Risk factors for complicated Mohs surgery in the South Sweden Mohs Cohort.

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.

Surgical treatment of basal cell carcinoma: a case series on factors influencing the risk of an incomplete primary excision.

BACKGROUND: Basal cell carcinoma (BCC) is the most common skin cancer form, and one first-line treatment is surgical excision. Complete excision is vital to minimize risk of recurrence. Studies on occurrence of incomplete excisions have given diverse results and seldom include large populations from a dermatological setting. OBJECTIVES: The rate of positive surgical margins in primary surgery of BCC at a tertiary dermatology clinic is studied. Factors associated with an incomplete primary excision are analysed. METHODS: Patients scheduled for standard excision, without perioperative margin control, of BCC during the years 2008-2015 were prospectively enrolled in the study. Tumour-specific factors, including histopathologic subtype, as well as postoperative outcome were registered. Incomplete excisions were analysed in relation to patient- and tumour-related factors. RESULTS: In total, 4.6% of 3911 BCC tumours were incompletely excised. The rate of incomplete excisions was higher for facial tumours and among tumours with an aggressive histological subtype. Morpheiform BCC on the nose or ear had the highest rate of an incomplete excision, 61.5% and 50%, respectively. CONCLUSIONS: Most BCCs, irrespective of subtype, were completely excised during the primary excision. Tumour sites nose and ears were associated with the highest rate of positive primary surgical margins, especially for infiltrative or morpheiform BCCs. Surgery with perioperative examination of margins is strongly recommended for these tumours.

Preoperative prediction of histopathological outcome in basal cell carcinoma: flat surface and multiple small erosions predict superficial basal cell carcinoma in lighter skin types.

BACKGROUND: Prediction of the histopathological subtype of basal cell carcinoma (BCC) is important for tailoring optimal treatment, especially in patients with suspected superficial BCC (sBCC). OBJECTIVES: To assess the accuracy of the preoperative prediction of subtypes of BCC in clinical practice, to evaluate whether dermoscopic examination enhances accuracy and to find dermoscopic criteria for discriminating sBCC from other subtypes. MATERIALS AND METHODS: The main presurgical diagnosis was compared with the histopathological, postoperative diagnosis of routinely excised skin tumours in a predominantly fair-skinned patient cohort of northern Europe during a study period of 3 years (2011-13). The study period was split in two: during period 1, dermoscopy was optional (850 cases with a pre- or postoperative diagnosis of BCC), while during period 2 (after an educational dermoscopic update) dermoscopy was mandatory (651 cases). A classification tree based on clinical and dermoscopic features for prediction of sBCC was applied. RESULTS: For a total of 3544 excised skin tumours, the sensitivity for the diagnosis of BCC (any subtype) was 93·3%, specificity 91·8%, and the positive predictive value (PPV) 89·0%. The diagnostic accuracy as well as the PPV and the positive likelihood ratio for sBCC were significantly higher when dermoscopy was mandatory. A flat surface and multiple small erosions predicted sBCC. CONCLUSIONS: The study shows a high accuracy for an overall diagnosis of BCC and increased accuracy in prediction of sBCC for the period when dermoscopy was applied in all cases. The most discriminating findings for sBCC, based on clinical and dermoscopic features in this fair-skinned population, were a flat surface and multiple small erosions.

Pinch grafting in hospital and primary care: a cost analysis.

The cost of treating venous leg ulcers with pinch grafting was evaluated for 58 consecutive patients: 29 in hospital care and 29 in primary care. The mean age was 76.8 and 74.3 years and the mean ulcer size 15.1 and 13.5 cm2, respectively. The operation technique, pinch grafting, was the same for all patients but primary care patients were not immobilised postoperatively. Healing rate within 12 weeks was the same for patients in hospital care and primary care (31%). Treatment costs for one week pre-operatively and three weeks postoperatively amounted to 5109 Pounds per patient in hospital care and 870 Pounds per patient in primary care (p < 0.001), and the costs for one week pre-operatively and 12 weeks postoperatively were 6738 Pounds and 1806 Pounds, respectively (p < 0.001). Costs for patients whose ulcers healed within 12 weeks were 5552 Pounds for those receiving hospital care and 1676 Pounds for those receiving primary care (p < 0.001). Pinch grafting in primary care was shown to cost 3.3 to 5.9 times less, with the same healing outcome, than pinch grafting in hospital care.

Excision of lipodermatosclerotic tissue: an effective treatment for non-healing venous ulcers.

In longstanding venous ulcers, the development of lipodermatosclerosis of the skin surrounding the ulcer is common. According to our clinical experience lipodermatosclerosis impairs the opportunities for the ulcer to heal. In this combined retrospective and prospective study the lipodermatosclerotic skin area was excised in 7 non-healing venous ulcers and then covered with split skin graft. All 7 legs had previously been treated with superficial venous surgery. Laser Doppler scanning of the ulcer area was performed pre- and postoperatively. Five of the 7 ulcers healed within 4 months and 1 healed within 9 months. Laser Doppler scanning showed increased blood flow in the lipodermatosclerotic skin area, which was decreased after the operation. This study indicates that excision of the lipodermatosclerotic skin area followed by split skin grafting can accomplish healing in non-healing venous leg ulcers that have failed to respond to previous superficial venous surgery.

Exposure to metallic gold in patients with contact allergy to gold sodium thiosulfate.

Gold allergy is common, with approximately 10% of patients patch tested because of eczematous disease being positive to gold sodium thiosulfate (GSTS). However, clinical relevance seems to be rare. The aim of this prospective double-blind study was to demonstrate the effects of exposure to metallic gold, in this case earrings, in gold-positive patients. 60 female patients with pierced earlobes test-positive to GSTS were included in the study. The patients were randomized into 2 groups, 30 patients receiving earrings with a surface layer consisting of 24-carat gold and 30 patients earrings with a surface layer of titanium nitride, virtually indistinguishable from gold. The patients wore the earrings for 8 weeks. During the study, any dermatitis on the earlobes, as well as on other body sites, was registered. The skin reactions observed were weak but, in total, 17 of the 60 patients had a skin reaction (local or remote) during the study, 12 of whom had received gold earrings and 5 titanium (p<0.05). 11 patients had a reaction on the earlobes, 7 of whom had received gold earrings and 4 titanium (NS). With these facts it is hard to exclude that exposure to gold jewelry can be clinically relevant in persons hypersensitive to gold.

Efficacy of pinch grafting in leg ulcers of different aetiologies.

The prevalence of leg ulcer disease is high and the health care costs are extensive. Effective therapy is essential to minimise the health care costs and suffering on the part of the patient. If possible, first and foremost, therapy should be aimed at correcting the underlying aetiological defect causing the ulcer. After this has been considered, one of the local therapeutic options is skin grafting using small full thickness skin grafts, i.e. pinch grafting. During the period 1991-1993 altogether 145 therapy-resistant leg ulcers were treated with the pinch graft method at the Department of Dermatology, Malmö University Hospital. The healing rate after 3 months was studied in retrospect. An overall healing rate of 36% was found. The healing rate was dependent on aetiological diagnosis, with a healing rate of 22% in venous and 50% in arterial ulcers. The pinch graft method, which may be used on an out-patient basis offers a simple and relatively effective option in the treatment of leg ulcers. It is recommended as first line skin grafting method. As second line skin grafting method split thickness skin graft, with or without ulcer excision, is recommended.