Identifying critical quality metrics in Mohs Surgery: A national expert consensus process

BACKGROUND

Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care.

OBJECTIVE

The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS.

METHODS

Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives.

RESULTS

Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback.

LIMITATIONS

Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes.

CONCLUSION

With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.

Considering Sun Safety Policies in the United States

As they are collectively the most common malignancies, the personal and systemic burden of skin cancers represent a significant public health concern in the United States. Ultraviolet radiation from the sun as well as from artificial sources such as tanning beds is a carcinogen well-known to increase the risk of developing skin cancer in individuals. Public health policies can help mitigate these risks. In this perspectives article, we review sunscreen and sunglasses standards, tanning bed utilization, and workplace sun protection guidelines in the US and provide focused examples for improvement from Australia and the United Kingdom where skin cancer is a well-documented public health concern. These comparative examples can inform interventions in the US that have the potential to modify exposure to risk factors associated with skin cancer.

Factors affecting outcomes of second intent healing of nasal defects after Mohs micrographic surgery

Reconstruction of nasal defects secondary to Mohs micrographic surgery (MMS) presents particular challenges related to the complex topography, skin quality, tissue laxity, and functional and aesthetic concerns of the region. Factors affecting outcomes resulting from second intent healing (SIH) on the nose have not been well described. The purpose of the study was to identify factors impacting outcomes of SIH for nasal tumors following MMS. Retrospective analysis was performed of all nasal lesions treated with MMS followed by SIH from a single surgical center over a 1.5-year period. Ninety-six cases were included. Chart review was performed, and data were collected including age, gender, nasal site, tumor type, defect size, depth, and number of MMS stages. Pre- and post-operative follow-up photographs were available for all cases. All five authors evaluated the photographs using the modified Manchester scar scale. Analysis was then conducted to identify features associated with good outcomes. Of the 96 tumors, 39 lesions (40.6%) were located on the nasal tip (including supratip), 32 (33.3%) on the ala/alar groove, 17 (17.7%) on the sidewall, and 8 (8.3%) on the dorsum. The average defect size was 0.83 cm² (diameter of 1.06 cm ± 0.4). Defect diameter and defect depth were the factors that significantly impacted scar outcome (p < 0.001) in multivariate analysis. No significant functional deficits were reported. This retrospective study suggests that nasal defects with area less than 0.83 cm² (or 1.06 cm diameter) and depth of defect not extending beyond the superficial fat healed well by SIH regardless of location on the nose.

Artificial intelligence in the detection of skin cancer

Recent advances in artificial intelligence (AI) in dermatology have demonstrated the potential to improve the accuracy of skin cancer detection. These capabilities may augment current diagnostic processes and improve the approach to the management of skin cancer. To explain this technology, we discuss fundamental terminology, potential benefits, and limitations of AI, and commercial applications relevant to dermatologists. A clear understanding of the technology may help to reduce physician concerns about AI and promote its use in the clinical setting. Ultimately, the development and validation of AI technologies, their approval by regulatory agencies, and widespread adoption by dermatologists and other clinicians may enhance patient care. Technology-augmented detection of skin cancer has the potential to improve quality of life, reduce health care costs by reducing unnecessary procedures, and promote greater access to high-quality skin assessment. Dermatologists play a critical role in the responsible development and deployment of AI capabilities applied to skin cancer.

Association of Treatment Facility Characteristics With Overall Survival After Mohs Micrographic Surgery for T1a-T2a Invasive Melanoma

Importance

Early-stage melanoma, among the most common cancers in the US, is typically treated with wide local excision. However, recent advances in immunohistochemistry have led to an increasing number of these cases being excised via Mohs micrographic surgery (MMS). Although studies of resections for other cancers have reported that facility-level factors are associated with patient outcomes, it is not yet established how these factors may affect outcomes for patients treated with Mohs micrographic surgery.

Objective

To evaluate the association of treatment center academic affiliation and case volume with long-term patient survival after MMS for T1a-T2a invasive melanoma.

Design, Setting, and Participants

In a retrospective cohort study, 4062 adults with nonmetastatic, T1a-T2a melanoma diagnosed from 2004 to 2014 and treated with MMS in the National Cancer Database (NCDB) were identified. The NCDB includes all reportable cases from Commission on Cancer-accredited facilities and is estimated to capture approximately 50% of all incident melanomas in the US. Multivariable survival analyses were conducted using Cox proportional hazards models. Data analysis was conducted from February 27 to August 18, 2020.

Exposures

Treatment facility characteristics.

Main Outcomes and Measures

Overall survival.

Results

The study population included 4062 patients (2213 [54.5%] men; median [SD] age, 60 [16.3] years) treated at 462 centers. Sixty-two centers were top decile-volume facilities (TDVFs), which treated 1757 patients (61.9%). Most TDVFs were academic institutions (37 of 62 [59.7%]). On multivariable analysis, treatment at an academic center was associated with a nearly 30% reduction in hazard of death (hazard ratio, 0.730; 95% CI, 0.596-0.895). In a separate analysis, treatment at TDVFs was also associated with improved survival (hazard ratio, 0.795; 95% CI, 0.648-0.977).

Conclusions and Relevance

In this cohort study, treatment of patients with T1a-T2a invasive melanoma excised with MMS at academic and top decile-volume (≥8 cases per year) facilities was associated with improved long-term survival compared with those excised by MMS at nonacademic and low-volume facilities. Identification and protocolization of the practices of these facilities may help to reduce survival differences between centers.

Dermatofibrosarcoma protuberans in pregnancy: a case series and review of the literature

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma, which has been reported in pregnancy. This case series reports the clinical and histopathological findings of DFSP in pregnancy.

METHODS

Eighteen cases of DFSP, including six unreported cases and 12 cases from the literature, were identified. Age, anatomic location, tumor size, changes in tumor characteristics during pregnancy, histopathological features, and treatment were recorded. Follow-up data, when available, were noted.

RESULTS

The average age of the cohort was 30.6 years (range 19-38). Ten tumors (55.6%) were located on the trunk, four (22.2%) on the head and neck, three (16.7%) on the extremities, and one (5.6%) in the genitalia. Most tumors demonstrated features of conventional DFSP (12/18, 66.7%), while the remaining were identified as DFSP with fibrosarcomatous (FS) change (3/18, 16.7%), atrophic DFSP (2/18, 11.1%), and myxoid DFSP (1/18, 5.6%). Treatment was reported in 17 cases, at least nine of which were treated postpartum. Ten patients were treated with excision, while seven underwent Mohs micrographic surgery. Three patients recurred on follow-up, one with local recurrence and two with distant metastasis.

CONCLUSIONS

DFSP can undergo enlargement or change in size or color in pregnancy, possibly mediated by hormones. While the majority of cases in this series represented conventional DFSP, unusual clinical and histopathological variants were also present. Treatment in most cases can be safely delayed until after delivery, but recurrent or very large tumors may require treatment prepartum. Close monitoring for recurrence or metastasis is advised.

Cutaneous immunohistochemical staining pattern of p53β isoforms

p53 is considered the guardian of the genome and as such has numerous functions. The TP53 gene is the most commonly mutated gene in cancer, and yet the exact biological significance of such mutations remains unclear. There are at least 12 different isoforms of p53, and the complexity of the p53 pathway may be in part related to these isoforms. Prior research has often not teased out what isoforms of p53 are being studied, and there is evidence in the literature that p53 isoforms are expressed differently. In this paper, we document the staining pattern of p53β isoforms in the skin and correlate it with mutational status in a subgroup of squamous proliferations of the skin. p53β isoforms are present in the cytoplasm of the differentiated layer of the epidermis and hair follicles (granular layer, infundibular and isthmus-catagen). p53β isoforms are diffusely expressed within the cytoplasm of well-differentiated squamous tumours with tetramerisation (C-terminal) domain mutations in TP53 Our results lend support to p53β isoforms being a marker of differentiation in keratinocytes.

Well-differentiated neuroendocrine tumors in skin: Terminology and diagnostic utility of cytokeratin 5/6 and p63

BACKGROUND

Well-differentiated neuroendocrine tumors (WDNETs) in skin include metastases from visceral primary sites and very uncommonly, primary cutaneous carcinoid tumors. Cutaneous WDNET may present a diagnostic challenge and in particular can be mistaken for a benign skin adnexal tumor. In contrast to cutaneous adnexal tumors, metastatic adenocarcinomas to the skin are cytokeratin 5/6 (CK5/6) and p63 negative in the majority of cases. It is unclear if failure to stain with CK5/6 and p63 would be helpful in differentiating WDNETs from cutaneous adnexal neoplasms.

METHODS

We reviewed 10 cases of cutaneous WDNETs (8 cases of metastatic disease and 2 presumed primary carcinoid tumors of the skin) and performed immunohistochemical stains for CK5/6 and p63 on all cases.

RESULTS

All 10 cases were negative with both CK5/6 and p63.

CONCLUSION

Negative staining for CK5/6 and p63 can be helpful to distinguish WDNETs from cutaneous adnexal neoplasms. It is important to consider WDNETs in the differential diagnosis of cutaneous adnexal neoplasms as low-grade tumors may be the first sign of aggressive metastatic disease.

Transparency and Dermatologic Device Approval by the US Food and Drug Administration

Importance

The US Food and Drug Administration approves Class III medical devices via the premarket approval pathway, often requiring clinical data on safety and efficacy. Manufacturers can submit incremental device changes via supplemental applications, which are not subjected to such vetting measures and can cause understudied changes that lead to drift from a device's original design.

Objectives

To characterize the postapproval changes to Class III dermatologic devices and to evaluate inconsistencies in the use of the premarket approval pathway.

Design, Setting, and Participants

This study was a cross-sectional retrospective cohort analysis of a public US Food and Drug Administration database for premarket approval of devices. Included were dermatologic devices approved by the US Food and Drug Administration between January 1, 1980, and November 1, 2016, through the premarket pathway for device approval.

Main Outcomes and Measures

Original devices were identified, and their supplements were characterized chronologically, by review track, and by modification category.

Results

The 27 dermatologic devices studied consisted of 14 injectables, 11 photodynamic therapies, a dermal replacement matrix, and a diagnostic imaging instrument. Supplemental applications are increasingly used: the data-requiring panel-track pathway was the least common approach (2.8% [16 of 562 supplements]), while the 30-day track, which does not require clinical data, was most frequently used (42.5% [239 of 562 supplements]). Four devices (14.8%) underwent low-risk recalls (Class II or Class III), and 10 devices (37.0%) were voluntarily withdrawn.

Conclusions and Relevance

As manufacturers make increasing use of supplemental applications, minor device changes may occur without supporting clinical data, which could pose a safety risk to patients.

Predictors of tanning dependence in white non-Hispanic females and males

BACKGROUND

Growing evidence suggests that some individuals may exhibit symptoms of dependence on ultraviolet (UV) light, a known carcinogen, in the context of tanning; however, few studies have investigated predictors of tanning dependence (TD).

OBJECTIVE

To identify predictors of TD.

METHODS

Non-Hispanics of European ancestry who had previously participated in a case-control study of early-onset basal cell carcinoma completed an online survey to ascertain TD and other behaviours (alcohol dependence, nicotine dependence, seasonal affective disorder (SAD), exercise 'addiction' and depression). Information on host factors, such as skin and eye colour and history of sunbathing and indoor tanning, was obtained from a study in which the participants were previously enrolled. Lifetime TD was assessed using the modified Cut down, Annoyed, Guilty, Eye-opener (mCAGE) and the modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (mDSM-IV-TR) questionnaires. Participants were classified as 'TD' if positive on both questionnaires and not TD if negative on both questionnaires.

RESULTS

In total, 499 individuals completed the online survey (81.9% participation rate), and 24.4% were classified as 'TD'. In the multivariate model, women were more likely to be TD [odds ratio (OR) 6.93; 95% confidence intervals (95% CI) (3.36-14.27)] than men. Alcohol dependence (OR 6.55: 95% CI 3.19-13.42), SAD (OR 2.77; 95% CI 1.26-6.09) and exercise 'addiction' (OR 5.47; 95% CI 1.15-26.06) were all significant predictors for TD.

CONCLUSION

Increased knowledge of those at risk for TD will allow appropriate interventions to be designed.

Body mass index, height and early-onset basal cell carcinoma in a case-control study

INTRODUCTION

Basal cell carcinoma (BCC) is the most common malignancy in the US. Body mass index (BMI) and height have been associated with a variety of cancer types, yet the evidence regarding BCC is limited. Therefore, we evaluated BMI and height in relation to early-onset BCC (under age 40) and explored the potential role of ultraviolet (UV) radiation exposure and estrogen-related exposures in the BMI-BCC relationship.

METHODS

BCC cases (n=377) were identified through a central dermatopathology facility in Connecticut. Control subjects (n=389) with benign skin conditions were randomly sampled from the same database and frequency matched to cases on age (median=36, interquartile range 33-39), gender, and biopsy site. Participants reported weight (usual adult and at age 18), adult height, sociodemographic, phenotypic, and medical characteristics, and prior UV exposures. We calculated multivariate odds ratios (ORs) and 95% confidence intervals (CIs) using unconditional logistic regression models.

RESULTS

Adult BMI was inversely associated with early-onset BCC (obese vs. normal OR=0.43, 95% CI=0.26-0.71). A similar inverse association was present for BMI at age 18 (OR=0.54, 95% CI=0.34-0.85). Excluding UV exposures from the BMI models and including estrogen-related exposures among women only did not alter the association between BMI and BCC, indicating limited mediation or confounding. We did not observe an association between adult height and BCC (OR per cm=1.00, 95% CI=0.98-1.02).

CONCLUSIONS

We found a significant inverse association between BMI and early-onset BCC, but no association between height and BCC. This association was not explained by UV exposures or estrogen-related exposures in women.

Histopathologic features of multiple cutaneous squamous cell carcinomas of the lower extremity

Recent studies suggest cutaneous squamous cell carcinomas (SCCs) of the leg, particularly those occurring multiply in sun exposed skin of nonimmunosuppressed women, are a distinct clinical subtype. There are few reports of the histopathologic features of this subtype. A retrospective chart review of 4 patients with multiple SCCs on the leg was performed and a total of 35 biopsies from the legs examined. Histopathologically, the tumors lacked adjacent actinic keratosis (AK) and often had adjacent basaloid retiform proliferations. Most lesions (all but one) were well differentiated and about 40% could be classified histopathologically as keratoacanthoma. Perineural invasion was absent in all but one case. Using the American Joint Committee on Cancer (AJCC) staging criteria for SCC, 21 tumors were Stage I, and 9 Stage II. During 7-10 years of follow-up, no recurrence or metastasis occurred. Patients with multiple SCCs on the lower extremities can have a range of histopathologic features, from keratoacanthoma-like to well-differentiated SCC.

Novel gene identified in an exome-wide association study of tanning dependence

Growing evidence suggests that some individuals may exhibit symptoms of dependence to ultraviolet light, a known carcinogen, in the context of tanning. Genetic associations with tanning dependence (TD) have not yet been explored. We conducted an exome-wide association study in 79 individuals who exhibited symptoms of TD and 213 individuals with volitional exposure to ultraviolet light, but who were not TD based on three TD scales. A total of 300 000 mostly exomic single nucleotide polymorphisms primarily in coding regions were assessed using an Affymetrix Axiom array. We performed a gene burden test with Bonferroni correction for the number of genes examined (P < 0.05/14 904 = 3.36 × 10(-6) ). One gene, patched domain containing 2 (PTCHD2), yielded a statistically significant P-value of 2.5 × 10(-6) (OR = 0.27) with fewer individuals classified as TD having a minor allele at this locus. These results require replication, but are the first to support a specific genetic association with TD.

Randomized comparison of the safety of Flublok(®) versus licensed inactivated influenza vaccine in healthy, medically stable adults ≥ 50 years of age

BACKGROUND

The safety and tolerability of Flublok(®), a purified recombinant hemagglutinin seasonal influenza vaccine, was compared to AFLURIA(®) in a randomized, blinded clinical trial in adults ≥ 50 years of age with attention to hypersensitivity reactions.

METHODS

This blinded, randomized trial of healthy adults ≥ 50 years of age compared safety of Flublok vs. AFLURIA with respect to pre-specified possible hypersensitivity: "rash," "urticaria," "swelling" and "non-dependent edema;" solicited reactogenicity and unsolicited adverse events. Subject-reported outcomes were collected for 30 days after vaccination. All adverse event terms were reviewed by physicians blinded to vaccine group, who added other terms possibly reflecting hypersensitivity. Case records of subjects with possible hypersensitivity were adjudicated by independent experts blinded to treatment assignment to identify likely hypersensitivity reactions. Non-inferiority of the incidence of hypersensitivity in the two vaccine groups was pre-defined as an absolute difference with an upper bound of 2-sided 95% confidence limits ≤ 0.015.

RESULTS

A total of 2640 subjects were enrolled, evenly split in age cohorts of 50-64 and ≥ 65 years. Fifty-two subjects reported at least one term possibly representing hypersensitivity, with a slight imbalance of 31 on Flublok and 21 on AFLURIA. The adjudicators determined that six and four subjects on Flublok and AFLURIA, respectively, likely met clinical criteria for hypersensitivity, yielding a difference in incidence between the two vaccine groups of 0.15% (upper bound of 2-sided 95% CI=0.9%). Reactogenicity and overall adverse event profiles were similar across both vaccines.

CONCLUSIONS

Flublok was non-inferior to AFLURIA in adults ≥ 50 years of age with respect to expert-adjudicated events of likely hypersensitivity during 30 days following vaccination (Sponsored by Protein Sciences Corporation; ClinicalTrials.gov number NCT01825200).

Abstract A50: Impact of indoor tanning and MC1R genotype on basal cell carcinoma risk in young people

Background: The incidence of basal cell carcinoma (BCC), which accounts for the majority of non-melanoma skin cancer (NMSC), is increasing, particularly in young people. While BCC is treatable, it can be associated with significant morbidity and health care costs. The ability to identify individuals at the highest risk of early-onset BCC could help focus public health efforts and mitigate the increasing incidence. However, to date, few risk prediction models exist for BCC. To identify individuals at risk of BCC at young ages, we assessed the utility of existing skin cancer risk prediction models (for melanoma or overall skin cancer) in the setting of early-onset BCC and built a novel risk prediction model, with a focus on indoor tanning and melanocortin 1 receptor (MC1R) genotype.

Methods: We evaluated unconditional multivariate logistic regression models among 759 (376 cases, 383 controls) non-Hispanic whites from the Yale Study of Skin Health, a case-control study of early-onset BCC conducted in Connecticut among individuals under age 40. BCC cases and randomly sampled controls with minor benign skin conditions diagnosed between July 2006 and September 2010 were identified through Yale University's Dermatopathology database. Participants completed a structured in-person interview, self-administered questionnaires, and provided a saliva sample. We gathered self-reported eye color, skin color (inner upper arm), hair color (natural color), freckling on the arms (based on images), number of moles on the back ≥ 5 mm (clear acetate size template), mole removal, skin reaction to sunlight for the first time in the summer for one hour without sunscreen, skin reaction after repeated and prolonged exposure to sunlight, family history of melanoma and NMSC, and indoor and outdoor ultraviolet (UV) radiation exposure.

We assessed the predictive performance of our novel risk prediction model and two models in the literature via summary measures of calibration, misclassification, and discrimination. We employed bootstrapping to better reflect the area under the receiver operating characteristic curve (AUC) expected when the model is tested on an independent, but similar set of patients. To investigate if indoor tanning and MC1R improved prediction performance over our early-onset BCC base model, we evaluated the regression coefficients for the markers in the expanded risk model and the corresponding likelihood ratio test statistic. All statistical tests were two-sided and analyses were performed in the statistical software R (Version 3.0.2).

Results: An existing model by Han et al. (2006) included seven MC1R variants and in our data the bootstrapped AUC for this model was 0.72 (95% CI, 0.66-0.78). Another existing model by Smith et al. (2012) with MC1R and indoor tanning resulted in a bootstrapped AUC of 0.69 (95% CI 0.63-0.75) in our population. Our base model, which included hair color, skin color, skin reaction with prolonged sun exposure, education, freckles on arm, family history of NMSC, and outdoor sun exposure in warm months, had greater predictive ability (bootstrapped AUC=0.75, 95% CI=0.72-0.79) than the existing models we evaluated. We also found that our model was significantly improved when we added ever indoor tanning, burns from indoor tanning, and the R151C MC1R variant (bootstrapped AUC=0.77, 95% CI, 0.74-0.81).

Conclusions: Our risk prediction model incorporating both MC1R and indoor tanning in the risk of early-onset BCC, validates and extends the work of other skin cancer risk prediction models and emphasizes the value of considering both genotype and indoor tanning in skin cancer risk prediction in young people. Therefore, in addition to the typical skin cancer characteristics clinicians rely on, assessing and counseling young people to reduce both indoor and outdoor UV exposure is needed to reduce BCC risk.

Citation Format: Annette M. Molinaro, Leah M. Ferrucci, Brenda Cartmel, Erikka Loftfield, David J. Leffell, Allen E. Bale, Susan T. Mayne. Impact of indoor tanning and MC1R genotype on basal cell carcinoma risk in young people. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr A50.

Melanoma in situ: Part II. Histopathology, treatment, and clinical management

Melanoma in situ (MIS) poses special challenges with regard to histopathology, treatment, and clinical management. The negligible mortality and normal life expectancy associated with patients with MIS should guide treatment for this tumor. Similarly, the approach to treatment should take into account the potential for MIS to transform into invasive melanoma, which has a significant impact on morbidity and mortality. Part II of this continuing medical education article reviews the histologic features, treatment, and management of MIS.

Melanoma in situ: Part I. Epidemiology, screening, and clinical features

The incidence of melanoma has steadily increased over the past 3 decades, with melanoma in situ comprising a disproportionately high percentage of the rising incidence. Our understanding of melanoma in situ has been shaped by epidemiologic and clinical studies. Central to a review of melanoma in situ is a focus on its epidemiology, pathology, biologic behavior, treatment, and clinical outcome, which may differ significantly from that of malignant melanoma. Part I of this continuing medical education article reviews the epidemiology, risk factors, and clinical features of melanoma in situ; part II covers the histopathology, treatment options, and clinical management.

Indoor tanning and the MC1R genotype: risk prediction for basal cell carcinoma risk in young people

Basal cell carcinoma (BCC) incidence is increasing, particularly in young people, and can be associated with significant morbidity and treatment costs. To identify young individuals at risk of BCC, we assessed existing melanoma or overall skin cancer risk prediction models and built a novel risk prediction model, with a focus on indoor tanning and the melanocortin 1 receptor gene, MC1R. We evaluated logistic regression models among 759 non-Hispanic whites from a case-control study of patients seen between 2006 and 2010 in New Haven, Connecticut. In our data, the adjusted area under the receiver operating characteristic curve (AUC) for a model by Han et al. (Int J Cancer. 2006;119(8):1976-1984) with 7 MC1R variants was 0.72 (95% confidence interval (CI): 0.66, 0.78), while that by Smith et al. (J Clin Oncol. 2012;30(15 suppl):8574) with MC1R and indoor tanning had an AUC of 0.69 (95% CI: 0.63, 0.75). Our base model had greater predictive ability than existing models and was significantly improved when we added ever-indoor tanning, burns from indoor tanning, and MC1R (AUC = 0.77, 95% CI: 0.74, 0.81). Our early-onset BCC risk prediction model incorporating MC1R and indoor tanning extends the work of other skin cancer risk prediction models, emphasizes the value of both genotype and indoor tanning in skin cancer risk prediction in young people, and should be validated with an independent cohort.

Fast Absorbing Gut Suture versus Cyanoacrylate Tissue Adhesive in the Epidermal Closure of Linear Repairs Following Mohs Micrographic Surgery

BACKGROUND

Cyanoacrylate topical adhesives and fast absorbing gut sutures are increasingly utilized by dermatologic surgeons as they provide satisfactory surgical outcomes while eliminating an additional patient visit for suture removal. To date, no head-to-head studies have compared the wound healing characteristics of these epidermal closure techniques in the repair of facial wounds after Mohs micrographic surgery.

OBJECTIVE

To compare the cosmetic outcome of epidermal closure by cyanoacrylate topical adhesive with fast absorbing gut suture in linear repairs of the face following Mohs micrographic surgery.

METHODS

Fourteen patients with wound length greater than 3cm who underwent Mohs micrographic surgery for nonmelanoma skin cancer of the face were enrolled in this randomized right-left comparative study. Following placement of dermal sutures, half of the wound was randomly selected for closure with cyanoacrylate and the contralateral side with fast absorbing gut suture. Using photographs from the three-month postoperative visit, six blinded individuals rated the overall cosmetic outcome.

RESULTS

The present study shows no significant difference in cosmetic outcomes between cyanoacrylate and fast absorbing gut suture for closure of linear facial wounds resulting from Mohs micrographic surgery. Cyanoacrylate tissue adhesive may not be as effective in achieving optimal cosmesis for wounds on the forehead or of longer repair lengths. The majority of patients did not have a preference for wound closure techniques, but when a preference was given, cyanoacrylate was significantly favored over sutures.

CONCLUSION

Cyanoacrylate tissue adhesive and fast absorbing gut suture both result in comparable aesthetic outcomes for epidermal closure of linear facial wounds following Mohs micrographic surgery. Consideration should be given to factors such as need for eversion, hemostasis, and wound tension when selecting an epidermal wound closure method. (ClinicalTrials.gov, Identifier: NCT01298167, http://clinicaltrials.gov/show/NCT01298167).

Mesenchymal stromal cells form vascular tubes when placed in fibrin sealant and accelerate wound healing in vivo

Non-healing, chronic wounds are a growing public health problem and may stem from insufficient angiogenesis in affected sites. Here, we have developed a fibrin formulation that allows adipose-derived mesenchymal stromal cells (ADSCs) to form tubular structures in vitro. The tubular structures express markers of endothelium, including CD31 and VE-Cadherin, as well as the pericyte marker NG2. The ability for the MSCs to form tubular structures within the fibrin gels was directly dependent on the stoichiometric ratios of thrombin and fibrinogen and the resulting gel concentration, as well as on the presence of bFGF. Fibrin gel formulations that varied in stiffness were tested. ADSCs that are embedded in a stiff fibrin formulation express VE-cadherin and CD31 as shown by PCR, FACS and immunostaining. Confocal imaging analysis demonstrated that tubular structures formed, containing visible lumens, in the stiff fibrin gels in vitro. There was also a difference in the amounts of bFGF secreted by ADSCs grown in the stiffer gels as compared to softer gels. Additionally, hAT-MSCs gave rise to perfusable vessels that were VE-cadherin positive after subcutaneous injection into mice, whereas the softer fibrin formulation containing ADSCs did not. The application of ADSCs delivered in the stiff fibrin gels allowed for the wounds to heal more quickly, as assessed by wound size, amount of granulation tissue and collagen content. Interestingly, following 5 days of healing, the ADSCs remained within the fibrin gel and did not integrate into the granulation tissue of healing wounds in vivo. These data show that ADSCs are able to form tubular structures within fibrin gels, and may also contribute to faster wound healing, as compared with no treatment or to wounds treated with fibrin gels devoid of ADSCs.

Alcohol intake and early-onset basal cell carcinoma in a case-control study

BACKGROUND

Previous epidemiological studies of overall alcohol intake and basal cell carcinoma (BCC) are inconsistent, with some evidence for differences by type of alcoholic beverage. While alcohol may enhance the carcinogenicity of ultraviolet (UV) radiation, this has not been evaluated in existing epidemiological studies.

OBJECTIVES

To evaluate alcohol intake in relation to early-onset BCC, and explore potential interactions with UV exposure.

METHODS

Basal cell carcinoma cases (n = 380) and controls with benign skin conditions (n = 390) under 40 years of age were identified through Yale Dermatopathology. Participants provided information on lifetime alcohol intake, including type of beverage, during an in-person interview. Self-reported data on indoor tanning and outdoor sunbathing were used to categorize UV exposure. We calculated odds ratios (OR) and 95% confidence intervals (CIs) using unconditional multivariate logistic regression in the full sample and in women only.

RESULTS

There was no statistically significant association between lifetime alcohol intake and early-onset BCC overall [above median intake vs. no regular alcohol intake (OR 1·10, 95% CI 0·69-1·73)] or in women only (OR 1·21, 95% CI 0·73-2·01). Similarly, intake of red wine, white wine, beer or spirits and mixed drinks was not associated with early-onset BCC. In exploratory analyses, we saw limited evidence for an interaction (P(interaction) = 0·003), with highest risk for high alcohol and high UV exposures, especially in women, but subgroup risk estimates had wide and overlapping CIs.

CONCLUSIONS

Overall, we did not observe any clear association between lifetime alcohol intake and early-onset BCC.

Point of care cutaneous imaging technology in melanoma screening and mole mapping

Melanoma is a malignancy of melanocytes or pigment-producing cells located predominantly in the skin. It is less common than other skin cancers but causes the greatest number of skin cancer-related deaths worldwide. The incidence of melanoma continues to increase and early detection is the most promising means of decreasing morbidity and mortality. Currently, physicians perform routine skin cancer screenings for melanoma without the benefit of imaging devices more advanced than handheld magnifiers or dermatoscopes. However, it is possible that the diagnosis of melanoma may be improved with technology that provides diagnostic discrimination beyond what is possible on routine inspection. This article reviews current and emerging technologies to aid in the diagnosis of melanoma. Ultimately, these advances may enhance the early diagnosis of melanoma.

Lifetime history of indoor tanning in young people: a retrospective assessment of initiation, persistence, and correlates

Background

Despite educational and public health campaigns to convey the risks of indoor tanning, many individuals around the world continue to engage in this behavior. Few descriptive studies of indoor tanning have collected information pertaining to the lifetime history of indoor tanning, thereby limiting our ability to understand indoor tanning patterns and potentially target interventions for individuals who not only initiate, but continue to persistently engage in indoor tanning.

Methods

In-person interviews elicited detailed retrospective information on lifetime history of indoor tanning among white individuals (n = 401) under age 40 seen by a dermatologist for a minor benign skin condition. These individuals were controls in a case-control study of early-onset basal cell carcinoma. Outcomes of interest included ever indoor tanning in both males and females, as well as persistent indoor tanning in females - defined as females over age 31 who tanned indoors at least once in the last three or all four of four specified age periods (ages 11-15, 16-20, 21-30 and 31 or older). Multivariate logistic regression was used to identify sociodemographic and lifestyle correlates of ever and persistent indoor tanning in females.

Results

Approximately three-quarters (73.3%) of females and 38.3% of males ever tanned indoors, with a median age of initiation of 17.0 and 21.5, respectively. Among indoor tanners, 39.3% of females and 21.7% of males reported being burned while indoor tanning. Female ever indoor tanners were younger, had darker color eyes, and sunbathed more frequently than females who never tanned indoors. Using unique lifetime exposure data, 24.7% of female indoor tanners 31 and older persistently tanned indoors starting as teenagers. Female persistent indoor tanners drank significantly more alcohol, were less educated, had skin that tanned with prolonged sun exposure, and sunbathed outdoors more frequently than non-persistent tanners.

Conclusions

Indoor tanning was strikingly common in this population, especially among females. Persistent indoor tanners had other high-risk behaviors (alcohol, sunbathing), suggesting that multi-faceted behavioral interventions aimed at health promotion/disease prevention may be needed in this population.

Correlation of Global MicroRNA Expression With Basal Cell Carcinoma Subtype

Basal cell carcinomas (BCCs) are the most common cancers in the United States. The histologic appearance distinguishes several subtypes, each of which can have a different biologic behavior. In this study, global miRNA expression was quantified by high-throughput sequencing in nodular BCCs, a subtype that is slow growing, and infiltrative BCCs, aggressive tumors that extend through the dermis and invade structures such as cutaneous nerves. Principal components analysis correctly classified seven of eight infiltrative tumors on the basis of miRNA expression. The remaining tumor, on pathology review, contained a mixture of nodular and infiltrative elements. Nodular tumors did not cluster tightly, likely reflecting broader histopathologic diversity in this class, but trended toward forming a group separate from infiltrative BCCs. Quantitative polymerase chain reaction assays were developed for six of the miRNAs that showed significant differences between the BCC subtypes, and five of these six were validated in a replication set of four infiltrative and three nodular tumors. The expression level of miR-183, a miRNA that inhibits invasion and metastasis in several types of malignancies, was consistently lower in infiltrative than nodular tumors and could be one element underlying the difference in invasiveness. These results represent the first miRNA profiling study in BCCs and demonstrate that miRNA gene expression may be involved in tumor pathogenesis and particularly in determining the aggressiveness of these malignancies.

Indoor tanning and risk of early-onset basal cell carcinoma

BACKGROUND

Despite an increase in incidence of basal cell carcinoma (BCC) among young people and the ubiquity of indoor tanning in this population, few epidemiologic studies have investigated this exposure-disease relationship.

OBJECTIVE

We sought to evaluate the association between indoor tanning and early-onset BCC.

METHODS

Patients with BCC (n = 376) and control subjects with minor benign skin conditions (n = 390) who were younger than 40 years of age were identified through Yale Dermatopathology. Participants provided information on ever indoor tanning, age of initiation, frequency, duration, burns while tanning, and type of tanning device during an in-person interview. We calculated odds ratios (OR) and 95% confidence intervals (CI) using multivariate logistic regression with never indoor tanners as the referent group.

RESULTS

Ever indoor tanning was associated with a 69% increased risk of early-onset BCC (95% CI 1.15-2.48). This association was stronger among females (OR 2.14, 95% CI 1.31-3.47), for multiple BCCs (OR 2.16, 95% CI 1.26-3.70), and for BCCs on the trunk and extremities (OR 2.81, 95% CI 1.57-5.02). Risk increased dose dependently with years using regular indoor tanning devices (P trend = .003), number of overall burns (P trend < .001), and burns to biopsy site (P trend < .001) from indoor tanning. Approximately one quarter (27%) of early-onset BCCs (or 43% among women) could be prevented if individuals never tanned indoors.

LIMITATIONS

Potential recall bias of indoor tanning by patients and generalizability of the control population suggest replication in other studies is warranted.

CONCLUSIONS

Indoor tanning was a strong risk factor for early-onset BCC, particularly among females. Indoor tanning should continue to be targeted by both policy-based and behavioral interventions, as the impact on BCC-associated morbidity may be substantial.

Abstract A83: Host phenotype characteristics and MC1R in relation to early-onset basal cell carcinoma

Background: Basal cell carcinoma (BCC), which accounts for 80% of non-melanoma skin cancers, is the most common cancer in the United States, with more than two million BCCs diagnosed annually. In recent decades, BCC incidence has been increasing, particularly among adults under age 40. While pigment-related characteristics have been associated with BCC in older populations, epidemiologic studies of these exposures in relation to BCC in younger individuals are lacking. In addition, investigations of potential interactions between pigment phenotype and pigment-related genotype for this malignancy are limited.

Methods: We examined self-reported phenotypes and melanocortin 1 receptor gene (MC1R) variants in relation to early-onset BCC in the Yale Study of Skin Health in Young People. BCC cases (n=377) and controls with benign skin conditions (n=390) under age 40 were identified through Yale Dermatopathology between 2006 and 2010. Approximately two-thirds of dermatologists in Connecticut send their biopsied tissue to Yale dermatopathologists for diagnosis. Controls were frequency matched to cases on age, gender, and body site of biopsy. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariate logistic regression. Cross-product terms in the multivariate models were used to evaluate potential effect modification of the association between MC1R and BCC by host phenotypes.

Results: Skin reaction to first summer sun of the season (severe sunburn vs. tan OR=12.27, 95% CI=4.08–36.94) and skin color (very fair vs. olive OR=11.06, 95% CI=5.90–20.74) were most strongly associated with early-onset BCC. Individuals with two or more MC1R non-synonymous variants were 3.59 times (95% CI=2.37–5.43) more likely to have BCC than those without variants. All exposures were much more strongly associated with multiple BCC (two or more BCCs; 37% of cases). For example, the OR for two or more MC1R non-synonymous variants compared to no variants was 2.93 (95% CI=1.82–4.71) for single BCC, while the OR for multiple BCC was 5.15 (95% CI=2.84–9.32). With mutual adjustment, MC1R, moles, skin reaction to sun exposure, and hair and skin color remained independently associated with BCC. Even after accounting for other pigment related factors, very fair skin was associated with a 4.48 fold increased risk of BCC compared to olive skin (95% CI=2.21–9.09) and individuals with two or more MC1R non-synonymous variants had a 91% independent increased risk of BCC compared to those with no non-synonymous variants (95% CI=1.20–3.03). While there were no statistically significant phenotype-genotype interactions, BCC risk conferred by MC1R tended to be stronger among those with darker pigment phenotypes, such as darker eye color and skin color, fewer moles and freckles, as well as tanning rather than burning with sun exposure.

Conclusions: Several pigment-related phenotypes and MC1R were strongly and independently associated with early-onset BCC. Even persons with darker phenotypes, traditionally considered to be at low risk of skin cancer, were at substantial risk of early-onset BCC if they had MC1R variants. Our observation of a pronounced effect of MC1R within low risk phenotype strata parallels existing research for melanoma and supports growing evidence that BCC may share etiologic similarities with melanoma. Despite an increasing prevalence of skin cancers in young people, this is the first epidemiologic investigation of BCC in this population. One-third of cases already had multiple BCCs, suggesting an urgent need for preventive interventions in at-risk persons.

Citation Information: Cancer Prev Res 2011;4(10 Suppl):A83.

Noninvasive assessment of dermal carotenoids as a biomarker of fruit and vegetable intake

BACKGROUND

Resonance Raman spectroscopy (RRS) has been suggested as a feasible method for noninvasive carotenoid measurement of human skin. However, before RRS measures of dermal carotenoids can be used as a biomarker, data on intra- and intersubject variability and validity are needed.

OBJECTIVE

The purpose of this study was to evaluate the reproducibility and validity of RRS measures of dermal total carotenoids and lycopene in humans.

DESIGN

In study 1, 74 men and women with diverse skin pigmentation were recruited. RRS measures of the palm, inner arm, and outer arm were obtained at baseline, 1 wk, 2 wk, 1 mo, 3 mo, and 6 mo (to maximize seasonal variation). The RRS device used visible light at 488 nm to estimate total carotenoids and at 514 nm to estimate lycopene. Reproducibility was assessed by intraclass correlation coefficients (ICCs). In study 2, we recruited 28 subjects and assessed dietary carotenoid intake, obtained blood for HPLC analyses, performed RRS measures of dermal carotenoid status, and performed dermal biopsies (3-mm punch biopsy) with dermal carotenoids assessed by HPLC.

RESULTS

ICCs for total carotenoids across time were 0.97 (palm), 0.95 (inner arm), and 0.93 (outer arm). Total dermal carotenoids assessed by RRS were significantly correlated with total dermal carotenoids assessed by HPLC of dermal biopsies (r = 0.66, P = 0.0001). Similarly, lycopene assessed by RRS was significantly correlated with lycopene assessed by HPLC of dermal biopsies (r = 0.74, P < 0.0001).

CONCLUSION

RRS is a feasible and valid method for noninvasively assessing dermal carotenoids as a biomarker for studies of nutrition and health.

Significant correlations of dermal total carotenoids and dermal lycopene with their respective plasma levels in healthy adults

Carotenoids in skin have been known to play a role in photoprotection against UV radiation. We performed dermal biopsies of healthy humans (N=27) and collected blood samples for pair-wise correlation analyses of total and individual carotenoid content by high performance liquid chromatography (HPLC). The hydrocarbon carotenoids (lycopene and beta-carotene) made up the majority of carotenoids in both skin and plasma, and skin was somewhat enriched in these carotenoids relative to plasma. Beta-cryptoxanthin, a monohydroxycarotenoid, was found in similar proportions in skin as in plasma. In contrast, the dihydroxycarotenoids, lutein and zeaxanthin, were relatively lacking in human skin in absolute and relative levels as compared to plasma. Total carotenoids were significantly correlated in skin and plasma (r=0.53, p<0.01). Our findings suggest that human skin is relatively enriched in lycopene and beta-carotene, compared to lutein and zeaxanthin, possibly reflecting a specific function of hydrocarbon carotenoids in human skin photoprotection.

Adenosquamous carcinoma: a report of nine cases with p63 and cytokeratin 5/6 staining

Adenosquamous carcinoma, a rare tumor of the skin with few reported cases in the literature, has not been studied with p63, cytokeratin 5/6 and cytokeratin 7. We stained nine such tumors with these markers. Histologically, the tumors showed superficial, atypical islands of keratinocytes in close association with islands displaying glandular differentiation. Clinically, lesions favored the head and trunk, and a subset of cases showed aggressive behavior. All tumors marked with p63 and cytokeratin 5/6, substantiating that diffuse positivity with these stains is supportive of a primary cutaneous origin. Six tumors stained focally in luminal areas with cytokeratin 7. Recognition of adenosquamous carcinoma is important for appropriate therapy, and stains for p63 and cytokeratin 5/6 may be helpful in ruling out metastatic adenocarcinoma.

Mohs micrographic surgery histopathology concordance

BACKGROUND

The low recurrence rate and tissue-sparing benefit associated with Mohs micrographic surgery (MMS) requires accurate interpretation of frozen sections by the MMS surgeon.

OBJECTIVE

We sought to assess concordance between dermatopathologists and MMS surgeons when reporting cutaneous malignancy in the MMS setting.

METHODS

This study is a retrospective analysis of 1156 slides submitted during 10 years as part of a pre-existing randomized, blinded, quality assurance protocol. Slides were read by one of 5 dermatopathologists and represent cases from 3 MMS surgeons and 5 MMS fellows. Agreement or disagreement was recorded.

RESULTS

Of the 1156 slides, 32 slides (2.8%) were disparate. Aside from differences regarding intraepidermal neoplasia, the concordance rate was 99.7%.

LIMITATIONS

This study represents data collected at a single institution in the United States alone.

CONCLUSION

There was statistically significant concordance between MMS surgeons and dermatopathologists in frozen section interpretation in the MMS setting. Discordance was primarily related to the interpretation of in situ malignancy.

Management of nonmelanoma skin cancer in 2007

As the incidence of nonmelanoma skin cancer (NMSC) increases, so does the number of modalities used to treat this condition. Surgery is the most frequent approach used to treat NMSC, and clinicians usually perform Mohs micrographic surgery, conventional excision, electrodesiccation and curettage or cryosurgery. The 'gold standard' for treatment continues to be Mohs micrographic surgery, but owing to the time and expense involved with this procedure, it is indicated only in patients with aggressive tumors or those where disfigurement or functional impairment is a risk. Although radiation therapy is effective, its use is limited because of the side effects induced; radiation therapy can be used in certain patients who are not surgical candidates. Newer noninvasive options for NMSC include topical chemotherapeutics, biological-immune-response modifiers, retinoids, and photodynamic therapy, which can be used particularly in patients with superficial tumors. Treatments should be tailored to tumor type, location, size, and histological pattern, and although surgical methods remain the most frequently used, newer noninvasive treatments can be used in select tumors and may reduce morbidity.

Correlation of Embryonic Fusion Planes with the Anatomical Distribution of Basal Cell Carcinoma

BACKGROUND

The clinical relevance of the anatomic distribution of basal cell carcinoma is not completely understood. Embryonic fusion planes--the regions of mesenchymal migration and fusion of the five primordial facial processes during the 5th to 10th weeks of human development--have been implicated in the pathogenesis of basal cell carcinoma.

OBJECTIVE

This study sought to examine the predilection of midfacial basal cell carcinoma for cutaneous anatomical sites correlated to embryonic fusion planes.

METHODS AND MATERIALS

Using archived digital images and a detailed anatomic diagram, cases of basal cell carcinoma were coded according to their specific location and were aggregated into two anatomic domains according to their correlation to embryonic fusion planes. The relative tumor densities were calculated.

RESULTS

Of the 1,457 cases examined, 859 were located in the midface. Thirty-five percent of the midfacial lesions were located on the domain correlated to embryonic fusion planes, which represented 11.3% of the total surface area of the midface. The relative tumor density of lesions in the fusion plane domain was 3.06 compared to 0.74 for the remaining lesions (p< .001).

CONCLUSIONS

Although there is no consensus about the importance of anatomic location in the pathogenesis of basal cell carcinoma, these data indicate that, after adjusting for surface area, basal cell carcinoma was more than four times more likely to occur on an embryonic fusion plane than on other regions of the midface. These data support the possibility of an embryologic role for the pathogenesis of basal cell carcinoma.

Mohs micrographic surgery: established uses and emerging trends

Mohs micrographic surgery is a surgical technique that seeks to ensure the clearance of cutaneous tumors while maximizing normal tissue conservation. This is accomplished through the sequential removal of thin layers of tissue in which the entire peripheral and deep margins are examined for residual tumor. This approach appears to be superior to conventional surgical excision in the treatment of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), the two most common cancers of the skin. Its efficacy in treating BCC and SCC has led clinicians to explore the role of Mohs micrographic surgery in the management of less common cutaneous neoplasms, such as melanoma, Merkel cell carcinoma, dermatofibrosarcoma protuberans, extramammary Paget's disease, and microcystic adnexal carcinoma.

PTCH codon 1315 polymorphism and risk for nonmelanoma skin cancer

BACKGROUND

The PTCH tumour suppressor gene is involved in the development of nearly all basal cell carcinomas (BCCs) of the skin and a fraction of squamous cell carcinomas (SCCs). A nonconservative Pro/Leu nucleotide polymorphism within PTCH exon 23 at codon 1315 was recently reported to be potentially important for the development of breast epithelial cell cancers. Objectives Accordingly, the status of PTCH codon 1315 was analysed for a possible association with the development of nonmelanoma skin cancers (NMSCs) in a pilot study. Because skin cancer risk is affected by specific population-dependent phenotypes such as skin and hair colour, codon 1315 was also analysed for normal allele frequency variation in human populations having differing extents of eumelanin vs. phaeomelanin.

METHODS

The single nucleotide polymorphism in codon 1315 of the human PTCH gene was analysed in genomic DNA from six different populations comprising 472 blood samples and from 170 patients in four different categories with NMSC. Polymerase chain reaction and pyrosequencing were used to determine the allele frequencies. Allelic loss was furthermore determined in tumours following microdissection.

RESULTS

The Pro/Pro genotype frequency ranged from 30% to 65% between populations, with a significant trend for a reduced frequency of the Pro/Pro genotype in populations having lighter pigmentation (P = 0.020). Pro/Pro frequency showed an increasing trend with increasing tumour case severity (P = 0.027). In 260 samples from 180 Swedish patients with NMSC and a control group of 96 healthy ethnically matched volunteers, no statistically significant pairwise differences between groups were detected in the PTCH codon 1315 allelic distribution, neither was a difference seen for multiple or early onset cases of BCC in the Swedish population. In Swedish patients with single tumours, allelic loss (loss of heterozygosity) was observed in 20 of 30 (67%) patients with BCC and four of 22 (18%) patients with SCC, with no preference in the allele lost. In contrast, the Pro/Pro genotype was frequent in seven U.S. patients having multiple independent BCCs. One of these patients was heterozygous, enabling allelic loss studies. Of 20 independent tumours, 11 had lost an allele; 10 of the 11 had lost Leu, suggesting nonrandom loss that favoured retention of Pro (P = 0.0059).

CONCLUSIONS

Our results indicate an association between the eumelanin-to-phaeomelanin shift and a shift from the Pro/Pro genotype to Leu-containing genotypes. Failure to lose Pro during the shift to phaeomelanin may be associated with an increased population risk for BCC and increased individual risk for multiple BCC. During development of a tumour, the effect of Pro may be magnified by loss of the Leu allele.

Bilobed transposition flap

This article reviews the indications and techniques for performing a bilobed flap for reconstruction of surgical wounds. Various examples of surgical defects where a bilobed flap can be used are shown. Possible complications and pitfalls are also reviewed.