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Experimental Dermatology Jul 2022Mohs micrographic surgery (MMS) is considered the gold standard for difficult-to-treat malignant skin tumors, whose incidence is on the rise. Currently, there are no...
Mohs micrographic surgery (MMS) is considered the gold standard for difficult-to-treat malignant skin tumors, whose incidence is on the rise. Currently, there are no agreed upon classifiers to predict complex MMS procedures. Such classifiers could enable better patient scheduling, reduce staff burnout and improve patient education. Our goal was to create an accessible and interpretable classifier(s) that would predict complex MMS procedures. A retrospective study applying machine learning models to a dataset of 8644 MMS procedures to predict complex wound reconstruction and number of MMS procedure stages. Each procedure record contained preoperative data on patient demographics, estimated clinical tumor size prior to surgery (mean diameter), tumor characteristics and tumor location, and postoperative procedure outcomes included the wound reconstruction technique and the number of MMS stages performed in order to achieve tumor-free margins. For the number of stages complexity classification model, the area under the receiver operating characteristic curve (AUROC) was 0.79 (good performance), with model accuracy of 77%, sensitivity of 71%, specificity of 77%, positive prediction value (PPV) of 14% and negative prediction value (NPV) of 98%. The results for the wound reconstruction complexity classification model were 0.84 for the AUROC (excellent performance), with model accuracy of 75%, sensitivity of 72%, specificity of 76%, PPV of 39% and NPV of 93%. The ML models we created predict the complexity of the components that comprise the MMS procedure. Using the accessible and interpretable tool we provide online, clinicians can improve the management and well-being of their patients. Study limitation is that models are based on data generated from a single surgeon.
Topics: Humans; Incidence; Machine Learning; Mohs Surgery; Retrospective Studies; Skin Neoplasms
PubMed: 35213063
DOI: 10.1111/exd.14550 -
Dermatologic Clinics Oct 2016Confocal microscopy is a modern imaging device that has been extensively applied in skin oncology. More specifically, for tumor margin assessment, it has been used in... (Review)
Review
Confocal microscopy is a modern imaging device that has been extensively applied in skin oncology. More specifically, for tumor margin assessment, it has been used in two modalities: reflectance mode (in vivo on skin patient) and fluorescence mode (on freshly excised specimen). Although in vivo reflectance confocal microscopy is an add-on tool for lentigo maligna mapping, fluorescence confocal microscopy is far superior for basal cell carcinoma and squamous cell carcinoma margin assessment in the Mohs setting. This article provides a comprehensive overview of the use of confocal microscopy for skin cancer margin evaluation.
Topics: Carcinoma, Basal Cell; Carcinoma, Squamous Cell; Humans; Hutchinson's Melanotic Freckle; Intravital Microscopy; Microscopy, Confocal; Microscopy, Fluorescence; Mohs Surgery; Skin; Skin Neoplasms
PubMed: 27692455
DOI: 10.1016/j.det.2016.05.012 -
The Journal of Dermatological Treatment Dec 2024Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive cutaneous sarcoma with a propensity for recurrence. Its management, particularly in the head and... (Meta-Analysis)
Meta-Analysis Review
Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive cutaneous sarcoma with a propensity for recurrence. Its management, particularly in the head and neck (H&N) region, presents unique challenges. This study aimed to evaluate the effectiveness of Mohs micrographic surgery (MMS) compared to wide local excision (WLE) in treating H&N DFSP and its impact on recurrence rates and tissue preservation. A comprehensive search was conducted in PubMed/MEDLINE, yielding 29 relevant studies. We included studies comparing MMS and WLE in adult patients with H&N DFSP and reporting local recurrence outcomes. Data were analyzed using random effects analysis, with a meta-analysis performed for comparative studies. Analysis of studies demonstrated a lower recurrence for MMS. Comparative analysis of five studies involving 117 patients showed a significantly lower recurrence rate in the MMS group (2%) compared to the WLE group (19%). Margin status varied between studies, with some achieving negative margins at shorter distances. In the management of H&N DFSP, MMS has emerged as a superior surgical technique, consistently associated with reduced recurrence rates and the potential for tissue preservation. The adoption of MMS should be considered for its capacity to achieve negative margins with fewer processing steps, particularly in anatomically complex regions like the H&N.
Topics: Adult; Humans; Dermatofibrosarcoma; Mohs Surgery; Neoplasm Recurrence, Local; Retrospective Studies; Skin Neoplasms
PubMed: 38146660
DOI: 10.1080/09546634.2023.2295816 -
Journal of the European Academy of... Jul 2022Mohs micrographic surgery (MMS) is a precise, tissue-sparing surgical technique that offers superior cure rates compared to traditional surgical excision. However, the...
BACKGROUND
Mohs micrographic surgery (MMS) is a precise, tissue-sparing surgical technique that offers superior cure rates compared to traditional surgical excision. However, the degree of difficulty of MMS depends on many variables, and consequently, the number of surgical stages required for each case is quite unpredictable.
OBJECTIVES
To identify risk factors for complicated MMS, defined as MMS requiring ≥3 stages.
METHODS
In a cohort study design, data were prospectively collected from 612 patients that underwent MMS for basal cell carcinoma (BCC) at the Department of Dermatology, Skåne University Hospital, Lund, between 2009 and 2020. Univariate and multivariate logistic regression were used to estimate the risk of MMS requiring ≥3 stages. Due to the risk of multicollinearity between recurrent or incompletely excised BCC and previous treatments, a partially and a fully adjusted multivariate logistic regression model were constructed.
RESULTS
In fully adjusted multivariate analyses, age (odds ratio (OR) 1.02; confidence interval (CI) 95% 1.00-1.04), previous cryotherapy (OR 2.3; CI 95% 1.1-4.8), and >1 previous surgery (OR 3.4; CI 95% 1.5-7.7) were significantly associated with risk of complicated MMS. Recurrent BCC was associated with the risk of complicated MMS in partially adjusted multivariate analyses, but not in the fully adjusted analyses. In this highly selected cohort, histopathological subtype, and tumour localization were not associated with the risk of complicated MMS.
CONCLUSIONS
Older age and tumours previously treated with cryotherapy or multiple prior surgeries increased the risk of MMS requiring ≥3 stages. Whether recurrent BCC is an independent risk factor for complicated MMS needs further evaluation. Knowledge of these risk factors may ameliorate the planning of Mohs surgeries.
Topics: Carcinoma, Basal Cell; Cohort Studies; Humans; Mohs Surgery; Neoplasm Recurrence, Local; Neoplasms, Basal Cell; Risk Factors; Skin Neoplasms; Sweden; Treatment Outcome
PubMed: 35366359
DOI: 10.1111/jdv.18124 -
Archives of Dermatological Research Aug 2023The impact of time to treatment (TTT) on the surgical management of keratinocyte carcinoma, specifically the complexity of Mohs micrographic surgery (MMS), is...
The impact of time to treatment (TTT) on the surgical management of keratinocyte carcinoma, specifically the complexity of Mohs micrographic surgery (MMS), is incompletely understood. We performed a retrospective chart review of patients undergoing MMS for keratinocyte carcinoma between July 1, 2019 and February 28, 2021 to examine associations between TTT and surgical characteristics. The median TTT for the 1571 patients treated with MMS during the study period was 42 days (interquartile range 28-61 days). In adjusted analyses, increasing TTT was not associated with increasing utilization of flap or graft repairs. Although a 42-day increase in TTT was associated with a 17.6 mm increase in the post-operative surgical defect size after MMS, TTT was not associated with linear repair length or flap/graft repair area. In conclusion, TTT was not independently associated with the type of repair or repair length after MMS, suggesting that the complexity of Mohs reconstruction is not influenced by TTT within the time range studied in this cohort.
Topics: Humans; Skin Neoplasms; Carcinoma, Basal Cell; Retrospective Studies; Mohs Surgery; Time-to-Treatment
PubMed: 36583761
DOI: 10.1007/s00403-022-02519-9 -
JAMA Dermatology Jul 2023The 2022 National Comprehensive Cancer Network (NCCN) reclassified cutaneous squamous cell carcinoma (CSCC) into low-, high-, and very high-risk groups to better risk...
IMPORTANCE
The 2022 National Comprehensive Cancer Network (NCCN) reclassified cutaneous squamous cell carcinoma (CSCC) into low-, high-, and very high-risk groups to better risk stratify tumors. Mohs micrographic surgery (Mohs) or peripheral and deep en face margin assessment (PDEMA) became preferred surgical modalities for high- and very high-risk tumors. This new risk stratification and the recommendation for Mohs or PDEMA in high- and very high-risk groups have not been validated.
OBJECTIVE
To compare outcomes in very high-, high-, and low-risk NCCN groups of CSCCs and in CSCCs treated with Mohs or PDEMA compared with wide local excision (WLE).
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study of CSCCs was performed in 2 tertiary care academic medical centers. Patients 18 years or older and diagnosed between January 1, 1996, and December 31, 2019, at Brigham and Women's Hospital and Cleveland Clinic Foundation were included. Data were analyzed from October 20, 2021, to March 29, 2023.
EXPOSURES
NCCN risk group, Mohs or PDEMA, and WLE.
MAIN OUTCOMES AND MEASURES
Local recurrence (LR), nodal metastasis (NM), distant metastasis (DM), and disease-specific death (DSD).
RESULTS
A total of 10 196 tumors from 8727 patients were stratified by NCCN guidelines into low-, high-, and very high-risk groups (6003 [59.0%] men; mean [SD] age, 72.4 [11.8] years). Compared with the low-risk group, the high- and very high-risk groups demonstrated a greater risk of LR (high-risk subhazard ratio [SHR], 1.99 [95% CI, 1.21-3.27; P = .007]; very high-risk SHR, 12.66 [95% CI, 7.86-20.39; P < .001]), NM (high-risk SHR, 4.26 [95% CI, 1.28-14.23; P = .02]; very high-risk SHR, 62.98 [95% CI, 19.24-206.17; P < .001]), DM (high-risk SHR, 2.2 × 107 [95% CI, 4.7 × 103-1.1 × 1011; P < .001]; very high-risk SHR, 6.3 × 108 [95% CI, 1.4 × 105-2.9 × 1012; P < .001]), and DSD (high-risk SHR, 4.02 [95% CI, 1.18-13.71; P = .03]; very high-risk SHR, 93.87 [95% CI, 29.19-301.85; P < .001]). Adjusted 5-year cumulative incidence was significantly higher in very high- vs high- and low-risk groups for LR (9.4% [95% CI, 9.2%-14.0%] vs 1.5% [95% CI, 1.4%-2.1%] and 0.8% [95% CI, 0.5%-1.2%], respectively), NM (7.3% [95% CI, 6.8%-10.9%] vs 0.5% [95% CI, 0.4%-0.8%] and 0.1% [95% CI, 0.03%-0.3%], respectively), DM (3.9% [95% CI, 2.6%-5.6%] vs 0.1% [95% CI, 0.04%-0.2%] and 0.01% [95% CI, not applicable], respectively), and DSD (10.5% [95% CI, 10.3%-15.4%] vs 0.5% [95% CI, 0.4%-0.8%] and 0.1% [95% CI, 0.04%-0.3%], respectively). Compared with CSCCs treated with WLE, those treated with Mohs or PDEMA had lower risk of LR (SHR, 0.65 [95% CI, 0.46-0.90]; P = .009), DM (SHR, 0.38 [95% CI, 0.18-0.83]; P = .02), and DSD (SHR, 0.55 [95% CI, 0.36-0.84]; P = .006).
CONCLUSIONS AND RELEVANCE
The findings of this cohort study suggest that the NCCN high- and very high-risk groups identify CSCCs at greatest risk for developing poor outcomes. Further, Mohs or PDEMA resulted in lower LR, DM, and DSD compared with WLE.
Topics: Male; Humans; Female; Aged; Carcinoma, Squamous Cell; Cohort Studies; Skin Neoplasms; Retrospective Studies; Risk Factors; Risk Assessment; Neoplasm Recurrence, Local; Mohs Surgery
PubMed: 37285135
DOI: 10.1001/jamadermatol.2023.1353 -
Dermatology Practical & Conceptual Oct 2023Mohs Micrographic Surgery (MMS) is a treatment option for high-risk facial nonmelanoma skin cancer with high cure rates. Especially on the nasal tip, the tissue sparing... (Review)
Review
INTRODUCTION
Mohs Micrographic Surgery (MMS) is a treatment option for high-risk facial nonmelanoma skin cancer with high cure rates. Especially on the nasal tip, the tissue sparing properties of MMS are appealing. The nasal tip is a common location of nonmelanoma skin cancer and can be a challenging anatomical structure for reconstructive surgery due to its prominent location in the face, the shortage of spare tissue, as well as the stiffness and composition of different skin types, cartilage and bone.
OBJECTIVES
The aim of the present paper is to review and demonstrate how reconstruction of the nasal tip can be done successfully to improve the care for patients undergoing MMS in this area.
METHODS
Using selected literature on the area and the surgeons experience, each method of repair are described including their individual advantages and challenges. Pictures and consent were selected from one patient who underwent each repair method and three photos are presented in this paper: one after tumor resection, one immediately after repair, and one minimum 6 months post-surgery.
RESULTS
We present eight surgical methods as well as pictures from previous surgeries.
CONCLUSIONS
The results demonstrate obtainable results using very different surgical methods and the importance of an individualized approach to repairing cutaneous defects of the nasal tip.
PubMed: 37992361
DOI: 10.5826/dpc.1304a228 -
Clinical & Translational Oncology :... Jul 2015Despite that basal cell carcinoma (BCC) is curative in the vast majority of cases, some patients are at high risk of recurrence and, in a few patients, lesions can... (Review)
Review
Despite that basal cell carcinoma (BCC) is curative in the vast majority of cases, some patients are at high risk of recurrence and, in a few patients, lesions can progress to a point unsuitable for local therapy and prognosis is quite poor. The aim of the present work is to review clinical and pathologic characteristics as well as classical and new treatment options for high-risk, metastatic and locally advanced BCC. Surgery and radiotherapy remain the selected treatments for the majority of high-risk lesions. However, some patients are located on a blurry clinical boundary between high-risk and locally advanced BCC. Treatment of these patients is challenging and need an individualized and highly specialized approach. The treatment of locally advanced BCC, in which surgery or radiotherapy is unfeasible, inappropriate or contraindicated, and metastatic BCC has changed with new Hedgehog pathway inhibitors of which vismodegib is the first drug approved by FDA and EMA.
Topics: Anilides; Antineoplastic Agents; Carcinoma, Basal Cell; Dermatologic Surgical Procedures; Humans; Mohs Surgery; Pyridines; Radiotherapy; Skin Neoplasms
PubMed: 25643667
DOI: 10.1007/s12094-014-1272-9 -
International Journal of Women's... Jun 2021Physician burnout is a response to chronic work stress characterized by emotional exhaustion, depersonalization, and reduced sense of personal accomplishment. Resiliency...
BACKGROUND
Physician burnout is a response to chronic work stress characterized by emotional exhaustion, depersonalization, and reduced sense of personal accomplishment. Resiliency is the ability to respond to chronic stress in a healthy and adaptive manner. No prior studies have specifically examined the prevalence of burnout and resilience in Mohs surgeons.
OBJECTIVE
This study aimed to assess the current well-being of Mohs surgeons and specific resilient behaviors that can protect against burnout.
METHODS
A cross-sectional electronic survey was sent to members of the American College of Mohs Micrographic Surgery. The survey combined the validated Maslach Burnout Inventory and The Resilience Profile ©.
RESULTS
Of the 1450 surgeons registered with the American College of Mohs Surgery listserv, 137 (9.4%) participated in the survey. Of those who participated, 46% of surgeons had at least 1 symptom of burnout based on a high emotional exhaustion and/or high depersonalization score. Female surgeons (56%) were found to have higher levels of burnout compared with male surgeons (40%). Individual resilient behaviors protective of burnout include the ability to pivot and exhibition of self-control.
CONCLUSION
Compared with all physicians and general dermatologists, Mohs surgeons have a lower rate of burnout. Similar to other surgical specialties, women report higher rates of burnout. Individual resilience factors that may be protective of burnout include ability to pivot and self-control.
PubMed: 34222590
DOI: 10.1016/j.ijwd.2021.01.011