Sentinel lymph node biopsy for head and neck cutaneous squamous cell carcinoma using the Brigham and Women's staging system: a cost analysis.

The objective is to determine the cost-effectiveness of sentinel lymph node biopsy (SLNB) for cutaneous squamous cell carcinoma (CSCC) according to the Brigham and Women's Hospital (BWH) Tumor Staging system. A decision analysis was utilized to examine costs and outcomes associated with the use of SLNB in patients with high-risk head and neck CSCC. Decision tree outcome probabilities were obtained from published literature. Costs were derived from Medicare reimbursement rates (US$) and effectiveness was represented by quality-adjusted life-years (QALYs). The primary outcome was the incremental cost-effectiveness ratio (ICER), with a willingness-to-pay set at $100,000 per QALY gained. SLNB was found to be a cost-effective tool for patients with T3 tumors, with an ICER of $18,110.57. Withholding SLNB was the dominant strategy for both T2a and T2b lesions, with ICERs of - $2468.99 and - $16,694.00, respectively. Withholding SLNB remained the dominant strategy when examining immunosuppressed patients with T2a or T2b lesions. In patients with head and neck CSCC, those with T3 or T2b lesions with additional risk factors not accounted for in the staging system alone, may be considered for SLNB, while in other tumor stages it may be impractical. SLNB should only be offered on an individual patient basis.

Differences in sentinel lymph node biopsy utilization in eligible melanoma patients treated with Mohs micrographic surgery or wide local excision: A population-based logistic regression model and survival analysis.

BACKGROUND: Primary melanoma management relies on tumor extirpation and staging sentinel lymph node biopsy (SLNB) in eligible patients. This study compares SLNB utilization in patients undergoing wide local excision (WLE) or Mohs micrographic surgery (MMS). METHODS: American Joint Committee on Cancer seventh edition ≥ patients with T1b melanoma undergoing WLE or MMS in the Surveillance, Epidemiology, and End Results program were included. Propensity score matching was performed to compare patients who underwent MMS or WLE. Kaplan-Meier analysis and Fine-Gray cumulative incidence functions were used for overall and melanoma-specific survival. RESULTS: Eight hundred twenty-five MMS cases and 38,760 WLE cases were identified. SLNB was performed in 32.61% of MMS patients and 61.77% of WLE patients with positive rates of 12.5% and 14.82%, respectively. Multiple logistic regression of factors associated with SLNB utilization revealed that WLE, male gender, younger age, extremity location, and nodular and rare melanoma subtypes were significantly associated with increased odds of receiving SLNB whereas head and neck location and lentigo maligna melanoma subtype were significantly less likely to receive SLNB. LIMITATIONS: Potential selection bias from a retrospective data set. CONCLUSION: Patients receiving WLE for ≥ T1b melanoma are more likely to receive a SLNB than patients undergoing MMS.

Delays in the surgical treatment of melanoma are associated with worsened overall and melanoma-specific mortality: A population-based analysis.

BACKGROUND: The effect of treatment delays on melanoma outcomes remains unclear. OBJECTIVE: To assess the impact of surgical treatment delays on melanoma-specific mortality (MSM) and overall mortality (OM). METHODS: Patients with stage I to III cutaneous melanoma were identified through the Surveillance, Epidemiology, and End Results database (N = 108,689). Included cases had time from diagnosis to definitive surgery and follow-up time. Cox proportional hazards and Fine-Gray competing risks analyses were used to assess the impact of treatment delays on mortality. RESULTS: Across all stages, treatment delays of 3 to 5 months were associated with worse MSM and any delay beyond 1 month was associated with worse OM. In a subgroup analysis of patients with stage I disease, delays of 3 to 5 months were associated with worse MSM and any delay beyond 1 month was associated with worse OM. In patients with stage II disease, worse MSM was found with delays of 6+ months and worse OM was seen with delays of 3 to 5 months. No significant effect of treatment delays was noted in stage III disease. LIMITATIONS: The Surveillance, Epidemiology, and End Results database does not collect comprehensive data on adjuvant treatments, disease recurrence, or treatment failure. CONCLUSION: Timely treatment of melanoma may be associated with improved OM and MSM.

Multilobed flaps for intermediate and large nasal defects: Flap characteristics, patient outcomes, and provider experience at two institutions.

BACKGROUND: While bilobed and trilobed transposition flaps are established workhorses for nasal reconstruction, their utility is often limited to defects less than 1.5 cm, subjecting patients to more involved multistage or cosmetically less favorable repairs. We highlight the use of bilobed and trilobed transposition flaps for intermediate (≥ 1.5 cm) and large (≥ 2.0 cm) nasal defects. METHODS: Patients reconstructed with multilobed transposition flaps 2017-2020 were identified at two institutions. Validated scar scale (SCAR) and patient component of the patient and observer scar assessment survey (POSAS) were used to assess patient outcomes at a minimum 5-week follow-up. Statistical analyses were performed. RESULTS: Thirty-four patients were identified with mean defect size 1.8 cm diameter. There were no major postoperative events. Scar revision was performed in 9 patients. The mean provider SCAR score was 3.06 (best possible 0, worst possible 13). The mean patient arm of the SCAR scale and POSAS were 0.07 (best possible 0, worst possible 2) and 10.93 (best possible 6, worst possible 60), respectively. CONCLUSION: Bilobed and trilobed flaps have excellent outcomes for intermediate and large nasal defects.

A Call for Evidence-Based Conservative Management of Nail Unit Malignancies.

SUMMARY: Nail unit squamous cell carcinoma and melanoma are the most common malignancies of the nail apparatus. Compared to their cutaneous counterparts, they are diagnosed later and perceived as more aggressive. This may result in overzealous management, including radiographic imaging with poor sensitivity and specificity, interventional nodal staging by sentinel lymph node biopsy, amputation over digit-sparing tumor resections, and elaborate reconstructions after tumor extirpation. In this review article, the authors evaluate the evidence behind several misconceptions in nail malignancy management and provide evidence-based guidance for more conservative care.

Artificial intelligence and melanoma: A comprehensive review of clinical, dermoscopic, and histologic applications.

Melanoma detection, prognosis, and treatment represent challenging and complex areas of cutaneous oncology with considerable impact on patient outcomes and healthcare economics. Artificial intelligence (AI) applications in these tasks are rapidly developing. Neural networks with increasing levels of sophistication are being implemented in clinical image, dermoscopic image, and histopathologic specimen classification of pigmented lesions. These efforts hold promise of earlier and highly accurate melanoma detection, as well as reliable prognostication and prediction of therapeutic response. Herein, we provide a brief introduction to AI, discuss contemporary investigational applications of AI in melanoma, and summarize challenges encountered with AI.

A systematic review of periungual eccrine neoplasms.

Eccrine tumors are a rare cutaneous adnexal neoplasm originating from the sweat glands. The periungual region represents an uncommon localization for these neoplasms. We analyzed all published demographic, clinical, and treatment data on periungual eccrine tumors. A systematic review following PRISMA guidelines was performed of articles published prior to March 2021. Articles were included in the review if a full-text English version was available. Of the surveyed literature, 27 full-text case reports were included in the final analysis. Benign eccrine poroma and porocarcinoma were the most common tumor subtypes (nine and eight cases, respectively). Males were only affected by poroma and porocarcinoma, while females were affected by all tumor subtypes. The first toe was the most common lower extremity affected. Misdiagnosis led to delayed treatment in 25% of cases. As such, while periungual eccrine neoplasms are rare diagnoses, the nonspecific presentations of these growths raise concerns about misdiagnosis and delayed treatment. Further research is needed related to sex-differences in the epidemiology of these growths and into the prevalence of the first toe as a location. These tumors should be considered in the differential diagnosis for nail unit afflictions.

American Joint Committee on Cancer Staging and Other Platforms to Assess Prognosis and Risk.

The eighth edition of the American Joint Committee on Cancer melanoma staging system relies on assessments of the primary tumor (T), regional lymph nodes (N), and distant metastatic sites (M). Its notable updates include tumor thickness measurements to the nearest 0.1 mm, revision of T1a and T1b definitions, re-evaluation of N category descriptors, increased number of stage III subgroupings, and incorporation of a new M1d designation, among others. These changes were based on analyses of a large contemporary international melanoma database. Ultimately, these revisions were made to improve staging and prognostication, risk stratification, and selection of patients for clinical trials.

Dermatologic Follow-up and Assessment of Suspicious Lesions.

As our knowledge and understanding of melanoma evolve, melanoma surveillance guidelines will reflect these findings. Currently, there is no consensus across international guidelines for melanoma follow-up. However, it is accepted that more aggressive surveillance is recommended for more advanced disease. When examining high-risk individuals, a systematic approach should be followed. Future considerations include the use of noninvasive imaging techniques, 'liquid biopsies,' and artificial intelligence to enhance detection of melanomas.

New Developments in the Management of Cutaneous Squamous Cell Carcinoma.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. List important prognostic features that affect cutaneous squamous cell carcinoma risk. 2. Summarize the changes to the AJCC Cancer Staging Manual, Eighth Edition, staging system for cutaneous squamous cell carcinoma. 3. Evaluate the draining nodal basin with appropriate imaging modalities. 4. Recommend adjuvant radiation therapy in the correct clinical setting for high-risk tumors. 5. Recognize the currently available treatments for advanced cutaneous squamous cell carcinoma. SUMMARY: This continuing medical education article reviews the features, management, and prognosis of cutaneous squamous cell carcinoma with an emphasis on high-risk squamous cell carcinoma and data from the past 3 years. This review will discuss the primary tumor management, high-risk features of a squamous cell carcinoma, changes to the American Joint Committee on Cancer staging system, and the utility of sentinel lymph node biopsy, and critically review the evidence regarding adjuvant therapy.

Disease Progression in Cutaneous Squamous Cell Carcinoma Patients With Satellitosis and In-transit Metastasis.

BACKGROUND/AIM: Satellitosis/in-transit metastasis (S-ITM) has prognostic value in melanoma and Merkel cell carcinoma, but is not incorporated into cutaneous squamous cell carcinoma (cSCC) staging. PATIENTS AND METHODS: From our IRB-approved registry, patients with high-risk cSCC, including patients with S-ITM, were identified. Univariate (UVA) and multivariate (MVA) analyses were performed to compare disease progression (DP) and overall survival (OS). Cumulative incidence of DP and OS analyses were performed using Fine-Gray and Kaplan-Meier methods, respectively. RESULTS: A total of 18 S-ITM subjects were compared to 247 high risk subjects including T3N0 (n=143), N1-N3 without extranodal extension (ENE) (n=56), N1-N3 with ENE (n=26) and M1 disease (n=22). Median follow up was 16.5 months. Three-year rates of DP were 22% for T3N0, 42% for S-ITM, 48% for T4 bone invasion, 50% for N1-N3 without extranodal extension (ENE), 53% for N1-N3 with ENE, and 66% for M1. Patients with S-ITM did not experience significantly worse DP compared to those with T3N0 (HR=1.96, 95%CI=0.8-4.9; p=0.14). CONCLUSION: Cutaneous SCC patients with S-ITM experienced outcomes similar to locally advanced non-metastatic cSCC patients. Larger studies are needed to guide incorporation into staging systems.

Evaluating the Utility of Routine Imaging in Squamous Cell Carcinoma of the Nail Unit.

BACKGROUND: Squamous cell carcinoma (SCC) is the most common malignant tumor of the nail unit. No guidelines currently exist regarding the role of imaging in this specific location. OBJECTIVE: To investigate the utility of routine imaging in SCC of the nail apparatus. METHODS: A multi-institutional retrospective review of patients treated for nail unit SCC was performed. Data were collected on patient characteristics, tumor qualities, treatment, and radiographic imaging. A change in treatment was defined as more aggressive treatment (amputation) rather than local excision or Mohs micrographic surgery (MMS). RESULTS: One hundred seven patients with nail unit SCC were identified. Approximately 44/107 (41.1%) of patients were imaged and 63/107 (58.9%) were not. Mohs micrographic surgery was the most common primary treatment (66.4%). Mohs micrographic surgery was more commonly performed in nonimaged patients, and amputation was more commonly performed in imaged patients (p < .001). Bony changes were identified in 13/44 (29.5%) of imaged patients. In 8/44 (18.2%), imaging findings caused a change in treatment. In 99/107 (92.5%) of the cohort, imaging was either not performed or did not change management. CONCLUSION: In select cases, imaging may help guide patient management. Sufficient evidence does not yet exist to support routine imaging for patients with nail unit SCC.

Use of Extranasal Bilobed Transposition Flaps in Cutaneous Reconstructive Surgery at 2 Institutions.

BACKGROUND: Bilobed transposition flaps are versatile random pattern flaps used in nasal and extranasal reconstruction as they preserve free margins, access distal tissue reservoirs, and reliably repair dynamic defects. OBJECTIVE: We highlight the utility of extranasal bilobed flaps to encourage surgeons to consider these flaps for Mohs micrographic surgery defects. METHODS: A two-institution retrospective chart review of patients reconstructed using an extranasal bilobed flap after Mohs micrographic surgery was performed. A validated scar scale was applied to postoperative photographs. Statistical analyses of the patient and surgery characteristics including patient co-morbidities, anatomic distribution, flap dimensions, and postprocedural events, including revisions, were conducted. RESULTS: Forty-eight patients were identified. Site-specific flap dimensions were obtained with the cheek/lower eyelid requiring greater tissue mobilization with a higher final to primary defect ratio when compared with other sites. Postoperative events (complications, erythema, flap fullness, dehiscence, infection, etc.) were minimal. No major complications were noted. Nine cases of flap fullness or swelling were identified. Neither flap fullness nor dehiscence compromised flap integrity or cosmetic outcome. Independent flap cosmetic outcome review was good using a validated photographic scar scale. CONCLUSION: Bilobed transposition flaps are versatile repairs for extranasal reconstruction with a favorable safety and outcome profile.

Mohs Surgery for SEER Registry-Captured Melanoma In Situ and Rare Cutaneous Tumors: Comparing National Utilization Patterns Before and After Implementation of the Affordable Care Act (2010) and Appropriate Use Criteria (2012).

BACKGROUND: The Affordable Care Act (ACA) and the appropriate use criteria (AUC) for Mohs micrographic surgery (MMS) had the potential to increase utilization rates of MMS for indicated skin cancers, but it is unknown whether this has occurred. OBJECTIVE: To determine whether rates of MMS utilization for head and neck melanoma in situ (MIS) and rare cutaneous tumors (RCTs) increased after the implementation of the ACA and AUC publication. MATERIALS AND METHODS: Retrospective review using data from the SEER database. Melanoma in situ and RCT tumor cases from before and after the ACA and AUC publication were compared. RESULTS: Twenty-four thousand six hundred seventy-eight cases were analyzed. Mohs micrographic surgery utilization for MIS decreased from 13.9% before the ACA to 12.3% after the ACA (odds ratio 0.87; p = .012). There was no significant change in MMS utilization for MIS after publication of the AUC. There was also no significant change in MMS utilization for treatment of RCT after the ACA or AUC publication. Stratification of patients into age groups younger or older than 65 years did not change utilization rates. CONCLUSION: Rates of MMS for treatment of MIS and RCT have not increased since the advent of the ACA or AUC. This finding highlights the need for continued efforts to improve access to MMS and to increase education of its utility in treating skin cancer.