Risk factors associated with tumor upstaging in melanomas treated with Mohs micrographic surgery with melanocytic immunohistochemistry

Background

Mohs micrographic surgery with melanocytic immunohistochemistry (MMS-I) is increasingly utilized for special site melanoma treatment. Yet, frequency and risk factors associated with upstaging of all-stage cutaneous melanomas treated with MMS-I remain undefined.

Objective

Determine upstaging frequency and factors associated with tumor upstaging for all-stage melanomas treated with MMS-I.

Methods

In this retrospective, single-center case series, all cases of invasive and in situ melanoma treated with MMS-I between 2008 and 2018 were reviewed. Patient and tumor characteristics were recorded and compared between tumors that were and were not upstaged from their initial T stage.

Results

Of the 962 melanoma MMS-I cases identified, 44 (4.6%) were upstaged, including 5.6% of in situ and 2.5% of invasive tumors. Risk factors for upstaging included lack of excisional intent at the time of initial biopsy (P < .01), nonlentigo maligna subtype (P = .03), female sex (P = .02), and initial in situ diagnosis (P = .03). Nonstatistically significant characteristics evaluated included patient age (P = .97), initial Breslow depth (P = .18), and biopsy type (P = .24).

Limitations

Retrospective study design.

Conclusions

All-stage cutaneous melanomas treated with MMS-I are associated with low upstaging rates. Tumor upstaging is associated with lack of excisional intent, female sex, and in situ tumors.

Cost-effectiveness analysis of margin-controlled surgery for vulvar Paget's disease

Objectives

To determine the cost of two surgical treatment approaches for vulvar Paget's disease and model the cost-effectiveness considering differences in recurrence and reoperation over time.

Methods

We assessed cost-effectiveness between excision guided by Mohs micrographic surgery (MMS-E) and traditional wide local excision (WLE). We examined billing data from patients with vulvar Paget's disease who underwent MMS-E (cases, n = 24, 2018-2022) or WLE (controls, n = 64, 1990-2020). We created typical treatment bundles incorporating physician-administered services and facility costs standardized to Medicare reimbursements in 2022 United States Dollars (USD). The primary measure of effectiveness was disease-free years of life. A secondary analysis estimated quality-adjusted life years (QALY). A Markov model simulated treatment pathways over a 10-year time horizon. Transition probabilities were based on institutional recurrence rates (3-year RR 6.7 % for MMS-E vs 34.1 % for WLE). We used a willingness-to-pay threshold of 100,000 USD per QALY.

Results

The cost of a single surgical episode was 34,664 USD for MMS-E and 14,969 USD for WLE. In the setting of lower recurrence rates with MMS-E, the incremental cost was 12,789 USD per disease-free year gained. A secondary analysis incorporating QALY showed an incremental cost of 72,820 USD per QALY.

Conclusions

MMS-E appears to be a cost-effective treatment for vulvar Paget's disease compared to historic standard of care. Our ability to estimate quality of life gained by avoiding disease recurrence was limited by scant data for this rare condition; thus, future studies incorporating health utility values are needed to facilitate a more comprehensive analysis.

Dermatologic surgeons' approaches to acral lentiginous melanoma: a survey of the American College of Mohs Surgery

Acral lentiginous melanoma (ALM) is a subtype of melanoma that primarily affects ethnic minorities and is associated with poor outcomes. Racial inequalities in melanoma survival, particularly between Blacks and Whites, have been well documented in the literature. There are limited data on the role of surgical approach to ALM and its contribution to the existing disparities in ALM survival. Thus, this study aimed to investigate the role of surgical approach to ALM among Mohs surgeons. The survey was distributed to members of the American College of Mohs Surgery (ACMS), with 43 physicians completing the survey. The results showed that there was no consensus among Mohs surgeons regarding the surgical approach for ALM, even for advanced stages. 74% respondents performed complete circumferential peripheral and deep margin assessment (CCPDMA) for ALM, including Mohs micrographic surgery (MMS) or en face staged excision. However, barriers such as limited training, low comfort operating on acral sites, and inadequate access to specialized biopsies were reported. Treatment recommendations varied widely regardless of the ALM stage, with no significant differences based on exposure to ALM during training, practice setting, or percent of skin of color patients served. These findings highlight the lack of guidelines and the need for more data on outcomes to support optimal management of ALM. The study emphasizes the importance of addressing healthcare disparities and improving survival outcomes, particularly for ethnic minorities affected by ALM. Consensus guidelines could help standardize treatment approaches and potentially reduce disparities in ALM management.

Mohs surgery for female genital Paget's disease: a prospective observational trial

BACKGROUND

Extramammary Paget's disease recurs often after traditional surgical excision. Margin-controlled surgery improves the recurrence rate for male genital disease but is less studied for female anatomy.

OBJECTIVE

This study aimed to compare surgical and oncologic outcomes of margin-controlled surgery vs traditional surgical excision for female genital Paget's disease.

STUDY DESIGN

We conducted a prospective observational trial of patients with vulvar or perianal Paget's disease treated with surgical excision guided by Mohs micrographic surgery between 2018 and 2022. The multidisciplinary protocol consisted of office-based scouting biopsies and modified Mohs surgery followed by surgical excision with wound closure under general anesthesia. Modified Mohs surgery cleared peripheral disease margins using a moat technique with cytokeratin 7 staining. Medial disease margins (the clitoris, urethra, vagina, and anus) were assessed using a hybrid of Mohs surgery and intraoperative frozen sections. Surgical and oncologic outcomes were compared with the outcomes of a retrospective cohort of patients who underwent traditional surgical excision. The primary outcome was 3-year recurrence-free survival.

RESULTS

Three-year recurrence-free survival was 93.3% for Mohs-guided excision (n=24; 95% confidence interval, 81.5%-100.0%) compared to 65.9% for traditional excision (n=63; 95% confidence interval, 54.2%-80.0%) (P=.04). The maximum diameter of the excisional specimen was similar between groups (median, 11.3 vs 9.5 cm; P=.17), but complex reconstructive procedures were more common with the Mohs-guided approach (66.7% vs 30.2%; P<.01). Peripheral margin clearance was universally achieved with modified Mohs surgery, but positive medial margins were noted in 9 patients. Reasons included intentional organ sparing and poor performance of intraoperative hematoxylin and eosin frozen sections without cytokeratin 7. Grade 3 or higher postoperative complications were rare (0.0% for Mohs-guided excision vs 2.4% for traditional excision; P=.99).

CONCLUSION

Margin control with modified Mohs surgery significantly improved short-term recurrence-free survival after surgical excision for female genital Paget's disease. Use on medial anatomic structures (the clitoris, urethra, vagina, and anus) is challenging, and further optimization is needed for margin control in these areas. Mohs-guided surgical excision requires specialized, collaborative care and may be best accomplished at designated referral centers.

Association between Hashimoto's thyroiditis and melanoma: a retrospective matched cohort study

An inflammatory microenvironment has been shown to increase risk for malignant melanoma, suggesting that melanoma may be related to a pro-inflammatory state. Though Hashimoto's thyroiditis is one of the most common autoimmune diseases, there are no investigations of its relationship with melanoma. We aim to determine if Hashimoto's increases risk of developing melanoma. A retrospective, validated cohort of patients with a diagnosis of Hashimoto's between 2005 and 2020 were identified using the Olmsted County database. Patients were age and sex matched to controls without a Hashimoto's diagnosis. The primary outcomes were development of melanoma and time to first melanoma diagnosis. 4805 patients were included in the study, with 1726 (36%) having a diagnosis of Hashimoto's. Hashimoto's patients had no significant difference in risk of melanoma (relative risk 0.96, 95% CI 0.78-1.17) or nonmelanoma skin cancer (relative risk 0.95, 95% CI 0.86-1.06) compared with matched controls. This suggests that the local proinflammatory environment present in Hashimoto's does not contribute significantly to melanoma risk. Larger studies may be needed to further characterize the relationship between these diseases.

Artificial intelligence and frozen section histopathology: A systematic review

Frozen sections are a useful pathologic tool, but variable image quality may impede the use of artificial intelligence and machine learning in their interpretation. We aimed to identify the current research on machine learning models trained or tested on frozen section images. We searched PubMed and Web of Science for articles presenting new machine learning models published in any year. Eighteen papers met all inclusion criteria. All papers presented at least one novel model trained or tested on frozen section images. Overall, convolutional neural networks tended to have the best performance. When physicians were able to view the output of the model, they tended to perform better than either the model or physicians alone at the tested task. Models trained on frozen sections performed well when tested on other slide preparations, but models trained on only formalin-fixed tissue performed significantly worse across other modalities. This suggests not only that machine learning can be applied to frozen section image processing, but also use of frozen section images may increase model generalizability. Additionally, expert physicians working in concert with artificial intelligence may be the future of frozen section histopathology.

Skin Cancer Associated With Chronic Leg Ulcers in the Population of Olmsted County, Minnesota

Malignant skin tumors in the setting of chronic leg ulcers (CLUs) are often underdiagnosed which may contribute to treatment delay and poor outcomes. The aims of our study were to determine the incidence and clinical characteristics of skin cancers in leg ulcers in the Olmsted County population from 1995 to 2020. We used the Rochester Epidemiology Project (a collaboration between health care providers) infrastructure to describe this epidemiology, allowing "population-based" research. Electronic medical records of adult patients with International Classification of Diseases diagnosis codes for leg ulcers and skin cancers on the legs were queried. Thirty-seven individuals with skin cancers in nonhealing ulcers were identified. The cumulative incidence of skin cancer over the 25-year period was 37:7864 (0.47%). The overall incidence rate was 470 per 100,000 patients. Eleven (29.7%) men and 26 (70.3%) women were identified with mean age of 77 years. History of venous insufficiency was present in 30 (81.1%) patients and diabetes in 13 (35.1%) patients. Clinical characteristics of CLU with skin cancer included abnormal granulation tissue in 36 (94.7%) and irregular borders in 35 (94.6%) cases. Skin cancers among CLUs included 17 (41.5%) basal cell carcinomas, 17 (41.5%) squamous cell carcinomas, 2 (4.9%) melanomas, 2 (4.9%) porocarcinomas, 1 (2.4%) basosquamous cell carcinoma, and 1 (2.4%) eccrine adenocarcinoma. The apparent association between chronic wounds and subsequent biopsy-proven skin cancer of the same site was primarily observed in elderly patients; malignant transformation of wounds favored basal cell carcinoma and squamous cell carcinoma. This retrospective cohort study further characterizes the association between skin cancers and chronic leg wounds.

Artificial intelligence for automatic detection of basal cell carcinoma from frozen tissue tangential biopsies

Evaluation of basal cell carcinoma (BCC) involves tangential biopsies of a suspicious lesion that is sent for frozen sections and evaluated by a Mohs micrographic surgeon. Advances in artificial intelligence (AI) have made possible the development of sophisticated clinical decision support systems to provide real-time feedback to clinicians which could have a role in optimizing the diagnostic workup of BCC. There were 287 annotated whole-slide images of frozen sections from tangential biopsies, of which 121 contained BCC, that were used to train and test an AI pipeline to recognize BCC. Regions of interest were annotated by a senior dermatology resident, experienced dermatopathologist, and experienced Mohs surgeon, with concordance of annotations noted on final review. Final performance metrics included a sensitivity and specificity of 0.73 and 0.88, respectively. Our results on a relatively small dataset suggest the feasibility of developing an AI system to aid in the workup and management of BCC.

Continuous positive airway pressure device-associated nonhealing ulcer on the nasal dorsum: chondrodermatitis nodularis nasi

With increasing use of positive airway pressure devices for disordered breathing during sleep, appreciation for potential associated side effects is essential. Chondrodermatitis nodularis nasi is a rare variant of chondrodermatitis nodularis chronic helicis that presents as a nonhealing erosion or ulcer on the nose and can occur in association with chronic use of positive airway pressure devices. We present a case of symptomatic chondrodermatitis nodularis nasi associated with continuous positive airway pressure use, fully responsive to treatment, and propose that this condition is highly underrecognized. Dermatology referral can assist in diagnosis, management, and exclusion of cutaneous malignancy.

CITATION

Reinhart JP, Isaq NA, Peters MS, Vidal NY. Continuous positive airway pressure device-associated nonhealing ulcer on the nasal dorsum: chondrodermatitis nodularis nasi. J Clin Sleep Med. 2023;19(6):1157-1159.

Artificial intelligence in medicine - dermatology compared to other medical specialties in FDA-cleared software as medical device

Artificial intelligence (AI) and machine learning (ML) have occupied the center stage in healthcare as research groups and institutions investigate their capabilities and risks. Dermatology is often cited as one of the medical specialties most ripe for disruption with AI technology due to the heavy incorporation of visual information into clinical decisions and treatments. Although the literature on AI in dermatology is rapidly growing, there has been a noticeable absence of mature AI solutions utilized by dermatology departments or patients. This commentary provides insight into the regulatory challenges facing AI solutions for the specialty of dermatology and the unique considerations that should be factored into AI development and deployment.

Delayed Diagnosis of Retronychia: How Ultrasound Can Nail the Diagnosis in Clinically Subtle Patients

A 47-year-old man presented to the dermatologic surgery clinic with a 7-month history of a painful, swollen left great toe after minor trauma. Intermittently, the toe became exquisitely tender such that even weight of a blanket exacerbated pain. The patient initially presented to primary care with purulence and pain, but the culture of expressed purulence revealed normal flora. Condition of the patient did not improve despite evaluation by several medical specialists and multiple rounds of topical antifungal and steroid creams, vinegar soaks, and oral antibiotics.

Socioeconomic predictors of cost and length of stay for erythroderma: a cross-sectional analysis of the national inpatient sample

Erythroderma is an uncommon but serious dermatologic disorder that often requires hospitalization for diagnosis and treatment. However, little is known about predictors influencing cost and patient outcomes. The present study sought to characterize the sociodemographic factors that predict patient outcomes and hospital cost. Data were obtained from the 2016-2018 National Inpatient Sample (NIS) provided by the Healthcare Cost and Utilization Project from the Agency for Healthcare Research and Quality for patients of any age with a primary or secondary diagnosis of exfoliative dermatitis. Regression analyses were performed to find predictors for hospital costs and patient outcomes, represented by the length of stay (LOS). Univariate analysis of LOS revealed urban teaching hospitals were associated with prolonged LOS (p = 0.023). Univariate analysis of hospital cost yielded the following factors associated with increased hospital cost: Black and Asian patients (p = .045), urban teaching hospitals (p = .035), and northeast or south geographic location (p = .004). Multivariable regression analysis revealed prolonged LOS was associated with female sex (p = .043) and large bed capacity (p = .044) while shorter LOS was associated with increased age (p = .025); lower hospital costs were associated with private-owned hospitals -  (p = .025). In patients diagnosed with erythroderma, there appear to be racial, economic, and geographic disparities for patients that lead to greater hospital costs and longer LOS.

Concomitant hypertrophic lichen planus and squamous cell carcinoma: Clinical features and treatment outcomes

BACKGROUND

Patients with hypertrophic lichen planus (HLP) and squamous cell carcinoma (SCC) diagnoses present clinicians with diagnostic and disease management challenges.

OBJECTIVE

To better define the clinical and treatment outcomes of patients with concomitant diagnoses of HLP and SCC.

METHODS AND MATERIALS

A retrospective review was performed from January 1, 2008, to July 31, 2015, at Mayo Clinic. Patients with a histologic diagnosis of HLP and SCC were included. Patient demographics, associated comorbidities, histopathologic characteristics, treatment, and outcomes were evaluated.

RESULTS

Thirty-three patients were identified; 79% were female, and mostly the lower extremities were involved. Most of the SCCs were well-differentiated and in situ with the majority treated with destruction or excision. There were no cases of local recurrence, metastasis, or disease-specific death during the follow-up period (mean 55.8 months).

CONCLUSION

Patients with diagnoses of both HLP and SCC appear to be a distinct population that is predominantly female with lesion predilection for the lower extremities. However, regardless of treatment modality or tumor size, there were no adverse outcomes. An initial trial of more conservative treatment measures with close follow-up may be reasonable with biopsy of lesions unresponsive to conventional treatment.

Incisional Biopsy Technique Is Associated With Decreased Overall Survival for Cutaneous Melanoma

BACKGROUND

Previous studies examining melanoma biopsy technique have not demonstrated an effect on overall survival.

OBJECTIVE

To examine overall survival of patients with cutaneous melanoma diagnosed by shave, punch, incisional, or excisional techniques from the National Cancer Database (NCDB).

MATERIALS AND METHODS

Melanoma data from the 2004 to 2016 NCDB data set were analyzed. A Cox proportional hazards model was constructed to assess the risk of 5-year all-cause mortality.

RESULTS

In total, 42,272 cases of melanoma were reviewed, with 27,899 (66%) diagnosed by shave biopsy, 8,823 (20.9%) by punch biopsy, and 5,550 (13.1%) by incisional biopsy. Both the univariate and multivariate analyses demonstrated that tumors diagnosed by incisional biopsy had significantly (p = .001) lower overall 5-year survival compared with shave techniques (hazard ratio [HR] = 1.140, 95% confidence interval [CI] 1.055 to 1.231). We found no difference (p = .109) between shave and punch biopsy techniques (HR 1.062, 95% CI 0.987-1.142) or between punch and incisional techniques (HR 1.074, 95% CI 0.979-1.177, p = .131).

CONCLUSION

Incisional biopsies were associated with decreased overall 5-year survival in the NCDB. No difference was observed between shave and punch biopsy techniques. These findings support current melanoma management guidelines.

The treatment of anogenital extramammary Paget's disease as part of a multidisciplinary approach: The use of Mohs surgery moat method with CK7

Although most cases of extramammary Paget's disease (EMPD) are localized to the intraepidermal, the extensive subclinical extension can lead to high rates of marginal recurrence with wide local excisions and topically destructive treatments. Recurrence rates of EMPD treated with Mohs micrographic surgery (MMS) without immunohistochemical staining are better but variable. Here, we describe our multidisciplinary approach for treating large EMPD tumors of the anogenital region involving critical anatomy using MMS for peripheral margin clearance (moat method) and intraoperative CK7 immunostaining. Our clinical pearls for the management of anogenital EMPD are based on 53 multidisciplinary cases treated at the author's institution between 2014 and 2020.

Social media use in residency recruitment during the COVID-19 pandemic

To investigate the extent to which dermatology programs use social media to connect with applicants, we conducted a search of all 140 residency programs on Instagram, Facebook, Twitter, and YouTube. Our search revealed 74 (53%) Instagram, 21 (15%) Facebook, 20 (14%) Twitter, and four (3%) YouTube accounts for dermatology programs, with the number of Instagram accounts increasing five-fold from the end of 2019 to present. Our results demonstrate that conditions created during the coronavirus disease 2019 (COVID-19) pandemic accelerated dermatology residency programs' acceptance of social media, particularly Instagram, as a means to communicate and share information with applicants.

Perspectives of Dermatology Faculty Toward Millennial Trainees and Colleagues: A National Survey

Objective

To assess the attitudes and beliefs of faculty dermatologists regarding perceived characteristics of millennial trainees and colleagues.

Participants and Methods

We conducted a cross-sectional survey of dermatology physician-educators listed in the Fellowship and Residency Electronic Interactive Database from August 1, 2019, to October 31, 2019. This survey consisted of 26 items (5-point Likert scales) representing positive, negative, and neutral millennial stereotypes relevant to graduate medical education. Participants' responses were analyzed using the chi-squared goodness of fit test with dichotomized data.

Results

Seventy-six dermatology physician-educators participated in the national survey. A statistically significant response pattern was seen in 18 of 26 (69%) tested stereotypes. Positive judgments included denial of hesitations about working with millennials (P = .038) and agreement with the notions that millennials are technologically savvy (P < .001), socially just (P < .001), equally capable dermatologists as other generations (P < .001), enjoyable to work with (P < .001), easy to connect with interpersonally (P < .001), and promising future leaders of medicine (P = .039). Negative judgments included perceptions of the word millennial as a pejorative (P < .001) and of millennials being relatively entitled (P < .001), overly sensitive to feedback (P < .001), less polite (P < .001), and less hard-working (P < .001) compared with prior generations.

Conclusion

This study represents the first national survey of the attitudes and perspectives of dermatology physician-educators regarding perceived characteristics of millennial trainees and colleagues. Our results suggest that dermatology faculty endorse various positive, negative, and neutral stereotypes regarding Generation Y. Early recognition of implicit biases can inform curricular design and prepare educators to address generational gaps in medical education.

The importance of palpation in the skin cancer screening examination

BACKGROUND

With the recent unprecedented shift towards contactless healthcare solutions, providers should recall the value that proper palpation adds to dermatologic practice.

AIMS

We present a case that demonstrates the limitations of touchless care and how proper palpation during skin cancer examinations may impact cosmetic outcomes.

PATIENTS

One 86 year-old male patient with Sezary syndrome and monoclonal B-cell lymphocytosis whose squamous cell carcinoma invasion was missed by visual inspection alone.

RESULTS

Our patient delayed treatment of his biopsy-proven squamous cell carcinoma for 15 months. On follow-up, visual exam only showed a well healed biopsy scar, and treatment was delayed another two months. Finally, thorough physical exam found perineural invasion. This helped guide the Mohs approach, but due to the delays resulted in a larger final defect and poorer cosmetic outcomes.

CONCLUSION

Proper, deep palpation of skin lesions, especially prior biopsy sites, is imperative to the treatment of skin cancer in cosmetically sensitive areas. Biopsy scars on the face often heal well, and visual only inspection may miss crucial details. This case also reminds dermatologists of the importance of patient education in the prompt treatment of skin cancer for the best cosmetic outcomes.