Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study

Importance

It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs.

Objective

To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals.

Design, Setting, and Participants

This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019.

Exposures

Mohs surgery for nonmelanoma skin cancer.

Main Outcomes and Measures

Reason for treatment selection.

Results

Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]).

Conclusions and Relevance

This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Development of a Core Outcome Set for Basal Cell Carcinoma (BCC), Including Low-Risk and Advanced Tumors

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.

Vitamin D metabolism and disorders in dogs and cats

Vitamin D plays an important role in regulating calcium metabolism and in the development and maintenance of skeletal health of companion animals. There is also a growing interest in understanding the role vitamin D plays in non-skeletal health in both human and veterinary patients. This review provides an update of our current understanding of vitamin D biology in dogs and cats and gives an overview of how vitamin D metabolism can be assessed in companion animals. Congenital and acquired vitamin D disorders are then summarised before the review concludes with a summary of recent studies which have explored the role of vitamin D in the development and outcomes of non-skeletal diseases of dogs and cats.

Histopathologic upgrading of cutaneous squamous cell carcinomas during Mohs micrographic surgery: A retrospective cohort study

BACKGROUND

Initial biopsies of cutaneous squamous cell carcinomas (cSCCs) may not reveal aggressive histologic features, which would otherwise inform appropriate surgical management and patient education.

OBJECTIVE

To assess the incidence of, and risk factors for, histopathologic upgrading of cSCC during Mohs micrographic surgery (MMS).

METHODS

This was a retrospective cohort study of invasive cSCCs treated with MMS between 2017 and 2019 at 1 academic institution. An "upgrade" was defined as a lesser degree of differentiation (poor or moderate) and/or bony or perineural invasion identified during MMS that was not reported in histopathologic evaluation of the initial biopsy.

RESULTS

Of the 1558 tumors studied, 115 (7.4%) were upgraded during MMS. In multivariate logistic regression analysis, male sex, prior field treatment, location on the ear/lip, rapid growth of cSCC, and tumor diameter ≥2 cm were significant predictors of tumor upgrading. Upgraded tumors were more likely to require ≥3 MMS stages to clear, complicated closure (flap or graft), or outside (referral) repairs.

LIMITATIONS

Single-center study, retrospective, and inter-rater variability.

CONCLUSIONS

A significant proportion of cSCCs is histopathologically upgraded with more aggressive features during MMS. Routinely documented patient and tumor characteristics can predict tumor upgrading and assist clinicians in directing the management of potentially high-risk cSCC patients.

Complications After Mohs Micrographic Surgery in Patients Aged 85 and Older

BACKGROUND

As the US population ages, safe surgical procedures are necessary for treatment of cutaneous neoplasms in very elderly patients.

OBJECTIVE

To determine the incidence of complications associated with Mohs micrographic surgery (MMS) in patients aged 85 and older, and the risk factors that predispose to complications.

METHODS

A 9-year retrospective chart review of patients aged 85 and older who underwent MMS at our institution between 07/2007 and 11/2016 was performed. Six types of complications associated with scalpel-based cutaneous surgery were recorded, as well as patient, tumor, and repair characteristics.

RESULTS

This study included 949 patients totaling in 1683 MMS cases. There were 30 complications: infection (N = 11), wound dehiscence (N = 6), hematoma (N = 6), hemorrhage (N = 5), flap necrosis (N = 1), and graft necrosis (N = 1), resulting in an overall complication rate of 1.78%. Independent risk factors associated with a statistically higher incidence of complications were anticoagulant use (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.26-6.13; p = .012), extremity location (OR, 2.80; 95% CI, 1.19-6.54; p = .018), greater than 2 MMS stages (OR, 2.43; 95% CI, 1.08-5.46; p = .032), and flap repair (OR, 2.27; 95% CI, 1.05-4.90; p = .036).

CONCLUSION

Mohs micrographic surgery is a safe procedure for treatment of cutaneous neoplasms in the very elderly.

Surveyed dermatologists are less likely to curette invasive squamous cell carcinoma in solid organ transplant recipients

Background

The risk of squamous cell carcinoma (SCC) is increased in solid organ transplant recipients (OTRs), and preferential treatment modalities vary among clinicians.

Objectives

The purpose of this study was to survey dermatologists regarding practice patterns for electrodesiccation and curettage (EDC) of SCC in OTRs and nontransplant patients.

Methods

An 18-question survey was sent to dermatologist members of the International Transplant Skin Cancer Collaborative, Association of Professors of Dermatology, and American College of Mohs Surgery. Differences in EDC practice patterns for treatment of SCC in OTRs and nontransplant patients were evaluated.

Results

Dermatologists in this study (N = 227) were more likely to treat SCC with EDC in nontransplant patients (67.4%) than in OTRs (48.0%; P = .0003).

Dermatologists who perform EDC in both groups (n = 108) were unlikely to use EDC on the H-zone of the face; they were more likely to EDC tumors on non-H-zone areas of the face and neck in nontransplant patients compared to OTRs (P = .0007). Dermatologists were more likely to use EDC over surgery in nontransplant patients compared to OTRs with the following demographics: dementia or psychiatric disease (P = .04), multiple medical comorbidities (P = .03), or anticoagulation medications (P = .02).

Conclusions

In OTRs with SCC, 48% of clinicians would consider EDC. The main factors that affect the decision to perform EDC include tumor location and patient comorbidities.

Adjuncts to Improve Nasal Reconstruction Results

The final cosmetic appearance of nasal reconstruction scars is of paramount importance to both the patient and surgeon. Ideal postreconstruction nasal scars are flat and indistinguishable from surrounding skin. Unfortunately, even with meticulous surgical execution, nasal scars can occasionally be suboptimal. Abnormal fibroblast response can lead to hypertrophic nasal scars, and excessive angiogenesis may lead to telangiectasias or an erythematous scar. Imperfect surgical closure or poor postoperative management can lead to surgical outcomes with step-offs, depressions, suture marks, or dyspigmentation. Aesthetically unacceptable nasal scars can cause pruritus, tenderness, pain, sleep disturbance, and anxiety and depression in postsurgical patients. Fortunately, there are several minimally invasive or noninvasive techniques that allow for enhancement and improvement of cosmetic results with minimal risk and associated downtime. This article provides an overview of adjuncts to improve nasal reconstruction with a focus on techniques to be used in the postoperative period. Armed with an understanding of relevant available therapies, skillful surgeons may drastically improve the final cosmesis and outcome of nasal reconstruction scars.

Combination therapy for perianal squamous cell carcinoma in situ with imiquimod and photodynamic therapy

Perianal squamous cell carcinoma in situ (SCCIS) is a relatively rare intraepidermal neoplasm that has the potential to progress to invasive squamous cell carcinoma. First-line treatment is surgical excision, though nonsurgical treatment modalities such as 5-aminolevulinic acid-based photodynamic therapy (ALA-PDT) and imiquimod also have been investigated for this neoplasm. Unfortunately, recurrences are known to occur after both surgical and nonsurgical monotherapies. We report a case of perianal SCCIS that was successfully treated with a novel combination of ALA-PDT and imiquimod.

Chronic allergic contact dermatitis promotes skin cancer

Allergic contact dermatitis (ACD) is well recognized as an adverse event associated with implantable medical devices that contain allergenic materials like nickel; however, other cutaneous consequences of chronic exposure to allergens in implanted devices are not well understood. Here, we present a clinical case of Marjolin's ulcer, an invasive squamous cell carcinoma (SCC) that developed in response to chronic ACD caused by an orthopedic implant. We used a standard murine model of contact hypersensitivity to determine whether chronic ACD promotes skin carcinogenesis. Chronic application of 1-fluoro-2,4-dinitrobenzene (DNFB) to carcinogen-treated skin led to the development of papillomas and aggressive SCC. DNFB-driven chronic ACD was marked by type 2 inflammation, which mediated skin carcinogenesis, as mice unable to mount an inflammatory response were less likely to develop skin tumors. Importantly, we found similar tumor-promoting inflammation surrounding the SCC in our patient. Our findings demonstrate that chronic ACD caused by constant exposure to an allergen can promote tumorigenesis at skin sites with preexisting cancer-initiated cells. Moreover, our results suggest that patients with implantable devices placed in close proximity to the skin should be monitored for ACD and highlight the importance of patch testing prior to the placement of such devices.

Pseudoaneurysm formation and repair after Mohs micrographic surgery: a report of 3 cases

IMPORTANCE

Pseudoaneurysm is a well-known complication of trauma and iatrogenic injury to the vasculature. We report 3 cases of postsurgical pseudoaneurysm after Mohs surgery.

OBSERVATIONS

Three patients who underwent Mohs surgery for nonmelanoma skin cancers presented between 2 and 4 weeks after surgery with several days' history of painful, enlarging, pulsatile subcutaneous masses. The lesions were diagnosed as postsurgical pseudoaneurysm. During surgical repair of each lesion, we identified vascular outpouchings that were connected to the injured arteries by sinus tracts. In all 3 patients, we ligated the affected artery and the neck of each lesion and reapproximated the skin. All wounds healed well without further recurrence.

CONCLUSIONS AND RELEVANCE

Most reported cases of pseudoaneurysm formation in the head and neck involve the superficial temporal artery and its branches, and they typically occur secondary to blunt force trauma. Our cases are unique in that they included 1 case of a superficial temporal lesion but also 2 cases outside this system: 1 of the lateral nasal artery and 1 of the angular artery. We propose operative repair as the treatment of choice for facial pseudoaneurysms that complicate dermatologic surgery.

Histopathologic characteristics of therapy-associated cutaneous neoplasms with vemurafenib, a selective BRAF kinase inhibitor, used in the treatment of melanoma

BACKGROUND

Activating mutations in BRAF have been observed in up to 60% of melanomas, indicating a pivotal role for kinase deregulation in tumor progression. Vemurafenib is a specific inhibitor of BRAF for treatment of melanomas with activating BRAF V600E mutations and has been a major advancement in melanoma treatment. Treatment with vemurafenib, and to a lesser extent, sorafenib, a relatively non-specific inhibitor of BRAF, has been associated with cutaneous squamous cell carcinoma (SCC).

METHODS

Clinical and microscopic characteristics of cutaneous neoplasms were evaluated following vemurafenib administration.

RESULTS

Twenty-four of 47 (51%) patients receiving vemurafenib at our institution developed 146 total cutaneous neoplasms, with 75% developing multiple lesions. The median number of lesions in affected patients was three. Body distribution included head/neck (29%), chest/back (21%), upper (23%) and lower extremities (27%). Lesions were biopsied and pathologically showed multiple types of epidermal tumors including, but not limited to, verrucous keratoses with/without partial thickness dysplasia, actinic keratoses and well-differentiated and invasive SCCs with/without keratoacanthomatous features.

CONCLUSIONS

We describe the histopathologic findings of skin lesions potentially associated with vemurafenib. Additional investigation is necessary to further elucidate cutaneous neoplasms associated with vemurafenib; however, frequent dermatologic evaluation is warranted in all patients receiving BRAF inhibitors.

Bleeding complications in dermatologic surgery

Although the overall incidence is low, bleeding complications in dermatologic surgery can occur and be the source of significant patient morbidity. In this article, we summarize the key aspects of preoperative assessment of patients at risk for bleeding. A review of current issues and literature regarding safe continuation of anticoagulant and antiplatelet medications in dermatologic surgery patients is also presented. In addition, principles for management of bleeding events, should they occur, are also highlighted.

Bleeding Complications in Dermatologic Surgery

Although the overall incidence is low, bleeding complications in dermatologic surgery can occur and be the source of significant patient morbidity. In this article, we summarize the key aspects of preoperative assessment of patients at risk for bleeding. A review of current issues and literature regarding safe continuation of anticoagulant and antiplatelet medications in dermatologic surgery patients is also presented. In addition, principles for management of bleeding events, should they occur, are also highlighted.

Infectious Complications and Antibiotic Use in Dermatologic Surgery

Infection rates in dermatologic surgery are low, ranging on average from 1 to 3%. Studies have shown that many practitioners likely overuse antibiotics, both for prevention of wound infection and in endocarditis prophylaxis. This article discusses patient and environmental risk factors in would infection. Data on wound infection prophylaxis are reviewed, and specific guidelines set forth with regards to appropriate antibiotic usage, drug selection, dosage, and timing. In addition, recommendations surrounding endocarditis and prosthetic joint infection prophylaxis are presented as they apply to dermatologic surgery.

Sarcoidosis Associated With Pegylated Interferon Alfa and Ribavirin Treatment for Chronic Hepatitis C

BACKGROUND

At least 2.7 million Americans are infected with chronic hepatitis C. An increasing number are treated with interferon alfa plus ribavirin regimens. Not surprisingly, this immune stimulation is associated with the development of autoimmune and cutaneous diseases. Several cases of sarcoidosis have been reported with hepatitis C treatment, most recently in association with pegylated interferon alfa plus ribavirin. Systemic manifestations of sarcoidosis are usually treated with oral steroids, which unfortunately often increase the hepatitis C viral load. Thus, it is important to ascertain whether systemic corticosteroids are required to treat interferon alfa-associated sarcoidosis.

OBSERVATIONS

We report the third case of cutaneous sarcoidosis in association with pegylated interferon alfa plus ribavirin treatment. Our patient had both cutaneous and pulmonary involvement, which has been spontaneously resolving since his treatment regimen was completed. In addition, we review the 12 previously reported cases of cutaneous sarcoidosis that occurred in patients undergoing hepatitis C treatment with interferon alfa.

CONCLUSIONS

As the number of patients being treated with interferon alfa and ribavirin for hepatitis C increases, it is essential that dermatologists recognize the association of this treatment with sarcoidosis, because skin lesions may provide the first clue to diagnosis. Development of sarcoidosis may relate to hepatitis C as a possible antigenic trigger in the presence of an enhanced helper T cells type 1 response from treatment. Sarcoidosis with skin lesions in patients undergoing hepatitis C treatment often follows a benign course, and interferon alfa therapy may sometimes be continued with resolution of sarcoidosis occurring spontaneously or within a few months of completing treatment. Cautious use of systemic corticosteroids is warranted given their adverse effects on hepatitis C viral loads.

Ocular melanoma: a review and the relationship to cutaneous melanoma

OBJECTIVES

The main objective of this review is to critically evaluate the present evidence regarding a relationship between ocular melanoma (OM) and cutaneous melanoma (CM). Melanomas are malignant neoplasms that develop from dendritic melanocytes that are found in the skin, eye, mucosal epithelia, and leptomeninges. While the skin is the most common site of melanoma development, these neoplasms can occur in any tissue that contains melanocytes. We review the incidence and characteristics of OM, evaluate the existent data regarding its potential relationship to CM, and provide some guidance for the dermatologist regarding the evaluation and diagnosis of this ocular tumor.

DATA SOURCES

A retrospective review of the literature.

STUDY SELECTION

Studies included those relevant to disease pathogenesis and incidence, cohort studies (ie, studies evaluating the incidence of CM in patients with OM), and pertinent investigations from the dermatologic literature (ie, cases of atypical nevus syndromes). The referenced study designs and methodologies varied.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by 2 independent reviewers, and the main results are presented in a qualitative, descriptive manner.

CONCLUSION

Evidence for comorbid OM and CM exists in patients with strong phenotypic expression of atypical nevi and conjunctival melanoma, although CDKN2A mutations have not been documented in patients with OM.