roenigk

Merkel cell carcinoma. Comparison of Mohs micrographic surgery and wide excision in eighty-six patients.

BACKGROUND. Merkel cell carcinoma is an uncommon malignant tumor of the skin that, after standard surgical excision, tends to recur locally and develop regional nodal spread. OBJECTIVE. This study evaluated the use of Mohs micrographic surgery for this aggressive neoplasm. METHODS. A retrospective study of 86 patients with Merkel cell carcinoma established rates of local persistence and the development of regional metastasis after standard surgical excision. Detailed follow‐up was availake on a subgroup of 13 patients treated with Mohs surgery. RESULTS. Standard surgical excision for local disease was associated with high rates of local persistence (13 of 41 [31.7%]) and regional metastasis (20 of 41 148.8%]). Mean follow‐up was 60 months. Mean follow‐up for the group treated with Mohs was 36 months. Only one of 12 (8.3%) Mohs‐treated patients with histologically confirmed clearance has had local persistence of disease. This patient underwent a second Mohs excision and has remained disease free for 84 months. Regional metastasis devel‐oped in four of 12 cases (33.3%). Regional metastasis developed in none of the four patients treated with radiotherapy after Mohs surgery and in four of eight patients treated with Mohs surgery without postoperative radiotherapy. CONCLUSION. Mohs surgery compares favorably with standard surgical excision. Radiotherapy after Mohs surgery may further reduce persistent metastases in transit and nodal disease.

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.

Antibiotic prophylaxis in dermatologic surgery: Advisory statement 2008

BACKGROUND Antibiotic prophylaxis is an important component of dermatologic surgery, and recommendations in this area should reflect the updated 2007 guidelines of the American Heart Association, the American Dental Association with the American Academy of Orthopaedic Surgeons guidelines, and recent prospective studies on surgical site infection. OBJECTIVE To provide an update on the indications for antibiotic prophylaxis in dermatologic surgery for the prevention of infective endocarditis, hematogenous total joint infection, and surgical site infection. METHODS A literature review was performed, expert consensus was obtained, and updated recommendations were created, consistent with the most current authoritative guidelines from the American Heart Association and the American Dental Association with the American Academy of Orthopaedic Surgeons. RESULTS For patients with high-risk cardiac conditions, and a defined group of patients with prosthetic joints at high risk for hematogenous total joint infection, prophylactic antibiotics are recommended when the surgical site is infected or when the procedure involves breach of the oral mucosa. For the prevention of surgical site infections, antibiotics may be indicated for procedures on the lower extremities or groin, for wedge excisions of the lip and ear, skin flaps on the nose, skin grafts, and for patients with extensive inflammatory skin disease. LIMITATIONS These recommendations are not based on multiple, large-scale, prospective trials. CONCLUSIONS There is a strong shift away from administration of prophylactic antibiotics in many dermatologic surgery settings, based on updated authoritative guidelines. These recommendations provide guidance to comply with the most current guidelines, modified to address dermatology-specific considerations. Managing physicians may utilize these guidelines while individualizing their approach based on all clinical considerations.

Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts

BACKGROUND The documented presence of human papillomavirus DNA in the plume after carbon dioxide laser treatment of warts has raised questions about the risk of transmission of human papillomavirus to laser surgeons. OBJECTIVE We sought to define more clearly the risks to surgeons of acquiring warts from the CO2 laser plume. METHODS A comparative study was conducted between CO2 laser surgeons and two large groups of population-based control subjects (patients with warts in Olmsted County and at the Mayo Clinic from 1988 to 1992). Conclusions were drawn about the risks to surgeons of acquiring warts from the CO2 laser plume. RESULTS There was no significant difference (p = 0.569) between the incidence of CO2 laser surgeons with warts (5.4%) and patients with warts in Olmsted County from 1988 to 1992 (4.9%). There was a significant difference between the incidence of plantar (p = 0.004), nasopharyngeal (p = 0.001), and genital and perianal warts (p = 0.004) in the study group and in patients with warts treated at the Mayo Clinic from 1988 to 1992. No significant difference was found between physicians who had acquired warts and those who were wart free, on the basis of the failure to use gloves (p = 0.418), standard surgical masks (p = 0.748), laser masks (p = 0.418), smoke evacuators (p = 0.564), eye protection (p = 0.196), or full surgical gowns (p = 0.216). Finally, the incidence rates of surgeons with warts per 1000 person-years did not increase significantly (p = 0.951) as the length of time that the CO2 laser was used to treat warts increased. CONCLUSION When warts are grouped together without specification of anatomic site, CO2 laser surgeons are no more likely to acquire warts than a person in the general population. However, human papillomavirus types that cause genital warts seem to have a predilection for infecting the upper airway mucosa, and laser plume containing these viruses may represent more of a hazard to the surgeon.

Dermatologic surgery : principles and practice

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A Comparison of Mohs Micrographic Surgery and Wide Excision for the Treatment of Atypical Fibroxanthoma

background Atypical fibroxanthoma (AFX) is an uncommon spindle cell neoplasm occurring most often in actinically damaged skin of elderly patients. This tumor has invasive potential, may recur locally after excision, and rarely metastasizes. To conserve tissue and improve the likelihood of cure, Mohs micro–graphic surgery (MMS) has been used for treatment. objective We review and discuss the Mayo Clinic experience treating AFX with MMS and retrospectively compare the clinical outcome with that in a similar cohort of patients treated with wide local excision (WE). methods The medical records of 45 patients were reviewed at three Mayo Clinic practices. Follow–up data were available for 44 patients: 19 treated with MMS and 25 with WE. results In patients treated with MMS, there were no recurrences after a mean follow–up of 29.6 months. There were three first recurrences in 25 patients (12%) treated with WE after a mean follow–up of 73.6 months. One patient had a single local recurrence, and two patients each had two local recurrences. Parotid node metastasis eventually developed in one of the patients with two local recurrences, so that the regional metastatic rate in this series was 4% (1 in 25 patients). conclusion Microscopic control of the surgical margins with MMS in the treatment of AFX results in a lower recurrence rate than that with WE and conserves normal tissue.

Prognostic factors in Merkel cell carcinoma: Analysis of 240 cases

BACKGROUND Knowledge regarding behavior of and prognostic factors for Merkel cell carcinoma (MCC) is limited. OBJECTIVE We sought to further understand the characteristics, behavior, prognostic factors, and optimal treatment of MCC. METHODS A multicenter, retrospective, consecutive study of patients with known primary MCC was completed. Overall survival and survival free of locoregional recurrence were calculated and statistical analysis of characteristics and outcomes was performed. RESULTS Among the 240 patients, the mean age at diagnosis was 70.1 years, 168 (70.0%) were male, and the majority was Caucasian. The most common location was head and neck (111, 46.3%). Immunosuppressed patients had significantly worse survival, with an overall 3-year survival of 43.4% compared with 68.1% in immunocompetent patients. In our study, patients with stage II disease had improved overall survival versus those with stage I disease, in a statistically significant manner. Patients with stage III disease had significantly worse survival compared with stage I and with stage II. Primary tumor size did not predict nodal involvement. CONCLUSION The data presented represent one of the largest series of primary MCC in the literature and confirm that MCC of all sizes has metastatic potential, supporting sentinel lymph node biopsy for all primary MCC. Because of the unpredictable natural history of MCC, we recommend individualization of care based on the details of each patients tumor and clinical presentation.

Carbon dioxide laser vaporization of recalcitrant symptomatic plaques of Hailey-Hailey disease and Darier's disease

Carbon dioxide laser vaporization of localized, recalcitrant intertriginous plaques was done in two patients with Hailey-Hailey disease and two patients with Dariers disease. After treatment, only one patient had recurrence in one treatment site. All patients had significant clinical and symptomatic improvement. Destructive treatment must include the follicular infundibulum in Dariers disease, because histologically this was the focus of recurrent disease at one treated site. We suggest carbon dioxide laser vaporization for the treatment of chronic, localized, symptomatic plaques of Hailey-Hailey or Dariers disease, if medical therapy has been ineffective.

Incidence of and Risk Factors for Skin Cancer After Heart Transplant

OBJECTIVE To examine the incidence, tumor burden, and risk factors for nonmelanoma and other skin cancer types in this heart transplant cohort. DESIGN Retrospective review of patient medical records. SETTING Tertiary care center. Patients All heart transplant recipients at Mayo Clinic from 1988 to 2006. MAIN OUTCOME MEASURES Cumulative incidence of skin cancer and tumor burden, with Cox proportional hazards regression models used to evaluate risk factors for posttransplant primary and secondary nonmelanoma skin cancer. RESULTS In total, 312 heart transplant patients had 1395 new skin cancers in 2097 person-years (mean, 0.43 per year per patient) with a range of 0 to 306 for squamous cell carcinoma (SCC) and 0 to 17 for basal cell carcinoma (BCC). The cumulative incidence rates of any skin cancer were 20.4%, 37.5%, and 46.4% at 5, 10, and 15 years after heart transplant, respectively. Cumulative incidence of SCC after the first BCC was 98.1% within 7 years. Multivariate analysis showed that posttransplant nonskin cancer, increased age, and heart failure etiologic factors other than idiopathic disease were associated with increased risk of SCC. Posttransplant herpes simplex viral infection, increased age, and use of mycophenolate mofetil for immunosuppression were associated with increased risk of BCC. CONCLUSIONS With prolonged survival, many heart transplant patients have numerous skin cancers. Vigilant sun protection practices, skin cancer education, and regular skin examination are appropriate interventions in these high-risk patients.

Cutaneous micrographic surgery : mohs procedure

Skin cancer is an increasingly serious public health issue that affects a high percentage of the population. Surgical resection is still standard treatment for skin cancer, but for difficult cases, cutaneous micrographic surgery, originally described by Mohs, is our preferred technique because of the routine methodic accuracy for evaluation of the surgical margin, the high rate of oncologic cure, and the tissue-sparing quality of the procedure. We report the Mayo Clinic experience with cutaneous micrographic surgery from July 29, 1986, through June 30, 1991, which consisted of 3,355 cases (principally basal cell and squamous cell carcinoma). Herein we discuss practical concerns about this procedure: duration of the technique, reconstruction, cure rates, tumors best treated by cutaneous micrographic surgery, and cost. In addition, we review the Mayo Clinic multidisciplinary management of difficult skin cancers.