Development of a core outcome set for cutaneous squamous cell carcinoma trials: identification of core domains and outcomes

BACKGROUND

The lack of uniformity in the outcomes reported in clinical studies of the treatment of cutaneous squamous cell carcinoma (cSCC) complicates efforts to compare treatment effectiveness across trials.

OBJECTIVES

To develop a core outcome set (COS), a minimum set of agreed-upon outcomes to be measured in all clinical trials of a given disease or outcome, for the treatment of cSCC.

METHODS

One hundred and nine outcomes were identified via a systematic literature review and interviews with 28 stakeholders. After consolidation of this long list, 55 candidate outcomes were rated by 19 physician and 10 patient stakeholders, in two rounds of Delphi exercises. Outcomes scored 'critically important' (score of 7, 8 or 9) by ≥ 70% of patients and ≥ 70% of physicians were provisionally included. At the consensus meeting, after discussion and voting of 44 international experts and patients, the provisional list was reduced to a final core set, for which consensus was achieved among all meeting participants.

RESULTS

A core set of seven outcomes was finalized at the consensus meeting: (i) serious or persistent adverse events, (ii) patient-reported quality of life, (iii) complete response, (iv) partial response, (v) recurrence-free survival, (vi) progression-free survival and (vii) disease-specific survival.

CONCLUSIONS

In order to increase the comparability of results across trials and to reduce selective reporting bias, cSCC researchers should consider reporting these core outcomes. Further work needs to be performed to identify the measures that should be reported for each of these outcomes.

Aging of the skin: implications for cutaneous surgery

There are precious few benefits, save perhaps experience and wisdom, that those of advanced age may claim over those who continue to dwell in their youth. One somewhat paradoxical advantage, however, is the ability of older patients to apparently heal better than younger patients after cutaneous surgery. In older patients, the incision lines are less red, the scarring is less hypertrophic, and "normalization" of appearance occurs more rapidly. And yet, the "wrapping" does not necessarily reflect the contents of the "box." Unfavorable age-dependent alterations in the physical properties of the skin and the wound-healing cascade may affect the viability and structural integrity of the postoperative result. Surgery on the aged population must therefore couple the optimism for a pleasing aesthetic result with the caution reflecting a cutaneous substrate altered by the perturbations of time. This somewhat shaky balance, although not altogether understood, is worthy of study by the physician approaching the patient of advanced age.

Nasal reconstruction with the cheek island pedicle flap

BACKGROUND

Reconstruction of the lower third of the nose can be challenging. Maintaining the nasal subunit symmetry and providing good tissue match with regard to color, sebaceous quality, and thickness is essential. For extensive defects in this area, paramedian forehead flaps are often considered.

OBJECTIVE

Our purpose was to develop the technique of preparing and executing the cheek island pedicle flap, as well as to define the limitations and "pitfalls" of the flap.

METHODS

The cheek island pedicle flap is described.

RESULTS

The cheek island pedicle flap can provide excellent cosmetic results in reconstructing defects of the lower third of the nose. The flap dynamics are predictable, and anticipated complications are described.

CONCLUSION

The cheek island pedicle flap provides an excellent alternative to the paramedian forehead flap for reconstruction of extensive defects of the lower third of the nose.

Conchal bowl skin grafting in nasal tip reconstruction: clinical and histologic evaluation

BACKGROUND

It is often difficult to achieve an esthetically pleasing cosmetic match when full-thickness skin grafts from periclavicular, preauricular, or postauricular donor sites are used to repair distal nasal defects. This, in large part, is due to the highly sebaceous nature of the skin on the distal aspect of the nose.

OBJECTIVE

Our purpose was to describe the benefits of using donor skin from the conchal bowl to repair defects of the nasal tip.

METHODS

The technique of conchal bowl grafting is described.

RESULTS

The conchal grafts give an excellent cosmetic result with respect to color and texture match and are time efficient because the donor site can be allowed to heal by secondary intention.

CONCLUSION

The conchal bowl offers an esthetically reliable source of donor skin for full-thickness and perichondrial cutaneous grafts to repair defects of the nasal tip.

DNA ploidy of basal cell carcinoma determined by image cytometry of fresh smears

Image analysis of nuclear DNA content (DNA ploidy) was performed on smears of basal cell carcinoma (BCC) obtained during Mohs microscopically-controlled surgery from 51 tumors. DNA ploidy was compared with histologic growth pattern and the contour of the invading edge. There was a statistically significantly increased frequency of DNA aneuploidy in smears from BCC exhibiting partial or total diffuse (infiltrative and superficial multicentric) growth patterns (80%; 32 of 40) as compared to solely circumscribed growth patterns (0%; 0 of 11) (p < 0.001).

Eccrine syringofibroadenoma (Mascaro): an ultrastructural study

To confirm the eccrine acrosyringeal differentiation of eccrine syringofibroadenoma (ESFA) and to elucidate the histogenesis of its angiofibrotic stroma, a case of ESFA from a 45-year-old man was examined by light and electron microscopy. Histologically, the parenchyma featured anastomosing, slender epithelial cords containing small cuboidal cells and occasional duct-like structures. The stroma had increased numbers of mast cells, increased capillaries with swollen endothelial cells, and prominent fibrosis. Ultrastructurally, the following findings were characteristic of ESFA: a) abundant glycogen particles in epithelial cells, b) numerous intracytoplasmic and extracellular spaces lined with microvilli, c) intraepithelial duct formation, consisting of microvilli, vesicles, rod-shaped dense bodies, multivesicular dense bodies, and peripheral network of tonofilaments, and d) large numbers of mast cells, closely associated with fibroblasts, surrounding increased numbers of capillaries containing swollen endothelial cells. These ultrastructural features support the acrosyringeal differentiation of ESFA. We hypothesize that mast cell hyperplasia and degranulation may play an important role in the formation of the angiofibrotic stroma.

Urokinase plasminogen activator is immunocytochemically detectable in squamous cell but not basal cell carcinomas

The presence of plasminogen activators (PA) in a variety of solid tumors appears to correlate, in a number of instances, with enhanced invasive or metastatic capabilities. In the present study, we have immunocytochemically examined basal cell (BCC) and squamous cell carcinomas (SCC) comprising a spectrum of histologic subtypes for the presence of urokinase-type (uPA) and tissue-type (tPA) PA. Neither uPA nor tPA was noted in any BCC, whether of the nodular, infiltrative, morpheaform, or basosquamous variety. uPA but not tPA was seen in 12 of 16 SCC examined; the tumors lacking uPA were all histologically well differentiated. No relationship between uPA expression and depth of invasion was noted, and uPA was not preferentially expressed at tumor borders. We conclude that uPA presence in SCC may relate to the degree of differentiation.

Delayed reconstruction following Mohs' chemosurgery for skin cancers of the head and neck

The case records of 52 patients with 55 cutaneous neoplasms treated by Mohs' chemosurgery and subsequently reconstructed by plastic surgeons were reviewed to determine if delay between resection and reconstruction adversely affected the outcome of reconstruction. Reconstruction was performed from 5 to 61 days after Mohs' chemosurgery for 45 basal cell carcinomas and 10 other cutaneous neoplasms. There were no complications during the interval between resection and reconstruction. Following reconstruction, minor wound complications occurred in 6% of patients; there were no major complications. Microscopic examination of the re-excised wound revealed residual disease in 2 of 45 cases of basal cell carcinoma and 0 of 10 other cutaneous malignancies. Both patients with residual basal cell carcinomas (i.e., false-negative margins after Mohs' surgery) had presented to the Mohs' surgeon with recurrent tumors. During a follow-up period of 3 months to 3 years after complete resection, recurrent tumor developed in 2 of 45 cases of basal cell carcinoma and 3 of 8 cases of squamous cell carcinoma. Delayed reconstruction, usually 5 to 20 days after Mohs' chemosurgery, can be performed without significant morbidity. Re-excision of the Mohs' chemosurgical wound for pathologic examination can detect residual disease and may be especially indicated for large recurrent wounds.

Suture tensor

The suture tensor is a simple stainless steel device that pulls the ends of a running subcuticular suture in opposite directions, maintaining the desired closure. The benefits of the use of this device may include minimization of train-track and excisional scarification (via the enhanced maintenance of "tenting"), time savings, and flexibility and durability for the sporting or physically active patient.

Defect subdivision as a technique to repair defects following Mohs surgery

Defects following Mohs surgery that cannot be closed primarily or with single flaps may often be reconstructed using the concept of defect subdivision. This involves mentally fragmenting the wound into smaller portions. Each subsegment is reconstructed with a small transposition flap. The closures of the donor sites of these flaps are designed so that each taps into a separate and distinct area of skin laxity. In this way efficient and optimal use is made of available matching regional skin for reconstruction.

The principle of cosmetic junctions as applied to reconstruction of defects following Mohs surgery

Reconstruction of defects that cross several cosmetic units can be aesthetically accomplished by preserving the integrity of the cosmetic boundaries using multiple grafts and flaps rather than one all-emcompassing repair.

Bulbous-lysing underminers

The blunt dissection offered by liposuction cannulas has greatly aided surgical undermining such as in face-lift surgery. Herein, we propose a new line of instruments that combines bulbous or blunt dissection with intervening lysing segments. The subgaleal version enables the surgeon to quickly undermine the scalp from ear to ear for scalp reductions in the subgaleal plane. In addition, the subgaleal device aids in the maintenance of the proper dissection plane and is useful in browlifts as well. A closely related "general" undermining device greatly facilitates face-life surgery and has found other uses in the undermining or separation of fibrous tissue planes.

The use of fascial plication to facilitate wound closure following microscopically controlled surgery

The closure of large wounds created by the Mohs method of skin cancer removal may often be facilitated by the plication of the underlying fascia. Fascial plication causes the movement of tissue without direct tension and vascular compromise on involved skin. This may be referred to as tissue drag. The tissue, once dragged toward the closure point by fascial movement, may often be stretched a further distance. Only the tension caused by stretching affects the vascular viability of the skin. This tension-alleviating maneuver may permit closure of wounds that might otherwise be subject to ischemic complications if only standard cutaneous and subcutaneous closures are employed.

Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection

Papillomavirus DNA has been reported recently in the vapor (smoke plume) derived from warts treated with carbon dioxide laser; this raises concerns for operator safety. We therefore have studied a group of human and bovine warts to define further the potential risk of wart therapy and to test whether a surgical mask could reduce exposure. Half of each wart was treated with carbon dioxide laser and the other half with electrocoagulation. The vapor produced by each form of therapy was collected with a dry filter vacuum apparatus and analyzed for the presence of papillomavirus. Vapor from human plantar warts was analyzed for the presence of human papillomavirus DNA, because there is no infectivity assay for human papillomavirus. Of plantar warts treated, five of eight laser-derived vapors and four of seven electrocoagulation-derived vapors were positive for human papillomavirus DNA. Greater amounts of papillomavirus DNA were usually recovered in the laser vapor than in the electrocoagulation vapor from the same wart. Bioassay readily detected infectious bovine papillomavirus in the vapor from bovine warts treated with either modality; more virus was present in laser-derived material. A surgical mask was found capable of removing virtually all laser- or electrocoagulation-derived virus, strongly suggesting that such masks can protect operators from potential inhalation exposure to papillomavirus.

Pseudoepitheliomatous hyperplasia following Mohs micrographic surgery

Pseudoepitheliomatous hyperplasia may arise secondarily in a number of cutaneous disorders. Herein we discuss this entity and describe its occurrence in a post Mohs micrographic surgery wound. We will also relate the subsequent histopathologic confusion engendered by its presence.

Sedation for dermatologic surgery

This review focuses on some of the most common classes of parenteral and inhalational sedating agents used during cutaneous surgery. Emphasis also is placed on potential adverse effects and their treatments.

Tissue movement--a macrobiomechanical approach

The surgical movement of skin involves both a respect for the biological integrity of the involved tissues and an understanding of its mechanical properties. The interaction of tissue biology and mechanics on the level of the organism therefore represents a macrobiomechanical approach to tissue movement. An understanding of anatomy and tissue movement dynamics is key in the performance of successful cutaneous surgery.

Scarring following herpes simplex infection of postsurgical cutaneous sites

Herpes simplex type 1 produces a perilabial vesicular eruption that normally resolves without scarring. Three cases of herpetic infection associated with different dermatologic surgical procedures are presented. Those procedures involving reduction of cutaneous macrovascular blood supply via undermining or flap creation were followed by clinical scarring. None of the recognized etiologies of tissue compromise (bacterial infection, tension, host vascular disease, excessive inflammation, or edema) could be identified. It is speculated that in the immunocompetent host, small vessel injury secondary to herpes simplex may eventuate in scarring if the subdermal vascular network is significantly compromised. Prophylactic oral acyclovir may be useful in select instances where tissue blood supply is judged clinically tenuous and the frequency of herpetic infection at the surgical site judged worrisome.