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The British Journal of Dermatology May 2024Autofluorescence (AF) - Raman spectroscopy is a technology that can detect residual basal cell carcinoma (BCC) on the resection margin of fresh surgically excised tissue...
BACKGROUND
Autofluorescence (AF) - Raman spectroscopy is a technology that can detect residual basal cell carcinoma (BCC) on the resection margin of fresh surgically excised tissue specimens. The technology does not require tissue fixation, staining, labelling, or sectioning, and provides quantitative diagnosis maps of the surgical margins in 30 minutes.
OBJECTIVES
To determine the accuracy of the AF-Raman instrument to detect incomplete excisions of BCC during Mohs micrographic surgery, using histology as reference standard.
METHODS
Skin layers from 130 patients undergoing Mohs surgery at the Nottingham University Hospitals NHS Trust (September 2022 to July 2023) were investigated with the AF-Raman instrument. The layers were measured fresh, immediately after excision. The AF-Raman results and the intra-operative assessment by Mohs surgeons were compared to a post-operative consensus-derived reference produced by three dermatopathologists. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated.
RESULTS
The AF-Raman analysis was successfully completed for 125 out of the 130 layers. The AF-Raman analysis covered 91% of the specimen surface area on average, with the lowest being 87% for eyelid and the highest being 94% for forehead specimens. The AF-Raman instrument identified positive margins in 24 out of 36 BCC-positive cases, resulting in a 67% sensitivity (95% confidence intervals (CI): 49%-82%) and negative margins in 65 out of 89 BCC-negative cases, resulting in a 73% specificity (95% CI 63%-82%). Only one out of the 12 false negative cases was caused by misclassification by the AF-Raman algorithm. The other 11 false negatives cases were produced because no valid Raman signal was recorded at the location of the residual BCC due to either occlusion by blood or poor contact between tissue and cassette window. The intra-operative diagnosis by Mohs surgeons identified positive margins in 31 out of 36 BCC-positive cases, 86% sensitivity (95% CI: 70%-95%), and negative margins in 79 out of 89 BCC-negative cases, 89% specificity (95% CI: 81%-95%).
CONCLUSIONS
This study shows that the AF-Raman instrument has potential for intra-operative microscopic assessment of surgical margins in surgery of BCC. Further improvements are required for tissue processing to ensure complete coverage of the surgical specimens. ClinicalTrials.gov ID NCT03482622.
PubMed: 38736216
DOI: 10.1093/bjd/ljae196 -
International Journal of Dermatology May 2024Squamous cell carcinoma of the nail unit (nSCC) is a rare malignant tumor of the hand and nail. Although skin cancer rarely affects individuals with phototypes IV-VI,... (Review)
Review
Squamous cell carcinoma of the nail unit (nSCC) is a rare malignant tumor of the hand and nail. Although skin cancer rarely affects individuals with phototypes IV-VI, its occurrence in these groups is often associated with greater morbidity and mortality. This study aims to characterize the clinical symptoms, presentations, and treatments of nSCC in patients with darker skin types. A systematic review of PubMed and Embase was performed in May 2023 for all peer-reviewed, English-language nSCC studies involving individuals with Fitzpatrick types IV-VI. Most tumors were located on the fingernails (84%), with the right third finger being the most frequently affected (31%). The nail bed (67%) exhibited a higher prevalence than the lateral/proximal nail folds (33%). The duration of symptoms before diagnosis ranged from 1 month to 7 years. nSCC was most commonly treated with Mohs surgery (38%), followed by amputation (35%). Our study was limited to case reports because of a lack of large nSCC studies that provide information on race or images of each patient. These tumors are generally slow-growing yet often misdiagnosed, leading to delays in presentation and diagnosis. Increased awareness about nSCC in phototype IV-VI individuals will reduce misdiagnoses, unnecessary treatment, and recurrences.
PubMed: 38736165
DOI: 10.1111/ijd.17237 -
Archives of Dermatological Research May 2024
Topics: Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Carcinoma, Basal Cell; Ethnicity; Healthcare Disparities; Mohs Surgery; Skin Neoplasms
PubMed: 38734798
DOI: 10.1007/s00403-024-02858-9 -
Journal of the American Academy of... May 2024
PubMed: 38734241
DOI: 10.1016/j.jaad.2024.05.006 -
Journal of the American Academy of... May 2024
PubMed: 38734238
DOI: 10.1016/j.jaad.2024.04.071 -
Journal of the European Academy of... May 2024Immunosuppressed (IS) patients, particularly solid organ transplant recipients and those on immunosuppressive therapy, face a higher incidence and recurrence of...
BACKGROUND
Immunosuppressed (IS) patients, particularly solid organ transplant recipients and those on immunosuppressive therapy, face a higher incidence and recurrence of nonmelanoma skin cancers (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Mohs micrographic surgery (MMS) is the preferred treatment for high-risk NMSC due to its high cure rate and margin examination capabilities. However, IS patients may experience more complications, such as surgical site infections, and a greater risk of recurrence, making their outcomes a subject of interest.
OBJECTIVES
This study aimed to compare IS and immunocompetent (IC) patients undergoing MMS for NMSC in terms of baseline characteristics, intra- and post-surgical complications, and postoperative recurrence rates.
METHODS
The study utilized data from the REGESMOHS registry, a 7-year prospective cohort study in Spain. It included 5226 patients, categorizing them into IC (5069) and IS (157) groups. IS patients included solid organ transplant recipients, those on immunosuppressive treatments, individuals with haematological tumours and HIV-positive patients. Patient data, tumour characteristics, surgical details and outcomes were collected and analysed.
RESULTS
IS patients demonstrated a higher proportion of SCC, multiple synchronous tumours and tumours invading deeper structures. Complex closures, unfinished MMS and more surgical sections were observed in the IS group. Although intra-operative morbidity was higher among IS patients, this difference became non-significant when adjusted for other variables such as year of surgery, antiplatelet/anticoagulant treatment or type of closure. Importantly, IS patients had a substantially higher recurrence rate (IRR 2.79) compared to IC patients.
CONCLUSIONS
This study suggests that IS patients may be at a higher risk of development of AE such as bleeding or tumour necrosis and are at a higher risk of tumour recurrence. Close follow-up and consideration of the specific characteristics of NMSC in IS patients are crucial. Further research with extended follow-up is needed to better understand the long-term outcomes for this patient group.
PubMed: 38733285
DOI: 10.1111/jdv.20103 -
Journal of Clinical Medicine Apr 2024Lentigo maligna (LM) is a melanoma in situ that is prevalent in chronically sun-damaged skin. Characterized by a slow growth pattern and high mutation rates due to... (Review)
Review
Lentigo maligna (LM) is a melanoma in situ that is prevalent in chronically sun-damaged skin. Characterized by a slow growth pattern and high mutation rates due to chronic UV exposure, LM poses diagnostic and therapeutic challenges, particularly given its tendency to mimic other skin lesions and its occurrence in cosmetically sensitive areas. Its diagnosis is based on an integrated approach using dermoscopy and reflectance confocal microscopy (RCM). Despite its slow progression, LM can evolve into lentigo maligna melanoma (LMM), making its treatment necessary. Treatment modalities encompass both surgical and non-surgical methods. Surgical treatments like Wide Local Excision (WLE) and Mohs Micrographic Surgery (MMS) aim for clear histological margins. WLE, a standard melanoma surgery, faces challenges from LM's subclinical extensions, which increase the recurrence risk. MMS, effective for large or poorly defined lesions, is defined by precise margin control while considering cosmetic outcomes. Non-surgical options, including radiotherapy and imiquimod, are alternatives for non-surgical candidates. Radiotherapy has been effective since the 1950s, offering good control and cosmetic results, especially for older patients. Imiquimod, an immunomodulator, shows promise in treating LM, though its application remains off-label. The increasing incidence of LM/LMM necessitates a balance in treatment choices to minimize recurrence and maintain cosmetic integrity. A multidisciplinary approach, integrating clinical examination with dermoscopy and RCM and histological assessment, is essential for accurate diagnosis and effective LM management.
PubMed: 38731056
DOI: 10.3390/jcm13092527 -
Dermatologic Surgery : Official... May 2024Immunohistochemical (IHC) staining can be used alongside Mohs micrographic surgery to aid in margin assessment of subtle tumors, yet existing estimates of IHC...
BACKGROUND
Immunohistochemical (IHC) staining can be used alongside Mohs micrographic surgery to aid in margin assessment of subtle tumors, yet existing estimates of IHC utilization have primarily relied on survey or older data that lacks stratification.
OBJECTIVE
To characterize national IHC utilization trends by Mohs surgeons, stratifying by surgeon characteristics and modeling future adoption.
METHODS
Longitudinal analysis of 2014 to 2021 Medicare Public Use Files.
RESULTS
In 2021, 158 of 2,058 Mohs surgeons (7.7%) used IHC as compared with 4.0% in 2014 (average annual growth rate [AAGR] +3.6%). Adoption change was highest in the Northeast (AAGR +19.9%), whereas volume growth was greatest in the West (AAGR +25.2%). Multivariable regression revealed significantly greater utilization propensity among Mohs surgeons in academics (adjusted odds ratio [aOR] 3.36), American College of Mohs Surgery (ACMS) members (aOR 2.12), and Micrographic Dermatologic Surgery (MDS)-certified surgeons (aOR 1.66).
CONCLUSION
Mohs surgeons are steadily incorporating IHC into practice across all regions, with volume growth driven by higher adoption rates. Greater utilization among ACMS members, recipients of MDS certification, and those in academics suggests value of formalized training in enhancing comfort. Additional educational opportunities at conferences may aid in recognition of value and help identify solutions to address integration challenges.
PubMed: 38722749
DOI: 10.1097/DSS.0000000000004232 -
Journal of Drugs in Dermatology : JDD May 2024
Topics: Humans; Artificial Intelligence; Mohs Surgery; Patient Education as Topic; Skin Neoplasms
PubMed: 38709704
DOI: 10.36849/JDD.8123 -
Journal of Drugs in Dermatology : JDD May 2024Functional and cosmetic outcomes following Mohs micrographic surgery (MMS) are poorly studied in individuals with skin of color (SOC). Postinflammatory hyperpigmentation... (Observational Study)
Observational Study
IMPORTANCE
Functional and cosmetic outcomes following Mohs micrographic surgery (MMS) are poorly studied in individuals with skin of color (SOC). Postinflammatory hyperpigmentation (PIH) may be long-lasting and highly distressing. SOC individuals are particularly susceptible to PIH following procedures. Objective: To characterize factors that contribute to the development of PIH following MMS in SOC.
DESIGN
This retrospective study included 72 SOC individuals with 83 cases of keratinocyte carcinoma treated with MMS between August 2020 and August 2021 at a single medical center in the Bronx, New York.
RESULTS
Postinflammatory hyperpigmentation following Mohs micrographic surgery was more common in Fitzpatrick skin types (FST) IV to V (48.0%) compared to FST I to III (18.2%; P=0.006). Grafts and granulation resulted in higher rates of PIH compared to linear repairs and flaps (87.5% vs 30.7%; P=0.003). Cases with postoperative complications resulted in higher rates of PIH compared to cases without (81.8% vs 29.2%; P=0.001). In a subset analysis of linear repairs, polyglactin 910 as a subcutaneous suture produced a higher rate of PIH compared to poliglecaprone 25 (46.2% vs 7.1%; P=0.015). Conclusions and Relevance: Individuals with SOC (FST IV to V) are more likely to develop PIH following MMS. Grafts and granulation lead to PIH more often than linear repairs and flaps. Postoperative complications significantly increase the risk of PIH. Surgeons should consider these risk factors during surgical planning in an effort to mitigate PIH in SOC individuals. Studies with larger sample sizes are indicated. J Drugs Dermatol. 2024;23(5):316-321. doi:10.36849/JDD.8146.
Topics: Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Carcinoma, Squamous Cell; Granulation Tissue; Hyperpigmentation; Mohs Surgery; Postoperative Complications; Retrospective Studies; Skin Neoplasms; Skin Transplantation; Surgical Flaps; Skin Pigmentation; Ethnic and Racial Minorities
PubMed: 38709696
DOI: 10.36849/JDD.8146