1
|
Dun C, Walsh CM, Hicks CW, Stasko T, Vidimos AT, Leshin B, Billingsley EM, Coldiron BM, Bennett RG, Marks VJ, Otley C, Rogers HW, Goldman GD, Albertini JG, Makary MA. 5-Year Follow-Up of a Physician Performance Feedback Report Intervention to Reduce Overuse and Excess Cost: A National Cohort Study. Dermatol Surg 2024:00042728-990000000-00750. [PMID: 38578837 DOI: 10.1097/dss.0000000000004165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
BACKGROUND Mohs micrographic surgery efficiently treats skin cancer through staged resection, but surgeons' varying resection rates may lead to higher medical costs. OBJECTIVE To evaluate the cost savings associated with a quality improvement. MATERIALS AND METHODS The authors conducted a retrospective cohort study using 100% Medicare fee-for-service claims data to identify the change of mean stages per case for head/neck (HN) and trunk/extremity (TE) lesions before and after the quality improvement intervention from 2016 to 2021. They evaluated surgeon-level change in mean stages per case between the intervention and control groups, as well as the cost savings to Medicare over the same time period. RESULTS A total of 2,014 surgeons performed Mohs procedures on HN lesions. Among outlier surgeons who were notified, 31 surgeons (94%) for HN and 24 surgeons (89%) for TE reduced their mean stages per case with a median reduction of 0.16 and 0.21 stages, respectively. Reductions were also observed among outlier surgeons who were not notified, reducing their mean stages per case by 0.1 and 0.15 stages, respectively. The associated total 5-year savings after the intervention was 92 million USD. CONCLUSION The implementation of this physician-led benchmarking model was associated with broad reductions of physician utilization and significant cost savings.
Collapse
Affiliation(s)
- Chen Dun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Biomedical Informatics and Data Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christi M Walsh
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomas Stasko
- Department of Dermatology, University of Oklahoma, Oklahoma City, Oklahoma
| | | | - Barry Leshin
- The Skin Surgery Center, Winston Salem, North Carolina
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | | | | | | | | | - Clark Otley
- College of Medicine, University of Oklahoma, Oklahoma City, Oklahoma
| | - Howard W Rogers
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | | | - John G Albertini
- The Skin Surgery Center, Winston Salem, North Carolina
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Carey Business School, Baltimore, Maryland
| |
Collapse
|
2
|
Ward RE, Stultz TW, Billings SD, Vidimos AT. Mohs Micrographic Surgery for Congenital Scalp Dermatofibrosarcoma Protuberans With Novel PLEKHH2-ALK Gene Fusion. Dermatol Surg 2024; 50:291-293. [PMID: 38085025 DOI: 10.1097/dss.0000000000004052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Rachel E Ward
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Todd W Stultz
- Section of Neuroradiology, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven D Billings
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
- Department of Pathology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Allison T Vidimos
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
| |
Collapse
|
3
|
Groover M, Gupta N, Granger E, Forrester VJ, Anstadt EJ, Su W, Heusinkveld L, Chen A, Lukens JN, Silk AW, Vidimos AT, Schoenfeld JD, Koyfman SA, Ruiz ES. A multicenter real-world analysis of risk factors, therapeutics, and outcomes of patients with metastatic basal cell carcinoma. J Am Acad Dermatol 2024; 90:545-551. [PMID: 37949119 DOI: 10.1016/j.jaad.2023.10.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/12/2023] [Accepted: 10/03/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Metastatic basal cell carcinoma (mBCC) is rare and there are limited data regarding patient and tumor risk factors, optimal treatments, and disease prognosis. OBJECTIVE To assess patient and tumor characteristics, therapeutics, and outcomes of mBCC stratified by location of metastasis. METHODS Retrospective cohort study of 53 patients with mBCC treated at 4 large academic centers in Boston, Massachusetts; Philadelphia, Pennsylvania; and Cleveland, Ohio between January 1, 2005 and December 31, 2021. RESULTS A total of 53 patients with mBCC were identified across 4 centers, 22 (42%) of whom had mBCC with spread limited to lymph nodes and 31 (58%) patients with distant organ spread (with or without lymph node involvement). Overall, half (n = 11) of patients with nodal metastasis achieved complete remission of disease, compared with just 1 (3%) patient with distant metastasis. The 5-year survival for nodal and distant metastatic patients was 89.3% and 61.0%, respectively. LIMITATIONS Small sample size due to disease rarity. CONCLUSIONS AND RELEVANCE Patients with nodal disease are more likely to have disease remission whereas patients with distant metastasis are more likely to have persistent disease and die from their disease. However, 5-year survival rates exceed 50%, even for stage IV disease.
Collapse
Affiliation(s)
- Morgan Groover
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Neha Gupta
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily Granger
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vernon J Forrester
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Emily J Anstadt
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Su
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren Heusinkveld
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Anna Chen
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann W Silk
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Allison T Vidimos
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Jonathan D Schoenfeld
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Emily S Ruiz
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
4
|
Groover M, Gupta N, Granger E, Forrester VJ, Anstadt EJ, Su W, Heusinkveld L, Lukens JN, Silk AW, Schoenfeld JD, Koyfman SA, Vidimos AT, Ruiz ES. Patterns of metastasis from a multicenter cohort of metastatic basal cell carcinoma. J Am Acad Dermatol 2024:S0190-9622(24)00244-5. [PMID: 38331097 DOI: 10.1016/j.jaad.2024.01.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Morgan Groover
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Neha Gupta
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily Granger
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vernon J Forrester
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Emily J Anstadt
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Su
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren Heusinkveld
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann W Silk
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jonathan D Schoenfeld
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Allison T Vidimos
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Emily S Ruiz
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
5
|
Gupta N, Mulvaney PM, Murad F, Gastman BR, Ilori E, Koyfman S, Schmults CD, Vidimos AT, Ruiz ES. Improved homogeneity and monotonicity of American Joint Committee on Cancer staging manual, 8th edition on cutaneous squamous cell carcinoma with addition of poor differentiation. J Am Acad Dermatol 2024; 90:423-425. [PMID: 37839735 DOI: 10.1016/j.jaad.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 08/18/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Neha Gupta
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Patrick M Mulvaney
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Fadi Murad
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brian R Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Evelyn Ilori
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas Texas
| | - Shlomo Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Chrysalyne D Schmults
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Emily S Ruiz
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
6
|
Groover M, Gupta N, Granger E, Murad F, Forrester VJ, Anstadt EJ, Su W, Heusinkveld L, Lukens JN, Silk AW, Schoenfeld JD, Koyfman SA, Ruiz ES, Vidimos AT. A multicenter retrospective cohort analysis of advanced basal cell carcinoma outcomes by sex. J Am Acad Dermatol 2024; 90:137-139. [PMID: 37604231 DOI: 10.1016/j.jaad.2023.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/06/2023] [Accepted: 08/10/2023] [Indexed: 08/23/2023]
Affiliation(s)
- Morgan Groover
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Neha Gupta
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily Granger
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fadi Murad
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vernon J Forrester
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Emily J Anstadt
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Su
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren Heusinkveld
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann W Silk
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jonathan D Schoenfeld
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Emily S Ruiz
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Allison T Vidimos
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| |
Collapse
|
7
|
Groover MK, Gupta N, Granger E, Murad F, Forrester VJ, Anstadt EJ, Su W, Heusinkveld L, Lukens JN, Silk AW, Vidimos AT, Schoenfeld JD, Koyfman SA, Ruiz ES. A multicenter real-world analysis of first-line systemic monotherapy for locally advanced basal cell carcinoma. JAAD Case Rep 2023; 42:69-71. [PMID: 38156099 PMCID: PMC10753044 DOI: 10.1016/j.jdcr.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Affiliation(s)
- Morgan K. Groover
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Neha Gupta
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily Granger
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fadi Murad
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vernon J. Forrester
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Emily J. Anstadt
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Su
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren Heusinkveld
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - John N. Lukens
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann W. Silk
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Allison T. Vidimos
- Department of Dermatology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Jonathan D. Schoenfeld
- Department of Radiation Oncology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shlomo A. Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Emily S. Ruiz
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
8
|
Lam C, Kim Y, Costigan HJ, Stuckey H, Vidimos AT, Billingsley EM, Albertini JG, Miller JJ, Shanafelt TD. Well-Being and Professional Fulfillment in Mohs Surgeons: An Explanatory Sequential Mixed-Method Design Study. Dermatol Surg 2023; 49:645-648. [PMID: 37184466 DOI: 10.1097/dss.0000000000003801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND There are limited data evaluating specific themes of well-being and professional fulfillment in Mohs surgeons. OBJECTIVE To identify factors that drive occupational distress and those that promote well-being and professional fulfillment among Mohs surgeons. METHODS This is an explanatory sequential mixed-method study, using semistructured individual interviews. Common drivers of physician well-being and fulfillment were identified based on the independent assessment of the coding in the interview transcripts. RESULTS This study reports the following qualitative themes: (1) gratitude for the chosen profession and relationships, (2) unrealistic standards of perfection that may have contributed to past career success but are unattainable and create emotional burden, and (3) ability to practice in a manner aligned with personal values promotes professional fulfillment. CONCLUSION This study suggests that gratitude, self-compassion, and ability to practice in a manner aligned with personal values promote well-being and professional fulfillment in Mohs surgeons. Notably, we found that unrealistic standards of perfection and personal-organization practice incongruences contribute to burnout.
Collapse
Affiliation(s)
- Charlene Lam
- Department of Dermatology, Pennsylvania State Hershey Medical Center, Hershey, Pennsylvania
| | - Yesul Kim
- Division of Dermatologic Surgery, Cooper University Health Care, Camden, New Jersey
| | - Heather J Costigan
- Department of Medicine, Pennsylvania State College of Medicine, Hershey, Pennsylvania
| | - Heather Stuckey
- Department of Medicine, Pennsylvania State College of Medicine, Hershey, Pennsylvania
| | | | | | | | - Jeffrey J Miller
- Department of Dermatology, Pennsylvania State Hershey Medical Center, Hershey, Pennsylvania
| | - Tait D Shanafelt
- Department of Medicine, Stanford University, Palo Alto, California
| |
Collapse
|
9
|
Schlessinger DI, Reynolds KA, Dirr MA, Ibrahim SA, Yanes AF, Lazaroff JM, Godinez-Puig V, Chen BR, Kurta AO, Cotseones JK, Chiren SG, Furlan KC, Iyengar S, Behshad R, DeHoratius DM, Denes P, Drucker AM, Dzubow LM, Etzkorn JR, Harwood CA, Kim JYS, Lawrence N, Lee EH, Lissner GS, Marghoob AA, Matin RN, Mattox AR, Mittal BB, Thomas JR, Zhou XA, Zloty D, Schmitt J, Kirkham JJ, Armstrong AW, Basset-Seguin N, Billingsley EM, Bordeaux JS, Brewer J, Brown M, Brown M, Collins SAB, Fargnoli MC, De Azevedo SJ, Dummer R, Eggermont A, Goldman GD, Haedersdal M, Hale E, Hanlon A, Harms KL, Huang CC, Hurst EA, In GK, Kelleners-Smeets N, Kheterpal M, Leshin B, Mcdonald M, Miller SJ, Miller A, Mostow EN, Trakatelli M, Nehal KS, Ratner D, Rogers H, Sarin KY, Soon SL, Stasko T, Storrs PA, Tagliaferri L, Vidimos AT, Wong SL, Yu SS, Zalaudek I, Zeitouni NC, Zitelli JA, Poon E, Sobanko JF, Cartee TV, Maher IA, Alam M. Development of a Core Outcome Set for Basal Cell Carcinoma (BCC), Including Low-Risk and Advanced Tumors. J Am Acad Dermatol 2022; 87:573-581. [PMID: 35551965 DOI: 10.1016/j.jaad.2022.04.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/18/2022] [Accepted: 04/23/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is variation in the outcomes reported in clinical studies of basal cell carcinoma (BCC). This can prevent effective meta-analyses to answer important clinical questions. OBJECTIVE To identify a recommended minimum set of core outcomes for BCC clinical trials. METHODS Patient and professional Delphi process to cull a long-list, culminating in a consensus meeting. To be provisionally accepted, outcomes needed to be deemed 'important' (score: 7-9, of maximum of 9) by 70% of each stakeholder group. RESULTS 235 candidate outcomes identified via a systematic literature review and survey of key stakeholders were reduced to 74 that were rated by 100 health care professionals and patients in two Delphi rounds. 27 outcomes were provisionally accepted. The final core set of 5 agreed-upon outcomes after the consensus meeting was: complete response; persistent or serious adverse events; recurrence-free survival; quality of life; and patient satisfaction, including with cosmetic outcome. LIMITATIONS English-speaking patients and professionals rated outcomes extracted from English-language studies. CONCLUSIONS A core outcome set (COS) for basal cell carcinoma has been developed. Use of relevant measures may improve the utility of clinical research and the quality of therapeutic guidance available to clinicians.
Collapse
Affiliation(s)
- Daniel I Schlessinger
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Kelly A Reynolds
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; University of Cincinnati College of Medicine, Cincinnati, OH
| | - McKenzie A Dirr
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sarah A Ibrahim
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Arianna F Yanes
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jake M Lazaroff
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Victoria Godinez-Puig
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Brian R Chen
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Jill K Cotseones
- Medical & Cosmetic Dermatology Service, Northwestern Medicine Regional Medical Group, Naperville, IL
| | - Sarah G Chiren
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Karina C Furlan
- Department of Pathology, Rush University Medical Center, Chicago, IL
| | - Sanjana Iyengar
- Department of Dermatology, West Virginia University, Morgantown, WV
| | - Ramona Behshad
- Department of Dermatology, Saint Louis University, St. Louis, MO
| | - Danielle M DeHoratius
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pablo Denes
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Aaron M Drucker
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada; Division of Dermatology, Department of Medicine and Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | | | - Jeremy R Etzkorn
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Catherine A Harwood
- Department of Dermatology, Royal London Hospital, Barts Health NHS Trust, Whitechapel, London, UK; Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - John Y S Kim
- Division of Plastic and Reconstructive Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Naomi Lawrence
- Division of Dermatologic Surgery, Department of Dermatology, Cooper University Hospital, Camden, NJ
| | - Erica H Lee
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gary S Lissner
- Department of Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Ashfaq A Marghoob
- Department of Dermatology, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Rubeta N Matin
- Department of Dermatology, Churchill Hospital, Oxford, UK
| | - Adam R Mattox
- Department of Dermatology, University of Minnesota, Minneapolis, MN
| | - Bharat B Mittal
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - J Regan Thomas
- Department of Otolaryngology- Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Xiaolong Alan Zhou
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - David Zloty
- Department of Dermatology & Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, Medical Faculty, Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jamie J Kirkham
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - April W Armstrong
- Keck School of Medicine, Department of Dermatology, University of Southern California Los Angeles
| | | | | | - Jeremy S Bordeaux
- Department of Dermatology, University Hospitals of Cleveland, Case Western Reserve University, OH, USA
| | | | - Marc Brown
- Professor of Dermatology and Oncology; University of Rochester, MN, USA
| | - Mariah Brown
- Department of Dermatology, University of Colorado Hospital and School of Medicine
| | | | - Maria Concetta Fargnoli
- Dermatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Sergio Jobim De Azevedo
- Professor, Department of Medicine, Chief of Medical Oncology at Hospital de Clinicas de Porto Alegre, Brazil
| | - Reinhard Dummer
- University Hospital, Skin Cancer Center, Zurich, Switzerland
| | | | | | - Merete Haedersdal
- Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
| | | | | | - Kelly L Harms
- Department of Dermatology, the Comprehensive Cancer Center University of Michigan Medical School, Ann Arbor
| | - Conway C Huang
- Department of Dermatology, University of Alabama at Birmingham, AL, USA
| | - Eva A Hurst
- Distinctive Dermatology, Fairview Heights, IL, USA
| | - Gino K In
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | | | | | | | | | | | | | - Eliot N Mostow
- Northeast Ohio Medical University (NEOMED), Rootstown, OH, USA
| | - Myrto Trakatelli
- Associate Professor of Dermatology, Papageorgiou Hospital, Aristotle University Department of Medicine, Thessaloniki, Greece
| | - Kishwer S Nehal
- Attending Physician, Memorial Sloan Kettering Cancer Center; Director, Mohs and Dermatological Surgery; Professor of Dermatology, Weill Cornell Medical College, NY, USA
| | | | | | | | | | - Thomas Stasko
- Professor and Chair, The University of Oklahoma Department of Dermatology, OK, USA
| | - Paul A Storrs
- University of Illinois Chicago, Department of Dermatology, IL, USA
| | - Luca Tagliaferri
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Italy
| | | | | | - Siegrid S Yu
- Department of Dermatology, University of California San Francisco, San Francisco, California
| | - Iris Zalaudek
- Department of Dermatology and Venereology, University of Trieste, Italy
| | | | - John A Zitelli
- Clinical Associate Professor of Dermatology, Otolaryngology, Plastic Surgery, University of Pittsburgh Medical Center, PA, USA
| | - Emily Poon
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Joseph F Sobanko
- Department of Dermatology, Perelman Center for Advanced Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; Division of Dermatologic Surgery, Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Todd V Cartee
- Department of Dermatology, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA
| | - Ian A Maher
- Department of Dermatology, University of Minnesota, Minneapolis, MN
| | - Murad Alam
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Otolaryngology- Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| |
Collapse
|
10
|
Smile TD, Ruiz ES, Kus KJB, Murad F, Wei W, Xiong DD, Vidimos AT, Schmults CD, Koyfman SA. Implications of Satellitosis or In-transit Metastasis in Cutaneous Squamous Cell Carcinoma: A Prognostic Omission in Cancer Staging Systems. JAMA Dermatol 2022; 158:390-394. [PMID: 35195668 PMCID: PMC8867391 DOI: 10.1001/jamadermatol.2022.0001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Unlike Merkel cell carcinoma and melanoma, satellitosis or in-transit metastasis (S-ITM) is not incorporated into the current cutaneous squamous cell carcinoma (CSCC) staging systems. It is important to determine if the clinical outcomes of S-ITM are relevant to prognosis for patients with CSCC. OBJECTIVES To evaluate the association of S-ITM with clinical outcomes in patients with CSCC and to determine its prognostic implications. DESIGN, SETTINGS, AND PARTICIPANTS A dual-institution (Cleveland Clinic and Brigham and Women's Hospital) database was queried for patients who were treated for CSCC in 2010 to 2020. Patients who were node-negative and had S-ITM-the presence of dermal lesions between the primary tumor and first-echelon lymphatic nodal basins at any point in the disease course-were identified. Subcohorts of patients with T3N0 tumors, T4N0 tumors (bone invasive), N1 to 3, and M1 disease were identified for comparison. The American Joint Committee on Cancer staging system was used to define cancer stages. Data were analyzed from January 15 to March 31, 2021. MAIN OUTCOMES AND MEASURES Pairwise comparison of CSCC recurrence and disease-specific survival in patients with and without S-ITM was performed using Cox proportional hazard modeling. Kaplan-Meier and Fine-Gray competing risk methods were used to estimate disease-specific survival and CSCC recurrence, respectively. RESULTS In a total of 518 patients with CSCC, S-ITM was present in 72 (13.9 %) patients (median age [range], 73.9 [31.6-95.8] years; 59 [82%] men; 69 [96%] White non-Hispanic individuals; 25 [35%] patients with immunosuppression) who were node-negative. The subcohorts were composed of 341 patients with T3N0 cancer, 36 with T4N0, 70 with N1 to 3, and 19 with M1 disease. Pairwise comparisons between disease levels using Cox proportional hazard model demonstrated lower cumulative incidence of CSCC recurrence rates in the T3N0 (HR, 0.21; 95% CI, 0.14-0.30; P < .001) and T4N0 (HR, 0.36; 95% CI, 0.19-0.68; P = .001) cohorts compared with the S-ITM cohort. No significant difference was observed between patients who were node-positive and those with S-ITM (HR, 0.74; 95% CI, 0.48-1.14; P = .16). The 5-year disease-specific survival rates were 76% for T3N0, 64% for T4N0, 41% for S-ITM, and 39% for N1 to 3. Compared with the S-ITM cohort, DSS was significantly higher in the T3N0 (HR, 0.23; 95% CI, 0.15-0.35; P < .0001) and T4N0 (HR, 0.37; 95% CI, 0.19-0.76; P = .01) cohorts, and not significantly different in the node-positive (HR, 0.77; 95% CI, 0.84-3.93; P = .30) and metastatic cohorts (HR, 1.81; 95% CI, 0.84-3.93; P = .13). CONCLUSIONS AND RELEVANCE This multi-institutional cohort study found that patients with CSCC and S-ITM appear to have clinical outcomes comparable to those of patients who are node-positive, and an increased risk of recurrence and worse survival compared with patients who have T3 and T4 disease. These outcomes are similar to those observed for Merkel cell carcinoma and melanoma. Given that S-ITM may be a powerful prognostic factor, it should be incorporated into clinical staging systems.
Collapse
Affiliation(s)
- Timothy D. Smile
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emily S. Ruiz
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kylee J. B. Kus
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts,Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Fadi Murad
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wei Wei
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - David D. Xiong
- Case Western Reserve University School of Medicine, Cleveland, Ohio,Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Allison T. Vidimos
- Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Chrysalyne D. Schmults
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shlomo A. Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
11
|
Gupta N, Weitzman RE, Murad F, Koyfman SA, Smile TD, Chang MS, Maher JM, Schmults CD, Vidimos AT, Ruiz ES. Identifying Brigham and Women's Hospital stage T2a cutaneous squamous cell carcinomas at risk of poor outcomes. J Am Acad Dermatol 2021; 86:1301-1308. [PMID: 34864111 DOI: 10.1016/j.jaad.2021.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/29/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although most of the poor outcomes with cutaneous squamous cell carcinoma (CSCC) occur in high-stage tumors, 26% of nodal metastases and 8% of disease-specific deaths develop in Brigham and Women's Hospital (BWH) T2a tumors. OBJECTIVE To determine risk factors associated with poor outcomes (nodal metastasis, distant metastases, and disease-specific deaths) in BWH T2a CSCC. METHODS A 17-year retrospective multi-institutional cohort study of primary CSCC BWH T2a tumors. A predictive model based on tumor characteristics was developed to identify those at higher risk of poor outcomes. RESULTS Presence of 1 major criterion (primary tumor diameter ≥40 mm, invasion depth beyond subcutaneous fat, poor differentiation, or large-caliber perineural invasion) and ≥ 1 minor criterion (invasion depth in subcutaneous fat, moderate differentiation, small-caliber perineural invasion, or lymphovascular invasion) was most predictive of developing poor outcomes (area under the curve, 0.53; C-statistic, 0.60). This model has a sensitivity of 7.7%, specificity of 97.4%, and a positive and negative predictive value of 33.3% and 86.1%, respectively. The 5-year cumulative incidence of poor outcomes in these tumors is 8.0% (95% CI, 5.1-13.7) compared to 2.8% (95% CI, 1.9-4.1) in other T2a tumors (sub-hazard ratio, 3.0; 95% CI, 1.5-5.8). LIMITATIONS Multi-institutional cohort study was not externally validated. CONCLUSIONS BWH T2a-high CSCCs have an 8% chance of developing poor outcomes.
Collapse
Affiliation(s)
- Neha Gupta
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Rachel E Weitzman
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fadi Murad
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Timothy D Smile
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael S Chang
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline M Maher
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; New York Medical College, Valhalla, New York
| | - Chrysalyne D Schmults
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Emily S Ruiz
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
12
|
Kus KJB, Murad F, Smile TD, Chang M, Ashrafzadeh S, Zhou G, Ilori EO, Koyfman SA, Vidimos AT, Schmults CD, Ruiz ES. Higher metastasis and death rates in cutaneous squamous cell carcinomas with lymphovascular invasion. J Am Acad Dermatol 2021; 86:766-773. [PMID: 34774657 DOI: 10.1016/j.jaad.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/25/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lymphovascular invasion (LVI) is an aggressive histologic finding but is excluded from current staging systems due to its lack of demonstrated independent prognostic significance. OBJECTIVE To evaluate the impact of LVI on cutaneous squamous cell carcinoma tumor outcomes. METHODS In total, 10,707 cutaneous squamous cell carcinoma tumors from a 20-year, retrospective, multicenter cohort were stratified by the presence (LVI+) or absence (LVI-) of LVI. Outcomes (local recurrence, in-transit metastasis, nodal metastasis, disease-specific death) were compared based on low (Brigham and Women's Hospital [BWH] stage T1/T2a) and high (BWH T2b/T3) tumor stages. RESULTS Of the 10,707 tumors, 78 had LVI. The analysis of low-stage BWH tumors showed the LVI+ group had a significantly higher 5-year cumulative incidence of local recurrence (LVI+: 12.3%; LVI-: 1.1%; P < .01), metastasis (LVI+: 4.2%; LVI-: 0.4%; P < .01), and disease-specific death (LVI+: 16.2%; LVI-: 0.4%; P < .01). The analysis of BWH high-stage tumors showed the LVI+ group maintained a higher 5-year cumulative incidence of metastasis (LVI+: 28.5%; LVI-: 16.8%; P = .06) and disease-specific death (LVI+: 25.3%; LVI-: 13.9%; P = .03), however, there was no difference in local recurrence (LVI+: 16.3%; LVI-: 15.8%; P = .11). LIMITATIONS Retrospective study design. CONCLUSION LVI+ cutaneous squamous cell carcinomas have higher rates of metastasis and death at 5 years. Future staging systems should consider incorporating LVI.
Collapse
Affiliation(s)
- Kylee J B Kus
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Fadi Murad
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy D Smile
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Chang
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sepideh Ashrafzadeh
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Guohai Zhou
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Evelyn O Ilori
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Department of Pathology, University of Texas Southwestern, Dallas, Texas
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Chrysalyne D Schmults
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily S Ruiz
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
13
|
Wirth PJ, Hobbs R, Billingsley E, Vidimos AT, Lam C. Sonic Hedgehog Pathway Blockade After Surgical Debulk of Large Exophytic Basal Cell Carcinomas. Dermatol Surg 2021; 47:1118-1119. [PMID: 34107497 DOI: 10.1097/dss.0000000000002957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Paul J Wirth
- Department of Dermatology, The Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Ryan Hobbs
- Department of Dermatology, The Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Elizabeth Billingsley
- Department of Dermatology, The Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | - Charlene Lam
- Department of Dermatology, The Milton S. Hershey Medical Center, Hershey, Pennsylvania
| |
Collapse
|
14
|
Smile TD, Xiong DX, Varra V, Winter IW, Beal BT, Gastman BR, Geiger JL, Adelstein DJ, Bergfeld WF, Piliang MP, Billings SD, Ko JS, Knackstedt TJ, Lucas JL, Poblete-Lopez CM, Meine JG, Vij A, Vidimos AT, Koyfman SA. Disease Progression in Cutaneous Squamous Cell Carcinoma Patients With Satellitosis and In-transit Metastasis. Anticancer Res 2021; 41:289-295. [PMID: 33419823 DOI: 10.21873/anticanres.14775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/28/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Satellitosis/in-transit metastasis (S-ITM) has prognostic value in melanoma and Merkel cell carcinoma, but is not incorporated into cutaneous squamous cell carcinoma (cSCC) staging. PATIENTS AND METHODS From our IRB-approved registry, patients with high-risk cSCC, including patients with S-ITM, were identified. Univariate (UVA) and multivariate (MVA) analyses were performed to compare disease progression (DP) and overall survival (OS). Cumulative incidence of DP and OS analyses were performed using Fine-Gray and Kaplan-Meier methods, respectively. RESULTS A total of 18 S-ITM subjects were compared to 247 high risk subjects including T3N0 (n=143), N1-N3 without extranodal extension (ENE) (n=56), N1-N3 with ENE (n=26) and M1 disease (n=22). Median follow up was 16.5 months. Three-year rates of DP were 22% for T3N0, 42% for S-ITM, 48% for T4 bone invasion, 50% for N1-N3 without extranodal extension (ENE), 53% for N1-N3 with ENE, and 66% for M1. Patients with S-ITM did not experience significantly worse DP compared to those with T3N0 (HR=1.96, 95%CI=0.8-4.9; p=0.14). CONCLUSION Cutaneous SCC patients with S-ITM experienced outcomes similar to locally advanced non-metastatic cSCC patients. Larger studies are needed to guide incorporation into staging systems.
Collapse
Affiliation(s)
- Timothy D Smile
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A.;
| | - David X Xiong
- College of Medicine, Case Western Reserve University, Cleveland, OH, U.S.A.,Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - Vamsi Varra
- College of Medicine, Case Western Reserve University, Cleveland, OH, U.S.A.,Department of Internal Medicine, University Hospitals Medical Center, Cleveland, OH, U.S.A
| | - Ian W Winter
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Brandon T Beal
- Jacksonville Skin Cancer Specialists, Jacksonville, FL, U.S.A
| | - Brian R Gastman
- Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Jessica L Geiger
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - David J Adelstein
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | | | | | | | - Jennifer S Ko
- Institute of Pathology, Cleveland Clinic, Cleveland, OH, U.S.A
| | | | - Jennifer L Lucas
- Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | | | - Jon G Meine
- Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Alok Vij
- Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Allison T Vidimos
- Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, U.S.A
| |
Collapse
|
15
|
Eversman A, Tracey EH, Michalik D, Rodriguez M, Varra V, Briskin IN, Vidimos AT, Poblete-Lopez CM. Moderate differentiation is a risk factor for extensive subclinical spread of cutaneous squamous cell carcinoma. J Am Acad Dermatol 2020; 85:1606-1608. [PMID: 33290800 DOI: 10.1016/j.jaad.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/24/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Anna Eversman
- School of Medicine Case Western Reserve University, Cleveland, OH
| | | | | | - Marla Rodriguez
- School of Medicine Case Western Reserve University, Cleveland, OH
| | - Vamsi Varra
- School of Medicine Case Western Reserve University, Cleveland, OH
| | - Isaac N Briskin
- Cleveland Clinic Foundation Department of Quantitative Health Sciences, Cleveland, OH
| | | | | |
Collapse
|
16
|
Rodriguez M, Beal BT, Manmohan M, Simmons E, Varra V, Xiong D, Eversman A, Briskin IN, Knackstedt T, Vidimos AT. Risk factors and timing of subsequent cutaneous squamous cell carcinoma in patients with cutaneous squamous cell carcinoma: A retrospective cohort study. J Am Acad Dermatol 2020; 84:719-724. [PMID: 32861709 DOI: 10.1016/j.jaad.2020.08.083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/16/2020] [Accepted: 08/24/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Information about the frequency and timing of subsequent cutaneous squamous cell carcinoma (cSCC), along with associated risk factors, is limited. However, this information is crucial to guide follow-up care for these patients. OBJECTIVE To evaluate the risk and timing of subsequent cSCC in patients who presented with an initial diagnosis of cSCC. METHODS Retrospective review of an institutional review board-approved, single-institution registry of invasive cSCC. All patients had at least 2 primary cSCCs diagnosed on 2 separate dates 2 months apart. RESULTS A total of 299 primary cSCCs were included. At 6 months from initial cSCC diagnosis, 18.06% (n = 54) of patients developed subsequent cSCC; at 1 year, 31.77% (n = 94); at 3 years, 67.56% (n = 202); and at 5 years, 87.96% (n = 263) developed subsequent cSCC. Risk factors associated with subsequent cSCC include age at initial diagnosis (hazard ratio [HR], 1.02; 95% confidence interval, 1.004-1.027; P = .008), T2 stage (HR, 1.66; 95% CI, 1.07-2.57; P = .025), and poor tumor grade. Tumor grades well, moderate, and unknown have HRs of 0.21 (P < .001), 0.16 (P .001), and 0.25 (P = .001), respectively. CONCLUSIONS Of patients who develop subsequent cSCC, 18.06% do so within 6 months, and 31.77% do so within 1 year of initial cSCC diagnosis. Patients with advanced age, poor histologic differentiation, and American Joint Committee on Cancer T2 stage are at highest risk. Close clinical follow-up after the initial diagnosis is recommended.
Collapse
Affiliation(s)
- Marla Rodriguez
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Brandon T Beal
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio; Jacksonville Skin Cancer Specialists, Jacksonville, Florida
| | | | - Elanee Simmons
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Vamsi Varra
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - David Xiong
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Anna Eversman
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Isaac N Briskin
- Cleveland Clinic Foundation, Department of Quantitative Health Sciences, Cleveland, Ohio
| | | | | |
Collapse
|
17
|
Beal BT, Xiong D, Rodriguez M, Varra V, Cundall H, Simmons L, Woody N, Koyfman SA, Vidimos AT, Knackstedt TJ. Noncompliance with surgical margin guidelines is associated with histologic margin positivity: A retrospective case-control study. J Am Acad Dermatol 2020; 84:1126-1128. [PMID: 32565212 DOI: 10.1016/j.jaad.2020.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/05/2020] [Accepted: 06/10/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Brandon T Beal
- Zitelli & Brodland PC, Jefferson Hills, Pennsylvania; Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David Xiong
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Marla Rodriguez
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Vamsi Varra
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Hannah Cundall
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Lanee Simmons
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Neil Woody
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Allison T Vidimos
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Thomas J Knackstedt
- School of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of Dermatology, MetroHealth Hospital, Cleveland, Ohio.
| |
Collapse
|
18
|
Gao Y, Twigg AR, Hirose R, Roll GR, Nowacki AS, Maytin EV, Vidimos AT, Rajalingam R, Arron ST. Association of HLA Antigen Mismatch With Risk of Developing Skin Cancer After Solid-Organ Transplant. JAMA Dermatol 2020; 155:307-314. [PMID: 30673077 DOI: 10.1001/jamadermatol.2018.4983] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Risk factors for the development of skin cancer after solid-organ transplant can inform clinical care, but data on these risk factors are limited. Objective To study the association between HLA antigen mismatch and skin cancer incidence after solid-organ transplant. Design, Setting, and Participants This retrospective cohort study is a secondary analysis of the multicenter Transplant Skin Cancer Network study of 10 649 adults who underwent a primary solid-organ transplant between January 1, 2003, and December 31, 2003, or between January 1, 2008, and December 31, 2008. These participants were identified through the Scientific Registry of Transplant Recipients standard analysis files, which contain data collected mostly by the Organ Procurement and Transplantation Network. Participants were matched to skin cancer outcomes by medical record review. This study was conducted from August 1, 2016, to July 31, 2017. Main Outcomes and Measures The primary outcome was time to diagnosis of posttransplant skin cancer, including squamous cell carcinoma, melanoma, and Merkel cell carcinoma. The HLA antigen mismatch was calculated based on the 2016 Organ Procurement and Transplantation Network guidelines. Risk of skin cancer was analyzed using a multivariate Cox proportional hazards regression model. Results In total, 10 649 organ transplant recipients (6776 men [63.6%], with a mean [SD] age of 51 [12] years) contributed 59 923 years of follow-up. For each additional mismatched allele, a 7% to 8% reduction in skin cancer risk was found (adjusted hazard ratio [HR], 0.93; 95% CI, 0.87-0.99; P = .01). Subgroup analysis found the protective effect of HLA antigen mismatch to be statistically significant in lung (adjusted HR, 0.70; 95% CI, 0.56-0.87; P = .001) and heart (adjusted HR, 0.75; 95% CI, 0.60-0.93; P = .008) transplant recipients but not for recipients of liver, kidney, or pancreas. The degree of HLA-DR mismatch, but not HLA-A or HLA-B mismatch, was the most statistically significant for skin cancer risk (adjusted HR, 0.85; 95% CI, 0.74-0.97; P = .01). Conclusions and Relevance The HLA antigen mismatch appears to be associated with reductions in the risk of skin cancer after solid-organ transplant among heart and lung transplant recipients; this finding suggests that HLA antigen mismatch activates the tumor surveillance mechanisms that protect against skin cancer in transplant recipients and that skin cancer risk may be higher in patients who received a well-matched organ.
Collapse
Affiliation(s)
- Yi Gao
- Department of Medicine, Banner University Medical Center, Phoenix, Arizona
| | - Amanda R Twigg
- Department of Dermatology, University of California, San Francisco, San Francisco
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco
| | - Garrett R Roll
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco
| | - Amy S Nowacki
- Department of Quantitative Health Sciences, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Edward V Maytin
- Department of Dermatology, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Allison T Vidimos
- Department of Dermatology, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Raja Rajalingam
- Immunogenetics and Transplantation Laboratory, Department of Surgery, University of California, San Francisco, San Francisco
| | - Sarah T Arron
- Department of Dermatology, University of California, San Francisco, San Francisco
| |
Collapse
|
19
|
Sun L, Chin RI, Gastman B, Thorstad W, Yom SS, Reddy CA, Nussenbaum B, Wang SJ, Knackstedt T, Vidimos AT, Koyfman SA, Manyam BV. Association of Disease Recurrence With Survival Outcomes in Patients With Cutaneous Squamous Cell Carcinoma of the Head and Neck Treated With Multimodality Therapy. JAMA Dermatol 2020; 155:442-447. [PMID: 30810715 DOI: 10.1001/jamadermatol.2018.5453] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance It has previously been demonstrated that immunosuppressed patients with cutaneous squamous cell cancer of the head and neck (cSCC-HN) treated with surgery and postoperative radiotherapy have significantly inferior disease-related outcomes compared with immunocompetent patients, but data on outcomes after disease recurrence are limited. Objectives To report survival outcomes in patients with cSCC-HN after disease recurrence after surgery and postoperative radiotherapy and to investigate the association of immune status with disease-related outcomes. Design, Setting, and Participants A multi-institutional study of 205 patients treated at the Cleveland Clinic, Washington University in St Louis, and the University of California, San Francisco, in which patients who underwent surgical resection and postoperative radiotherapy for primary or recurrent stage I to IV (nonmetastatic) cSCC-HN between January 1, 1995, and December 31, 2014, were identified. Patients with any disease recurrence, defined as local, regional, and/or distant failure, were included. Patients were categorized as immunosuppressed if they received a diagnosis of chronic hematologic malignant neoplasm or HIV or AIDS, or were treated with immunosuppressive therapy for organ transplantation 6 months or more before diagnosis. Statistical analysis was conducted from January 1, 1995, to December 31, 2015. Main Outcomes and Measures Overall survival calculated using the Kaplan-Meier method and compared using the log-rank test. Results Of the 205 patients in the original cohort, 72 patients (63 men and 9 women; median age, 71 years [range, 43-91 years]) developed disease recurrence after surgery and postoperative radiotherapy. Forty patients (55.6%) were immunosuppressed, and 32 patients (44.4%) were immunocompetent. Locoregional recurrence was the most common first pattern of failure for both groups (31 immunosuppressed patients [77.5%]; 21 immunocompetent patients [65.6%]). After any recurrence, 1-year overall survival was 43.2% (95% CI, 30.9%-55.4%), and median survival was 8.4 months. For patients for whom information on salvage treatment was available (n = 45), those not amenable to surgical salvage had significantly poorer median cumulative incidence of survival compared with those who were amenable to surgical salvage (4.7 months; 95% CI, 3.7-7.0 months vs 26.1 months; 95% CI, 6.6 months to not reached; P = .01), regardless of their immune status. Conclusions and Relevance Results of this study suggest that patients with cSCC-HN who experience disease recurrence after definitive treatment with surgery and postoperative radiotherapy have poor survival, irrespective of immune status. Survival rates are low for patients with recurrent disease that is not amenable to surgical salvage. The low rate of successful salvage underscores the importance of intensifying upfront treatment to prevent recurrence.
Collapse
Affiliation(s)
- Lillian Sun
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Re-I Chin
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Brian Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Wade Thorstad
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Brian Nussenbaum
- Department of Otolaryngology, Washington University in St Louis, St Louis, Missouri
| | - Steven J Wang
- Department of Otolaryngology, University of Arizona, Tucson
| | | | | | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Bindu V Manyam
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
20
|
Affiliation(s)
| | - Melanie A Clark
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Allison T Vidimos
- Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
21
|
Xiong DD, Beal BT, Varra V, Rodriguez M, Cundall H, Woody NM, Vidimos AT, Koyfman SA, Knackstedt TJ. Outcomes in intermediate-risk squamous cell carcinomas treated with Mohs micrographic surgery compared with wide local excision. J Am Acad Dermatol 2019; 82:1195-1204. [PMID: 31887322 DOI: 10.1016/j.jaad.2019.12.049] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 12/15/2019] [Accepted: 12/21/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Brigham and Women's Hospital stage T2a squamous cell carcinomas, demonstrating a single high-risk feature, have a low risk of metastasis and death but an increased risk of local recurrence. Little evidence exists for the best treatment modality and associated outcomes in T2a squamous cell carcinoma. OBJECTIVE We aimed to compare outcomes for T2a squamous cell carcinoma treated by Mohs micrographic surgery compared with wide local excision with permanent sections. METHODS Retrospective review of an institutional review board-approved single-institution registry of T2a squamous cell carcinoma. RESULTS Three hundred sixty-six primary T2a tumors were identified, including 240 squamous cell carcinomas (65.6%) treated with Mohs micrographic surgery and 126 (34.4%) treated with wide local excision. A total of 32.5% of patients were immunosuppressed and mean oncologic follow-up was 2.8 years. Local recurrence was significantly more likely after wide local excision (4.0%) than after Mohs micrographic surgery (1.2%) (P = .03). Multiple logistic regression demonstrated immunocompromised state (odds ratio [OR] 5.1; 95% confidence interval [CI] 1.1-23.3; P = .03) and wide local excision (OR 4.8; 95% CI 1.1-21.6; P = .04) associated with local recurrence; and wide local excision (OR 7.8; 95% CI 2.4-25.4; P < .001), high-risk head and neck location (OR 8.3; 95% CI 1.8-38.7; P = .004), and poor histologic differentiation (OR 4.7; 95% CI 1.4-15.4; P = .03) associated with poor outcomes (overall recurrence or disease-specific death). CONCLUSION Mohs micrographic surgery provides improved outcomes in Brigham and Women's Hospital T2a squamous cell carcinoma.
Collapse
Affiliation(s)
- David D Xiong
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Brandon T Beal
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
| | - Vamsi Varra
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Marla Rodriguez
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Hannah Cundall
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Neil M Woody
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | | | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Thomas J Knackstedt
- School of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of Dermatology, MetroHealth System, Cleveland, Ohio.
| |
Collapse
|
22
|
Albertini JG, Wang P, Fahim C, Hutfless S, Stasko T, Vidimos AT, Leshin B, Billingsley EM, Coldiron BM, Bennett RG, Marks VJ, Park A, Overton HN, Bruhn WE, Xu T, Krishnan A, Makary MA. Evaluation of a Peer-to-Peer Data Transparency Intervention for Mohs Micrographic Surgery Overuse. JAMA Dermatol 2019; 155:906-913. [PMID: 31055597 DOI: 10.1001/jamadermatol.2019.1259] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness. Objective To evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally. Design, Setting, and Participants This nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery. Interventions Individualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group. Main Outcomes and Measures The primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated. Results Of the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, -1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, -0.19 to -0.09; P = .002). The total administrative cost of the intervention program was $150 000, and the estimated reduction in Medicare spending was $11.1 million. Conclusions and Relevance Sharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.
Collapse
Affiliation(s)
- John G Albertini
- The Skin Surgery Center, Winston Salem, North Carolina.,Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Peiqi Wang
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Christine Fahim
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Susan Hutfless
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland.,Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Thomas Stasko
- Department of Dermatology, University of Oklahoma, Oklahoma City
| | | | - Barry Leshin
- The Skin Surgery Center, Winston Salem, North Carolina.,Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | | | | | | | | | - Angela Park
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Heidi N Overton
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - William E Bruhn
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Tim Xu
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Aravind Krishnan
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Martin A Makary
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
23
|
Koyfman SA, Gastman B, Vidimos AT, Joshi NP, Lucas J, Poblete-Lopez C, Vij A, Meine J, Burkey BB, Ku J, Lamarre E, Prendes B, Scharpf J, Billings SD, Samsa J, Robinson SB, Adelstein DJ, Geiger JL. Preliminary safety results of a phase II study investigating pembrolizumab in combination with postoperative intensity modulated radiotherapy (IMRT) in resected high risk cutaneous squamous cell cancer of the head and neck. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e21056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e21056 Background: High risk cutaneous squamous cell cancer of the head and neck (cSCC-HN) have suboptimal outcomes with surgery and postoperative radiation. We report preliminary safety outcomes of a phase II study (NCT03057613) exploring the safety and efficacy of the addition of Pembrolizumab to postoperative IMRT. Methods: Patients with cSCC-HN were eligible for this IRB approved study if they had resection of all gross disease and demonstrated (a) invasion of the skeleton or skull base; (b) node positive disease; (c) or a tumor > 2cm with ≥1 of the following risk factors: recurrent disease, perineural invasion, lymphovascular space invasion, poorly differentiated, positive margins, satellitosis or in-transit metastases. Immune competent pts and those with CLL were eligible. This study aimed to accrue 34 evaluable patients to assess a primary safety endpoint of dose limiting toxicity (DLT) defined as any grade ≥3 toxicity at least possibly related to the immunotherapy. Assuming toxicity of < 20% is acceptable and > 40% is unacceptable, if ≥11 of 34 (32%) patients experienced a DLT, the regimen would be considered unsafe. Results: Of 15 pts already enrolled on this study, 11 have completed the protocol treatment. There were no DLTs observed to date. Grade 2 immune related toxicity was seen in two patients, one with bullous pemphigoid and another with lymphopenia and peripheral neuropathy and weakness in his hands in the setting of a prior cervical spine injury. Both responded to steroids and recovered completely. Based on this initial cohort, the 95% confidence intervals (CI) on DLTs for the entire cohort is 0-28%. Using the most conservative CI of 28%, the likelihood of 11 of the remaining 23 patients experiencing a DLT is 3.4%. Assuming a CI of 20%, the risk is 0.3%. None of the 11 pts who have completed protocol therapy have experienced a recurrence. Conclusions: The addition of Pembrolizumab to postoperative IMRT in high risk cSCC-HN is safe and will be studied in a randomized phase III adjuvant study (Keynote 630). This phase II study will continue to enroll CLL patients to assess safety and efficacy signals in this unique higher risk population. Clinical trial information: NCT03057613.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Julia Samsa
- Taussig Cancer Institue, Cleveland Clinic Foundation, Cleveland, OH
| | | | | | | |
Collapse
|
24
|
Brewer JD, Elston DM, Vidimos AT, Rizza SA, Miller SJ. Managing sharps injuries and other occupational exposures to HIV, HBV, and HCV in the dermatology office. J Am Acad Dermatol 2017; 77:946-951.e6. [PMID: 28865865 DOI: 10.1016/j.jaad.2017.06.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 06/09/2017] [Accepted: 06/18/2017] [Indexed: 12/13/2022]
Abstract
Dermatologists and their staff are at risk for needlestick injuries and exposures to body fluids. Despite the availability of treatment to reduce the risk of blood-borne infection, many exposures go unreported. This paper identifies current recommendations and the specific details for response to occupational exposures to HIV, hepatitis B virus, and hepatitis C virus in the dermatology office. Issues surrounding each virus are discussed individually, and a summary step-by-step algorithm of how to proceed in the event of an occupational exposure is presented. In addition, a focused Practice Improvement Activity that is based on this paper and provides Maintenance of Certification credit has been developed. To view and participate, visit https://secure.dataharborsolutions.com/abdermorg/.
Collapse
Affiliation(s)
- Jerry D Brewer
- Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Dirk M Elston
- Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina
| | | | - Stacey A Rizza
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Stanley J Miller
- Department of Dermatology, Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
25
|
Bayart CB, Tamburro JE, Vidimos AT, Wang L, Golden AB. Atenolol Versus Propranolol for Treatment of Infantile Hemangiomas During the Proliferative Phase: A Retrospective Noninferiority Study. Pediatr Dermatol 2017; 34:413-421. [PMID: 28556385 DOI: 10.1111/pde.13177] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES The nonselective beta-blocker propranolol is the current criterion standard for treatment of infantile hemangiomas (IHs) and the first therapy that the U.S. Food and Drug Administration has approved for the condition, but concern about adverse effects, such as bronchospasm, hypoglycemia, and sleep disturbances, has sparked interest in the use of alternative agents such as the selective β1 antagonist atenolol. Our aim was to compare the efficacy and adverse effect profiles of atenolol with those of propranolol in the treatment of IHs in a retrospective noninferiority trial. METHODS Twenty-seven children with IHs treated with atenolol according to the Cleveland Clinic foundation's standardized clinical assessment and management plan (SCAMP) met inclusion criteria and were compared with a matched group of 53 children with IHs treated with propranolol. Three reviewers assessed response to therapy using a modified version of the previously validated Hemangioma Activity Score (HAS). RESULTS The mean change in HAS was -2.94 ± 1.20 for patients treated with atenolol and -2.96 ± 1.42 for those treated with propranolol. There was no statistically significant difference in pre- and posttreatment modified HAS scores between the two groups (p = 0.60). There was no significant difference in the overall rate of adverse effects (p = 0.10), although 11% of patients treated with propranolol experienced reactive airway symptoms, whereas this was not seen in any of the patients treated with atenolol. CONCLUSION Our study supports previous findings that atenolol is at least as effective as propranolol for treatment of IHs and poses less risk of bronchospasm. Our SCAMP proposes guidelines for dosing and monitoring parameters.
Collapse
Affiliation(s)
- Cheryl B Bayart
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Pediatrics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Joan E Tamburro
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Pediatrics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Allison T Vidimos
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lu Wang
- Department of Biostatistics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alex B Golden
- Department of Cardiology, Connecticut Children's Medical Center, Hartford, Connecticut
| |
Collapse
|
26
|
Krishnan A, Xu T, Hutfless S, Park A, Stasko T, Vidimos AT, Leshin B, Coldiron BM, Bennett RG, Marks VJ, Brandt R, Makary MA, Albertini JG. Outlier Practice Patterns in Mohs Micrographic Surgery: Defining the Problem and a Proposed Solution. JAMA Dermatol 2017; 153:565-570. [PMID: 28453605 PMCID: PMC5817605 DOI: 10.1001/jamadermatol.2017.1450] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/03/2017] [Indexed: 11/14/2022]
Abstract
Importance Outlier physician practices in health care can represent a significant burden to patients and the health system. Objective To study outlier physician practices in Mohs micrographic surgery (MMS) and the associated factors. Design, Setting, and Participants This retrospective analysis of publicly available Medicare Part B claims data from January 2012 to December 2014 includes all physicians who received Medicare payments for MMS from any practice performing MMS on the head and neck, genitalia, hands, and feet region of Medicare Part B patients. Main Outcomes and Measures Characteristics of outlier physicians, defined as those whose mean number of stages for MMS was 2 standard deviations greater than the mean number for all physicians billing MMS. Logistic regression was used to study the physician characteristics associated with outlier status. Results Our analysis included 2305 individual billing physicians performing MMS. The mean number of stages per MMS case for all physicians practicing from January 2012 to December 2014 was 1.74, the median was 1.69, and the range was 1.09 to 4.11. Overall, 137 physicians who perform Mohs surgery were greater than 2 standard deviations above the mean (2 standard deviations above the mean = 2.41 stages per case) in at least 1 of the 3 examined years, and 49 physicians (35.8%) were persistent high outliers in all 3 years. Persistent high outlier status was associated with performing Mohs surgery in a solo practice (odds ratio, 2.35; 95% CI, 1.25-4.35). Volume of cases per year, practice experience, and geographic location were not associated with persistent high outlier status. Conclusions and Relevance Marked variation exists in the number of stages per case for MMS for head and neck, genitalia, hands, and feet skin cancers, which may represent an additional financial burden and unnecessary surgery on individual patients. Providing feedback to physicians may reduce unwarranted variation on this metric of quality.
Collapse
Affiliation(s)
- Aravind Krishnan
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Tim Xu
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Susan Hutfless
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Angela Park
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Thomas Stasko
- Department of Dermatology, University of Oklahoma, Oklahoma City
| | | | - Barry Leshin
- The Skin Surgery Center, Winston-Salem, North Carolina
| | | | | | | | | | - Martin A. Makary
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Health Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - John G. Albertini
- The Skin Surgery Center, Winston-Salem, North Carolina
- Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | |
Collapse
|
27
|
Koyfman SA, Manyam BV, Garsa AA, Chin RI, Reddy CA, Gastman B, Thorstad W, Yom SS, Nussenbaum B, Wang S, Vidimos AT. A multi-institutional study of immunosuppressed and immunocompetent patients with cutaneous squamous cell carcinoma of the head and neck treated with definitive surgery and radiotherapy: Outcomes after disease recurrence. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.7_suppl.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
63 Background: Our multi-institutional group previously demonstrated that immunosuppressed (IS) patients with cutaneous squamous cell cancer of the head and neck (cSCC-HN) treated with surgery and adjuvant radiotherapy had inferior survival compared to immunocompetent (IC) patients. This study further examines those patients who experienced disease recurrence and compares the impact of immune status on overall survival after recurrence. Methods: Pts who received surgical resection and postoperative RT for primary or recurrent, stage I-IV (non-metastatic) cSCC-HN between 1995-2015 at Cleveland Clinic, Washington University St. Louis, and University of California San Francisco were included in this IRB approved study. Pts were categorized as IS if they were diagnosed with chronic hematologic malignancy, HIV/AIDS, or were treated with immunosuppressive therapy for organ transplantation ≥ 6 months prior to diagnosis. Pts with recurrence included those who experienced local, regional, or distant failure after completion of definitive surgery and radiation. Overall survival (OS) and progression free survival (PFS) were calculated using the Kaplan Meier method. Results: In the initial study of 205 pts, 138 (67.3%) were immunocompetent (IC) and 67 (32.7%) were IS, and were followed for a median of 25 months. PFS was significantly lower in IS pts compared to IC at 2 years (38.7% vs. 71.6%; p = 0.002), while 2yr OS demonstrated a similar but non-significant trend (60.9% vs. 78.1%; p = 0.135). A total of 72 patients (35%) recurred, including 31 with distant failure. 1yr post-recurrence OS was 42% with a median survival of 8.4 months. Median survival did not significantly differ between the IS and IC groups (8.0 vs. 12.9 months; p = 0.9). Conclusions: Pts with cSCC-HN who experience disease recurrence after definitive treatment with surgery and radiation have poor survival, irrespective of immune status. Clinical trials testing immunotherapies are needed for both IC and IS patients with this understudied disease.
Collapse
Affiliation(s)
| | | | | | - Re-I Chin
- Washington University - St Louis, St. Louis, MO
| | - Chandana A. Reddy
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | | | - Sue S. Yom
- University California San Francisco, San Francisco, CA
| | - Brian Nussenbaum
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | | |
Collapse
|
28
|
Manyam BV, Garsa AA, Chin RI, Reddy CA, Gastman B, Thorstad W, Yom SS, Nussenbaum B, Wang SJ, Vidimos AT, Koyfman SA. A multi-institutional comparison of outcomes of immunosuppressed and immunocompetent patients treated with surgery and radiation therapy for cutaneous squamous cell carcinoma of the head and neck. Cancer 2017; 123:2054-2060. [PMID: 28171708 DOI: 10.1002/cncr.30601] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/12/2016] [Accepted: 01/01/2017] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients who are chronically immunosuppressed have higher rates of cutaneous squamous cell carcinoma of the head and neck (cSCC-HN). This is the largest multi-institutional study to date investigating the effect of immune status on disease outcomes in patients with cSCC-HN who underwent surgery and received postoperative radiation therapy (RT). METHODS Patients from 3 institutions who underwent surgery and also received postoperative RT for primary or recurrent, stage I through IV cSCC-HN between 1995 and 2015 were included in this institutional review board-approved study. Patients categorized as immunosuppressed had chronic hematologic malignancy, human immunodeficiency/acquired immunodeficiency syndrome, or had received immunosuppressive therapy for organ transplantation ≥6 months before diagnosis. Overall survival, locoregional recurrence-free survival, and progression-free survival were calculated using the Kaplan-Meier method. Univariate and multivariate analyses were performed using Cox proportional-hazards regression. RESULTS Of 205 patients, 138 (67.3%) were immunocompetent, and 67 (32.7%) were immunosuppressed. Locoregional recurrence-free survival (47.3% vs 86.1%; P < .0001) and progression-free survival (38.7% vs 71.6%; P = .002) were significantly lower in immunosuppressed patients at 2 years. The 2-year OS rate in immunosuppressed patients demonstrated a similar trend (60.9% vs 78.1%; P = .135) but did not meet significance. On multivariate analysis, immunosuppressed status (hazard ratio [HR], 3.79; P < .0001), recurrent disease (HR, 2.67; P = .001), poor differentiation (HR, 2.08; P = .006), and perineural invasion (HR, 2.05; P = .009) were significantly associated with locoregional recurrence. CONCLUSIONS Immunosuppressed patients with cSCC-HN had dramatically lower outcomes compared with immunocompetent patients, despite receiving bimodality therapy. Immune status is a strong prognostic factor that should be accounted for in prognostic systems, treatment algorithms, and clinical trial design. Cancer 2017;123:2054-2060. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Bindu V Manyam
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Adam A Garsa
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Re-I Chin
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Brian Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Wade Thorstad
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Sue S Yom
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Brian Nussenbaum
- Department of Otolaryngology, Washington University, St. Louis, Missouri
| | - Steven J Wang
- Department of Otolaryngology, University of California San Francisco, San Francisco, California
| | | | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
29
|
Perry JD, Polito SC, Chundury RV, Singh AD, Fritz MA, Vidimos AT, Gastman BR, Koyfman SA. Periocular Skin Cancer in Solid Organ Transplant Recipients. Ophthalmology 2015; 123:203-8. [PMID: 26520170 DOI: 10.1016/j.ophtha.2015.09.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To determine the proportion of solid organ transplant recipients developing periocular nonmelanoma skin cancer and to describe the morbidity of these cancers in transplant recipients. DESIGN Cohort study. PARTICIPANTS Consecutive patients undergoing solid organ transplantation at the Cleveland Clinic between 1990 and 2008. METHODS The charts of all patients receiving a solid organ transplant from 1990-2008 evaluated in the dermatology department for a subsequent biopsy-proven head and neck malignancy through April 2015 were reviewed. Patients with a periocular region nonmelanoma skin cancer (NMSC) or a nonperiocular NMSC causing a complication requiring eyelid surgery were included. Charts were reviewed for demographic data; transplant date, type, and source; immunosuppressive agents received at diagnosis; and type of NMSC, number of nonperiocular NMSCs, ophthalmologic findings, and periocular sequelae after the repair. MAIN OUTCOME MEASURES Primary outcome measures included the type, location, final defect size, tumor-node-metastasis classification, presence of perineural invasion, and reconstruction technique(s) used for each periocular NMSC. Secondary outcome measures included the type and treatment of ocular sequelae due to nonperiocular facial NMSC. RESULTS A total of 3489 patients underwent solid organ transplantation between 1990 and 2008. Of these, 420 patients were evaluated in the dermatology clinic for biopsy-proven NMSC of the head and neck during the study period, and 11 patients (15 malignancies) met inclusion criteria. Nine patients developed 12 periocular malignancies and 3 patients required eyelid surgery for facial malignancies outside the periocular zone. All 11 patients developed a squamous cell carcinoma (14 malignancies), and 1 patient (1 malignancy) also developed a periocular basal cell carcinoma. There was orbital invasion in 4 cases and paranasal and/or cavernous sinus invasion in 3 cases. Two patients underwent exenteration. Seven cases required reconstruction with a free flap or graft. Periocular sequelae included lower eyelid ectropion (6 malignancies), dry eye and/or exposure symptoms (8 malignancies), unilateral vision loss (3 malignancies), and facial nerve paresis (5 malignancies). CONCLUSIONS Squamous cell carcinoma affecting the periocular region represents a risk of solid organ transplantation and may produce significant ocular morbidity, including the need for major eyelid reconstruction, globe loss, and disfiguring surgery.
Collapse
Affiliation(s)
| | - Sara C Polito
- Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Arun D Singh
- Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Fritz
- Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio
| | | | - Brian R Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
30
|
Manyam BV, Gastman B, Zhang AY, Reddy CA, Burkey BB, Scharpf J, Alam DS, Fritz MA, Vidimos AT, Koyfman SA. Inferior outcomes in immunosuppressed patients with high-risk cutaneous squamous cell carcinoma of the head and neck treated with surgery and radiation therapy. J Am Acad Dermatol 2015; 73:221-7. [DOI: 10.1016/j.jaad.2015.04.037] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 04/15/2015] [Accepted: 04/20/2015] [Indexed: 11/29/2022]
|
31
|
Anderson KA, Vidimos AT. Two Primary Dermatofibrosarcoma Protuberans Associated with Different Pregnancies in a Single Patient. Dermatol Surg 2012; 38:1876-8. [DOI: 10.1111/j.1524-4725.2012.02519.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
32
|
Connolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA, Vidimos AT, Zalla MJ, Brewer JD, Smith Begolka W, Berger TG, Bigby M, Bolognia JL, Brodland DG, Collins S, Cronin TA, Dahl MV, Grant-Kels JM, Hanke CW, Hruza GJ, James WD, Lober CW, McBurney EI, Norton SA, Roenigk RK, Wheeland RG, Wisco OJ. 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. J Am Acad Dermatol 2012; 67:531-50. [DOI: 10.1016/j.jaad.2012.06.009] [Citation(s) in RCA: 224] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/07/2012] [Accepted: 06/12/2012] [Indexed: 10/27/2022]
|
33
|
Connolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA, Vidimos AT, Zalla MJ, Brewer JD, Begolka WS, Berger TG, Bigby M, Bolognia JL, Brodland DG, Collins S, Cronin TA, Dahl MV, Grant-Kels JM, Hanke CW, Hruza GJ, James WD, Lober CW, McBurney EI, Norton SA, Roenigk RK, Wheeland RG, Wisco OJ. 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. Dermatol Surg 2012; 38:1582-603. [PMID: 22958088 DOI: 10.1111/j.1524-4725.2012.02574.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
-
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Seth R, Revenaugh PC, Vidimos AT, Scharpf J, Somani AK, Fritz MA. Simultaneous intraoperative Mohs clearance and reconstruction for advanced cutaneous malignancies. ACTA ACUST UNITED AC 2012; 13:404-10. [PMID: 22106186 DOI: 10.1001/archfacial.2011.563] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Improved control of cutaneous malignancies using Mohs micrographic pathologic clearance has been well established. However, surgical margin control of advanced and complex cutaneous tumors of the head and neck is commonly performed by far less reliable frozen section margin analysis. OBJECTIVE To describe a routine and ideal collaboration between dermatologic surgery and facial plastic surgery/head and neck surgery in which the Mohs micrographic method is used intraoperatively to achieve marginal clearance during resection and reconstruction. METHODS A single-institution retrospective analysis was performed of patients who underwent intraoperative Mohs micrographic surgery. Intraoperative margins (peripheral and deep) of tissue specimens were analyzed by the Mohs surgeon. RESULTS Twenty-six patients underwent large cutaneous tumor resection using intraoperative Mohs micrographic surgery. Most lesions were basal (48%) or squamous (34%) cell carcinoma. A mean (SD) of 2.1 (0.98) resection layers were required before negative margins were achieved. CONCLUSIONS We demonstrate the intraoperative technique and utility of Mohs micrographic analysis via an efficient collaborative effort. Well established for accuracy greater than intraoperative frozen section margin analysis, intraoperative Mohs micrographic surgery provides an optimal method of intraoperative margin assessment of cutaneous malignancies.
Collapse
Affiliation(s)
- Rahul Seth
- Head and Neck Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | | | | | | | | | | |
Collapse
|
35
|
Abstract
The ever-increasing incidence of primary cutaneous malignancies has heralded the need for multiple treatment options. Surgical modalities remain the mainstay of treatment of nonmelanoma skin cancer. However, it is important for the dermatologic surgeon to have an understanding of all treatment options to assist the patient in making the most informed decision possible, ultimately leading to the most favorable outcome. This article explores the available nonsurgical treatment options, their indications, and their efficacy.
Collapse
Affiliation(s)
- Edward M Galiczynski
- Department of Dermatology, A-61, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | | |
Collapse
|
36
|
|
37
|
Vidimos AT, Poblete-Lopez C, Gasbarre CC. Preface. Mohs Surgery. Dermatol Clin 2011; 29:xiii-xiv. [PMID: 21421138 DOI: 10.1016/j.det.2011.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Allison T Vidimos
- Section of Dermatologic Surgery and Cutaneous Oncology, Department of Dermatology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | | | | |
Collapse
|
38
|
Allen EJ, Ammirati CT, Bailin PL, Bhatia AC, Billingsley EM, Campbell LB, Minsue Chen T, Conologue TD, Do DV, Ebner J, Fulchiero GJ, Gasbarre CC, Grandinetti LM, Greco JF, Hayes CM, Jones CR, Lee KK, Marks VJ, Maytin EV, McGillis ST, Meine JG, Moosally AJ, Nguyen TH, Poblete-Lopez C, Ricks MR, Skvarka CB, Taneja A, Trost LB, Vidimos AT, Vogel PS, Wanitphakdeedecha R, Willey A, Wilson B, Wisco OJ, Woodhouse JG, Youker SR. Contributors. Dermatol Surg 2009. [DOI: 10.1016/b978-0-7020-3049-9.10021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
39
|
Moosally AJ, Vidimos AT. Sclerotherapy of varicose and telangiectatic leg veins. Dermatol Surg 2009. [DOI: 10.1016/b978-0-7020-3049-9.00018-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
40
|
Abstract
Dermatofibrosarcoma protuberans (DFSP) is especially challenging to recognize and diagnose in children. Prompt and definitive treatment is essential based on the tumor's high rate of recurrence. Our purpose is to increase physician awareness and recognition of DFSP in the pediatric population with the largest case series of childhood DFSP to our knowledge thus reported in the literature. We also propose that magnetic resonance imaging (MRI) may be useful in the preoperative assessment. The records of 10 patients with primary DFSP between the ages of 8 months and 16 years were reviewed. Only 1 of 10 patients was given the correct diagnosis at the initial medical evaluation. Of the 10 cases, 5 were congenital. The average delay in diagnosis was 5 years. Of the patients, 5 had preoperative MRI to delineate the size and extent of the tumor. In the two cases with the largest tumors preoperative MRI significantly altered surgical planning and execution. Thus, preoperative MRI may be helpful in planning for successful surgical clearance of large tumors and preventing local recurrence. All 10 cases were treated with Mohs micrographic surgery and no recurrences were noted with a follow-up range of 6 weeks to 17 years.
Collapse
Affiliation(s)
- Sharon Longshore Thornton
- Division of Dermatologic Surgery, Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | | | | | |
Collapse
|
41
|
Abstract
Varicose veins are not only a cosmetic annoyance: they can lead to complications that result in lost time from work and lost wages. Treatment has improved with the use of minimally invasive techniques that reduce recovery time and complications and offer better long-term results--encouraging news, considering that the problem affects 10% to 20% of adult men and 25% to 33% of adult women.
Collapse
Affiliation(s)
- John R Bartholomew
- Department of Cardiovascular Medicine, Section of Vascular Medicine, The Cleveland Clinic Foundation, OH, 44195, USA.
| | | | | | | |
Collapse
|
42
|
Abstract
BACKGROUND Trigeminal trophic syndrome is a unilateral, frequently crescent-shaped neurotrophic ulceration of the face occurring after injury to the trigeminal nerve. The appearance of the ulcers resembles other disease entities such as granulomatous disease, neoplasm, vasculitis, infection, and factitial dermatitis. OBJECTIVES The objectives of this study are to increase awareness of this disorder and to emphasize the importance of eliciting a thorough neurologic history when evaluating facial ulcerations. METHODS Four cases are reported and, using MEDLINE, the English and non-English literature from 1982 to 2002 is reviewed. RESULTS Including this report, there have been 60 cases of trigeminal trophic syndrome reported from 1982 to 2002. The age at presentation ranged from 14 months to 93 years. Time of onset from injury to the trigeminal ganglion or its branches and the development of the ulcers ranged from 2 weeks to 30 years. One-third of the patients had undergone trigeminal nerve ablation for the treatment of trigeminal neuralgia and another third had a history of stroke. Other causes included craniotomy, head trauma, herpes infection. CONCLUSION The majority of cases of trigeminal trophic syndrome are associated with a history of stroke or trigeminal nerve ablation. Successful surgical outcome can be achieved if the underlying neurologic pathology is addressed before the reconstructive procedure.
Collapse
Affiliation(s)
- Parrish Sadeghi
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | | | |
Collapse
|
43
|
Abstract
BACKGROUND Microcystic adnexal carcinoma (MAC), or sclerosing sweat duct tumor, is an uncommon, locally aggressive tumor. It typically involves the upper lip or face of middle-aged adults and rarely involves the scalp. It is characterized histologically by both pilar and eccrine differentiation and is associated with frequent perineural invasion. MAC is frequently misdiagnosed because of its bland and asymptomatic clinical presentation. In addition, its defining histologic features may be missed with a superficial biopsy. OBJECTIVE To describe a case of MAC in the scalp treated with Mohs surgery. We describe a case with extensive pilar differentiation and clear cell changes. In addition, the clinical and histologic characteristics of this rare neoplasm are reviewed. METHODS Mohs micrographic surgery (MMS) was performed on this neoplasm. RESULTS The tumor was successfully excised in one surgery (five stages) and is without evidence of recurrence at 18 months. CONCLUSION We present a case of MAC of the scalp in a 64-year-old white man treated successfully with MMS.
Collapse
Affiliation(s)
- Elizabeth F Callahan
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | | | |
Collapse
|
44
|
Doctoroff A, Vidimos AT, Taylor JS. Cactus skin injuries. Cutis 2000; 65:290-2. [PMID: 10826089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Cactus spine injuries to the skin are usually treated by removing the visible spines and applying a topical corticosteroid. With this approach, granulomatous inflammation usually resolves in 2 to 4 months. We describe a case of a 54-year-old Caucasian woman who presented for treatment of painful cactus spine granulomas on her right hand. Unroofing the granulomatous papules and removing the cactus spine fragments under a dissecting microscope, and subsequent soaking in an antibacterial solution, resulted in rapid resolution of the granulomatous lesions.
Collapse
Affiliation(s)
- A Doctoroff
- Maimonides Medical Center, Brooklyn, New York, USA
| | | | | |
Collapse
|
45
|
Abstract
alpha-Hydroxy acid (AHA) peels and home regimens have recently been recognized as important adjunctive therapy in a variety of conditions including photodamage, actinic damage, melasma, hyperpigmentation disorders, acne, and rosacea. Overall in our experience and in the literature, AHAs have a proven level of safety and efficacy in a variety of skin types. Although their exact mechanism of action is unknown, it has been demonstrated that AHAs improve these disorders by thinning the stratum corneum, promoting epidermolysis, dispersing basal layer melanin, and increasing collagen synthesis within the dermis. In patients with photodamage, AHA peels and topical products are often combined with retinoids and other antioxidants for maximum benefit. Similarly, synergistic effects of fluorouracil and glycolic acid are observed in the treatment of diffuse actinic keratoses. For patients with melasma, AHA peels and combination products containing bleaching agents such as hydroquinone, kojic acid, and glycolic acid seem to have increased efficacy. Acne and rosacea patients can see improved results when standard regimens like antibacterials and topical retinoids are supplemented with AHA peels and lotions. However, care should always be taken prior to commencing treatment with AHA peels and topical products. By obtaining a thorough history and physical examination, the physician will identify any specific factors like medications, prior procedures and medical conditions which can affect the outcome of the peel. During the interview, there should be open discussion of patient questions and concerns so that realistic expectations can be made. Pre- and post-peel regimens should also be reviewed in full as patient compliance is essential to ensure the success of a series of AHA peels.
Collapse
Affiliation(s)
- R C Tung
- Cleveland Clinic Foundation, Department of Dermatology, Cleveland, Ohio, USA
| | | | | | | |
Collapse
|
46
|
Gay D, Vidimos AT. Answers to Self-Assessment examination of the American Academy of Dermatology Identification No. 899-207. J Am Acad Dermatol 1999. [DOI: 10.1016/s0190-9622(99)70428-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
47
|
Kahn TA, Liranzo MO, Vidimos AT, Papay FA, Bergfeld WF. Pathological case of the month. Congenital dermatofibrosarcoma protuberans. Arch Pediatr Adolesc Med 1996; 150:549-50. [PMID: 8620241 DOI: 10.1001/archpedi.1996.02170300103021] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- T A Kahn
- Department of Dermatology, Cleveland Clinic Foundation, Ohio, USA
| | | | | | | | | |
Collapse
|
48
|
Narurkar VA, Vidimos AT, Papay F, Bailin PL. Discussion of questions 11–20. J Am Acad Dermatol 1995. [DOI: 10.1016/0190-9622(95)90056-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
49
|
Vidimos AT, Lucas A, Warner M, Narurkar VA, Papay F, Bailin PL, Ghorbani AJ, Helm TM. Macrodactyly. Trigeminal trophic syndrome. Extramammary Paget's disease. Self-assessment examination of the American Academy of Dermatology. J Am Acad Dermatol 1995; 33:154-8; quizz 148-53. [PMID: 7601940 DOI: 10.1016/0190-9622(95)90055-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
50
|
Saff DM, Taylor JS, Vidimos AT. Allergic reaction to intralesional triamcinolone acetonide: a case report. Arch Dermatol 1995; 131:742-3. [PMID: 7778940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|