FOR PHYSICIANS

Journal Club

Led by Dr. Ian Maher — a Professor, Director of Dermatology, and Mohs Fellowship Director at the University of Minnesota — the American College of Mohs Surgery's Virtual Journal Club meets each month to discuss the best new literature related to dermatologic surgery.

Directors:
Ian A. Maher, MD, FACMS
Murad Alam, MD, MSCI, MBA, FACMS
Adam R. Mattox, DO, MS

September 2023

Coming soon

August 2023

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Article 1 take home points:
- Globe sparing surgery remains a reasonable tool for preserving critical functions in patients with advanced periocular BCC
- Clinical signs of recurrence are often highly nonspecific
- Recurrent status predisposes to further recurrence
- Recurrences often occur LATE
- Vismodegib is a viable alternative to radiation with lower ocular risks but risk of non-response
- Prolonged close follow up with imaging is critical
Article 2 take home points:
- Poor prognostic features are more common in SCCs in OTRs compared to general population
  - SCCs on arms/hands: PNI and poor differentiation were over 4x more frequent in OTRs
  - SCCs on H/N and trunk/LE: Poor differentiation was over 3x more frequent in OTRs
- Results reinforce the need for early detection of SCCs in OTRs and intensive surveillance over time
- Limitation
  - No central review of SCC pathology
Article 3 take home points:
- ED+C continues to be a reasonable treatment option for low risk tumors
- Is the recurrence rate really that low?
  - Data quality always a problem with retrospective recurrence studies
  - Early in this study period they probably weren't using photos as freely as we are now.
- Lack of standard technique - though results are good so...
Article 4 take home points:
- For clinically and pathologically node-negative patients, no overall or MCC-specific survival difference for MMS compared to WLE
- MMS has advantage of tissue sparing
- Limitations:
  - Retrospective database study, exact margin used not available, data on use of immunostains and immunosuppression status not available, recurrence rates not available
- SLNB associated with improved OS and DSS
- Significantly less patients got SLNB in MMS group vs WLE group
- "MMS should be considered for treatment of MCC as long as SLNB can be performed before surgical resection."
Article 5 take home points:
- N/A

Dr. Ian Maher and Dr. Laura Archibald will present the best dermatologic surgery relevant literature from the August Journals.:

July 2023

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Article 1 take home points:
- Slightly more than half of MMS for melanoma on head and neck
- No survival difference between groups.
  - Kind of a glass half full/half empty thing
  - Wide margin had a higher Breslow depth (0.7 vs. 0.4)
  - More higher stage patients in wide margin group
- No survival disadvantage for narrow margins in on average a T1 population
- Detractors might say that the lack of difference was due to taking wider margins in higher risk tumors
Article 2 take home points:
- Complication definitions have to be the same for everybody
  - We all need to be using the same definition
  - That definition needs to align with other specialties doing the same work
- There have been previous efforts within Mohs to make a standard definition
- Knowledge of that definition is a major gap
- A lot of respondents seemed to be using an inappropriately short horizon for SSI.
Article 3 take home points:
- MCC treatment in a facility with academic affiliation and high case volume seems to improve survival.
- Care regionalization helps improve outcomes in some malignancy.
- Care regionalization may help improve MCC outcomes
  - More data on disease specific survival and local recurrence needed.
- Potential benefits and feasibility of MCC care regionalization studies needed.
Article 4 take home points:
- In this cohort, digital pathology decreased operative time and improved accuracy of Mohs surgery
- Limitations:
  - Retrospective, single institution
  - Relatively small cohort (80 patients)
  - Not generalizable
Article 5 take home points:
- In this cohort, pain level did not significantly increase with subsequent Mohs stages
- Vast majority of patients (~90%) reported only mild to moderate levels of intraoperative pain, supporting the use of Mohs surgery in the outpatient setting as a well-tolerated procedure
- Limitations:
  - Pain is an inherently subjective measure

Dr. Ian Maher (University of Minnesota), Dr. Adam Mattox (University of Minnesota), and Dr. Laura Archibald (Fellow, University of Minnesota), present the best dermatologic surgery relevant literature from the July Journals.:

June 2023

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Article 1 take home points:
- Bony Invasion is not well defined.
- Management of periosteum involvement is variable
  - Referral for superficial cranioplasty is most common
  - Superficial Cranioplasty seems to have the most evidence supporting
- Consider Tumor Boarding T3-T4 tumors
Article 2 take home points:
- PDT seems more effective resolving AKs
  - SCC prevention undetermined
- Excellent cosmetic outcomes and patient preference.
- More common and severe adverse effects
  - AE's resolve
  - Protocols can be manipulated to lessen adverse effects
Article 3 take home points:
- Mohs Surgeons Dominate!
  - Cutaneous reconstructions at CFS sites broadly
  - All recon categories, except interpolation flaps
  - With increasing lead from 2013-2019
- Interpolations: "you can do it"
- Tell your friends!
Article 4 take home points:
- N/A

Dr. Adam Mattox (University of Minnesota), Dr. Addison Demer (Mayo) and Dr. Daniel Knabel (Medical College of Wisconsin), present the best dermatologic surgery relevant literature from the June Journals.:

May 2023

No Journal Club meeting reviewing May 2023 literature.

April 2023

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Article 1 take home points:
- We need to prescribe fewer opiates
- Many patients do not take their full course ergo excess can be diverted
- Effective non-addicting alternatives are available
- Legislation is effective, but do we want that level of administrative encroachment
Article 2 take home points:
- Studies show efficacy of resurfacing laser for improving scar appearance as early as day 0
- No difference in appearance at day 0 vs. day 14 for fractional ablative resurfacing
- Question of early vs. delayed scar treatment remains
Article 3 take home points:
- Baseline US and PET can be used to detect regional MCC prior to SLNB
  - But why? Would you trust it?
- Baseline US w/ FNA is not a substitute for SLNB in those with localized MCC
  - FN rate of >30%
  - In those with negative imaging, ~25% were upstaged with SLNB
- PET may be useful in those w/ stage III MCC to detect distant dz
Article 4 take home points:
- MMS patients with eligible melanomas significantly less likely to have SLNB
  - Across all T stages
  - Even in matched cohort analysis
- Further studies needed to explore root cause
Article 5 take home points:
- SLNB added net benefit at treatment thresholds of 30% or higher, at which adjuvant therapy is typically given
  - Persisted across T stages and age ranges
- Prognostic value of SLNB is clinically meaningful

Dr. Kyle Rismiller (University of Minnesota Fellow), Dr. Katie Shahwan (Altru Health System) and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the April Journals.:

March 2023

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Article 1 take home points:
- Both procedures were equally efficacious, had minimal complications, and showed no recurrence at 6 months and 1 year.
  - Both with variable pros/cons
Article 2 take home points:
- Education level was not statistically significantly associated with health care literacy
- Increased age was associated with lower health care literacy
Article 3 take home points:
- Understanding processing needs for special tissue types are important for successfully running a Mohs lab
- Additionally, these are easy things to write questions about.
- Very high yield
- This article is an excellent, concise resource for adipose processing.
Article 4 take home points:
- Tough area to repair
- Seems to be a good option for small defects in this area
- Does not require grafting of donor site or immobilization like many flaps on the finger
- Can survive over bare nail plate or tendon unlike graft
- Always good to have options

Dr. Laurin Council (Washington University in St. Louis), Dr. Addison Demer (Mayo Clinic), and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the March Journals:

February 2023

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Article 1 take home points:
- Risk factors for poor outcomes in SCC are well established
- Event though established in small testing subset they are widely extrapolable
- We still don't REALLY know what to do to improve outcomes
- Prospective randomized trials on the use of adjuvant radiation, neoadjuvant PD-1, etc. are needed to define care pathways for high-risk patients.
Article 2 take home points:
- Dermatologists' visual dx of BCC is very accurate
- Shave removal has some advantages over shave and ED+C for the rare instances when we are wrong
- Shave removal of low-risk BCCs in low-risk areas produced histological clearance ~75% of the time
- Reasonable option for patients looking to minimize trips
- N.B. intention matters. 2mm clinical margin was taken on these shaves. Larger or smaller margins would influence results.
- Authors report no clinical recurrences
Article 3 take home points:
- In-office treatments such as photodynamic therapy represent a cost-effective (low cost and high adherence) alternative to topical therapies with comparable efficacy.
- Treatment choice for AK should balance efficacy, adherence, cost, tolerability, individual risk of KC, and patient concerns and motivation.
Article 4 take home points:
- Compliance with NCCN guideline of SLNB for MCC is increasing but remains low (~55%)
  - Significantly lower than for SLNB rates for melanoma and breast cancer
- Lower compliance of SLNB with Mohs
  - Head/neck location
  - Requires 2 asynchronous surgeries
Article 5 take home points:
- Complication rates following interpolated flap repair in outpatient setting are low
- Bleeding and infection are most common (4-5%), more frequent after 1st stage (3:1)
  - Manageable in outpatient setting

Dr. Adam Mattox (University of Minnesota), Dr. Kyle Rismiller (University of Minnesota Fellow), and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the February Journals:

January 2023

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Article 1 take home points:
- Excellent outcomes with Mohs surgery alone in high risk SCC
  - Superior to those reported in cohorts treated with wide local excision
- Adjuvant radiation and/or selective neck dissection may be unnecessary in patients with clear margins following Mohs surgery
- Favorable survival outcomes even after salvage therapy
Article 2 take home points:
- Fellowship-trained Mohs surgeons show 99.79% concordance with board-certified dermatopathologists in frozen section interpretation
Article 3 take home points:
- High local control and low mortality with histologic PNI in BCC with both surgery and surgery + RT
- No statistically significant benefit with adjuvant RT compared to surgery alone
- Adjuvant RT unlikely to be of significant benefit in histologic PNI with clear margins
Article 4 take home points:
- Local recurrence rates for EMPD were significantly lower following Mohs surgery vs. WLE
  - 2.67x higher odds of recurrence after WLE than MMS
  - 7.3% rate of recurrence with MMS vs. 26.3% with WLE
Article 5 take home points:
- In patients with T1a melanomas, risk factors significantly associated with SLNB positivity on multivariable analysis were:
  - Age less than or equal to 42 years
  - Mitotic rate less than or equal to 2/mm²
  - LVI
  - Head and neck location
- SLNB positivity significantly reduced survival in T1a melanomas
  - 5-year disease specific survival: 90.7% vs. 99.5% (P<.0001)
  - 5-year recurrence free survival: 81.4% vs. 95.6% (P<.0001)

The best dermatologic surgery relevant literature from the January Journals is presented.:

December 2022

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Article 1 take home points:
- Immunosuppressed patients are more likely to get nasty tumors
- They don't seem to do any worse than immunocompetent controls
- Really bad SCCs are really bad
- There is always a risk of misclassification of tumors in retrospective studies, but these are two institutions who have been tracking these variables for some time
Article 2 take home points:
- There is no evidence for routinely prescribing post-op antibiotics
- We should minimize this practice as much as possible for primary surgical site infection
- Guidelines should be followed for endocarditis and joint infection prophylaxis
Article 3 take home points:
- Application of Porcine Xenograft associated with reduction in postoperative pain and analgesic use.
- Difference in pain most relevant in 1st week.
- Healing time and degree of scar contracture were similar between groups.
Article 4 take home points:
- Nylon, IPG, and FG top sutures are equivalent in "long-term" scar erythema
  - Inert, single-stranded top sutures may not be less inflammatory
- Greatest change in incisional erythema happens within first 2 months
Article 5 take home points:
- Current staging systems work but do not capture the non-significant number of patients with early-stage CM that die from their disease
  - The 31-GEP may be key to bridging this gap
- 31 GEP alone is not sufficient

Dr. Ian Maher (University of Minnesota), Dr. Kyle Rismiller (University of Minnesota Fellow), and Dr. Adam Mattox (University of Minnesota) present the best dermatologic surgery relevant literature from the December Journals.:

November 2022

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Article 1 take home points:
- Local bupi significantly decreased pain scores in the first 24 hours
  - When pain is highest
  - Many have negligible pain scores after first 24h
- Less opiates consumed in bupi group
  - Most patients can have their pain controlled without opiates
  - Did availability of opiates decrease difference between groups
- Alternating Tylenol and Ibuprofen shows similar efficacy to opiates
- Many patients lack enzyme to convert both codeine and tramadol to active moieties
Article 2 take home points not available
Article 3 take home points:
- Education Satisfaction Scores Trend Toward
  - Higher satisfaction with video education on the day of surgery
  - Higher satisfaction with handout (reviewable) after 3 months
- Maximum satisfaction might include a video on the day of surgery and reviewable materials.
Article 4 take home points:
- Prior retrospective studies generally showed no significant difference in OS for WLE and MMS
  - Similar limitations (small census, retrospective)
- No clear benefit in outcome for MMS but still has a role in select patients
Article 5 take home points:
- Overall risk of motor nerve injury for MMS in the temporofrontal region is <5%
- Aggressively counsel on nerve injury for tumors ≥ 3 cm, reassure for tumors < 2 cm
  - Risk x40 for tumors/defects ≥ 3 cm
- No difference in risk for SCC vs BCC
- Nerve damage attributable to extirpation over recon

October 2022

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Article 1 take home points:
- Affirms the known morbidity of bone invasion
- Also affirms that bone invasion doesn't occur routinely
- Reinforces the importance of good physical exam in setting of recurrence or marjolin ulcers
- Consider imaging if tumor is fixed or if it's hard to tell
Article 2 take home points:
- ~30% difference in DSS in those with neg and pos SLNB status
- There is prognostic utility of SLNB in those with high-risk primary tumors
  - May assist in deciding on adjuvant PD1 inhibitor tx with ≥ T3b
- Data c/w prior studies showing no DSS benefit for SLNB vs observation
Article 3 take home points:
- Local flaps and grafts may be a/w higher risk of SSI
  - Did not account for possible sampling bias and other confounders (site, defect size, bleeding, surgery duration, etc.)
  - Purulent/infected sites a/w SSI
  - No increased risk of SSI with second intent and (likely) delayed closure
Article 4 take home points:
- 95% of AFX tumors cleared with surgical margins of 2 cm, and cUPS, of 3 cm.
- Smaller margins may be effective for smaller AFX tumors.
- Larger tumors may require larger margins.
- MMS allows the chance to clear tumors with smaller margins
- Margin-controlled techniques increase clearance rates, spare normal tissue, and preserve structure and function.
- A multicenter cohort study or additional case-level data would provide more inputs for the model.

September 2022

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Article 1 take home points:
- RTCs in OTRs with topical therapy are feasible
- 5-FU may be superior to IMIQ and sunscreen in AK clearance & prevention
  - May be more side effects associated with 5-FU
- Sunscreen is still important! Approx. 1/3 of AKs cleared in sun-screened arm
Article 2 take home points:
- Cosmetic outcome with repairs likely summation of many individual components. Any single minor component unlikely to be make or break
  - Including deep suture spacing 1-cm vs. 2-cm
- Central deep suture likely most important for tension offloading/bearing
  - If midpoint suture doesn’t fail, others may be “superfluous”
- PDS (and Vicryl) like (2) to split… 17 suture abscesses among 50 cases
Article 3 take home points:
- Rule of thirds (33% CR, 66% OR, 100% SE, 33% discontinue 2/2 SE) likely applies to periocular tumors
- Neoadjuvant SMOi important tool in the tool box, but literature is limited and optimal approach/timing unknown
- Low threshold to respect initial tumor footprint if feasible. Timing = maximum tumor response/nadir
- Systemic review/metanalysis data only as good as individual studies; herein pool overall
- CR after successful neoadjuvant vismodegib/surgery is very good (in limited published cases to date); however, selection bias.
Article 4 take home points:
- Location alone cannot predict risk of CI
  - Gross tumor on the medial canthus was NOT a predictor
  - Shallow defects on the eyelids may cause CI without involving the medial canthus or lacrimal sac
- Aggressive histology is more likely in cases of CI
- Number of stages approaches significance
  - Each stage is subjective
- Facial radiation, immunocompromised status, preoperative and postoperative size, and history of eyelid procedures cannot predict risk of CI

Dr. Daniel Knabel (Medical College of Wisconsin), Dr. Addison Demer (Mayo Clinic) and Dr. Adam Mattox (University of Minnesota) present the best dermatologic surgery relevant literature from the September Journals.:

August 2022

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Article 1 take home points:
- Keloids have a heavy burden of disease
- Removal is challenging
- Adjunctive therapy with ICS/antiproliferatives/radiation is helpful in decreasing recurrence
- Familiarity with various RT options can help guide decisions
- RT is a reasonable and safe adjuvant
- This article is a great resource for counseling patients on what to expect and reasonable range of recurrence rates.
Article 2 take home points:
- A lot more of us are doing immunostains than used to
- This is awesome
- There is an industry now that is developing new products
- We need to be familiar with the attributes of the stains we use
- All of them require interpretation within this context
- H+E correlation is ALWAYS necessary
Article 3 take home points:
- Bilobed/trilobed flaps are repair options for large defects of nose with good cosmesis
  - Even in smokers
- Tips for lobed flaps with large defects:
  - Extend flap in glabella if needed
  - Meticulous undermining of flap and adjacent tissue in submuscular plane
  - Detach fibrous attachment of skin to bone at periosteum with CTA
  - Slightly oversize primary lobe to reduce tension
Article 4 take home points:
- Increasing Breslow strongly a/w worsening survival for thin, intermediate and thick melanomas
  - Progressive association lost for "ultrathick" melanomas ≥ 15 mm
- Desmoplastic melanomas may be overrepresented in ultrathick melanomas
- Further studies of ultrathick melanoma may indentify novel drivers of prognosis (Gene Expression Profiling?)

Dr. Ian Maher (University of Minnesota) and Dr. Adam Mattox (University of Minnesota) present the best dermatologic surgery relevant literature from the August Journals.:

July 2022

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Article 1 take home points:
- Whether Mohs surgery makes sense for a very elderly patient can depend on many factors
  - Thoughtful patient-physician discussion avoids these nuances being overlooked
- A few key factors presently identified by Mohs surgeons are facial tumor, functional status, and high-risk tumor histology
Article 2 take home points:
- The MAUDE database complements published literature on device safety with post-market surveillance data
- An increased awareness of the MAUDE database can increase both its data in and data out
- Limitations of MAUDE database
  - Potential underreporting
  - Quality of patient-submitted reports may vary
  - Reported adverse effects could be medically unsubstantiated or unrelated to device; counterfeit devices could be used
- Database user should correlate number of reports to total number of a given procedure performed in US for best interpretation
Article 3 take home points:
- Pharmacologic anxiolytics are used rarely (<10% of cases)
- Music and talk therapy more commonly used
- Benzodiazepines are leading pharmacologic anxiolytic used
- Study limitations include recall bias and small sample size
Article 4 take home points:
- CMA reduces recurrence of high-risk KC by > 3-fold compared to SA
Article 5 take home points:
- ED&C and C&C carry lower recurrence rates for SCC and SCCIS
  - Recurrence rate of 2-5%

Dr. West Mori and Dr. Kyle Rismiller will present the best dermatologic surgery relevant literature from the July Journals.:

June 2022

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Article 1 take home points:
- Risk of invasive SCC was highest in patient with Olson grade III AK lesions.
- Risk was substantially increased in patients who received additional treatment.
- "Close" follow up of these patients recommended.
Article 2 take home points:
- The quality of the data you put into a systematic review correlates with the quality of the information you get out.
- Our data for cSCC is almost entirely retrospective
- This affirms what we already know - there is not strong evidence for the efficacy of ART in the setting of negative surgical margins
- However these patients do poorly and I imagine may will continue referring these patients (myself included)
- We need real trials that look at this issue
Article 3 take home points:
- Mohs well tolerated by vast majority of patients
- Authors used bupivacaine on all patients
- Higher pain scores with non-primary closures
- This study excluded those on chronic analgesics who are at risk of difficult to control post op pain
- Check out Bryan Carroll's lecture from the ACMS meeting last year
Article 4 take home points:
- There are always many more low stage than high stage tumors
- A significant proportion of mets/deaths will occur from these due to the huge denominator
- Increasing granularity in staging can help identify patients at risk for poor outcomes and drive study
- This model has higher specificity and NPV than sensitivity and PPV
- Likelihood still under 10% with this model so ? application

Dr. Ian Maher (University of Minnesota) presents the best dermatologic surgery relevant literature from the June Journals.:

May 2022

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Article 1 take home points:
- Overall, surgical treatment of H/N BCC in older adults is safe, minimally burdensome, and well-tolerated
- No difference between MMS and CE in treatment burden or complication
- Frailty-related characteristics (iADL dependency and polypharmacy) predicted higher treatment burden and overall mortality
- Physicians should avoid making treatment decisions solely based on age
- Frailty-related patient characteristics should instead be prioritized when considering treatment approach for H/N BCC in elderly patients
- Early intervention is beneficial for: robust and fit patients, and those experiencing symptoms
- Treatment choices should align with pt values/goals/preferences and consider estimation of life expectancy, risk of treatment, and timeline of sequelae of BCC non-treatment
Article 2 take home points:
- BWH and AJCC8 are superior to the Tubingen and Salamanca Refinement
- BWH has the highest discriminative ability
- PPV important to recommend intervention, all 4 need improvement
- NPV important to know when intervention is unnecessary
Article 3 take home points:
- Many possible "whys": incisional biopsies may be taken of large lesions, partial biopsy may contribute to sampling error and undertreatment, not the favored method of dermatologists so maybe receiving treatment by specialty not as familiar with skin cancer
- Also, a relatively imprecise term (a punch of a large lesion is an incisional biopsy)
- Supports use of common derm biopsy techniques to drive proper treatment
Article 4 take home points:
- Lip lift is a surgical technique within the capabilities of a Mohs surgeon
- It provides lasting increase in red show
- Does not address volume loss
- Could be an interesting adjunct to the cosmetic arsenal

Dr. Adam Mattox (University of Minnesota), Dr. Addison Demer (Mayo Clinic), and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the May Journals:

April 2022

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Article 1 take home points:
- Subclinical extension of superficial BCC was as likely as SCE as "aggressive" subtypes. Study also found that when HS drift occurs, the most likely subtype to extend subclinically is superficial BCC.
- We often think of sBB as harmless, low risk subtype...but perhaps we should consider MMS more often?
- Limitations: Histologic subtypes from index biopsy may not be representative of all HSs present, resulting in sampling bias.
Article 2 take home points:
- Not available
Article 3 take home points:
- Utilization of pharmacologic anxiolytics is low among Mohs surgeons.
  - If using anxiolytic, predominantly using benzodiazapines
- What do we do at CDCS? Music therapy and talk-esthesia. Also if patients requests or has prescription already.
  - Make sure pt is of sound mind when signing consent; make sure have a driver for day of procedure.
- Limitations: small sample size, recall bias (survey); would be nice to know dos'ing used.
Article 4 take home points:
- Not available

Dr. M. Laurin Council and Dr. Ali Edelman present the best dermatologic surgery relevant literature from the April Journals:

March 2022

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Article 1 take home points:
- Skin grafts with "augmentation" can be a viable option for defects that would otherwise not produce an acceptable cosmetic outcome with FTSG alone.
- Reserved for patients unable or unwilling to tolerate local flaps or two-staged flaps.
Article 2 take home points:
- Not available
Article 3 take home points:
- We still need data from well-designed, prospective, multi-site studies
- This contributes to mounting evidence that MMS may be superior to WLE for MIS and invasive melanoma
  - Particularly in specialty sites
- Many studies in the MMS group did not use IHC
- Effect of initial margins is not made clear
Article 4 take home points:
- No tumors required a total circumferential re-excision margin
  - Mohs offers benefit of *selective* directional re-excision
- Cure rates for MMS for NIM and IM may be superior to WLE
  - Prospective RCT data needed
  - Data in other work indicates use of IHC may lead to even lower recurrence

Dr. Nick Golda (University of Missouri Health Care) and Dr. Brianna Castillo (Fellow, University of Missouri Health Care) present the best dermatologic surgery relevant literature from the March Journals.

February 2022

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Article 1 take home points:
- SLN Bx is a test with prognostic implications
- It will modulate outcomes when there are interventions based on the result that modulate the outcome
- If it doesn't predict outcomes reliably then it can't guide therapy
- So what's the point?
Article 2 take home points:
- Hispanic/Latino patients have statistically significantly larger MMS defect sizes
  - So do patients with Medicaid/HMO
- Many factors may contribute to these findings
- Authors recommend more efforts to promote sun-protective behaviors through media, community outreach, in school, and at PCP offices
Article 3 take home points:
- Insufficient data to reliably compare WLE and MMS for MCC
  - 2,000 patients worth of data for WLE versus 113 patients worth of data for MMS
- Patients who received WLE had more severe and advanced disease at onset, complicating comparisons of recurrence rates
- When performing sub-analysis on patients with stage I MCC, WLE and MMS were similar regarding local, regional, and distant recurrence
- MMS may be favored in areas with early-stage tumors where excising with 1-2 cm margins is not feasible for functions or cosmesis
Article 4 take home points:
- You're not an expert unless you're trained
- You're not "trained" unless it's documented
- Demonstrating and documenting competence is going to be key
Article 5 take home points:
- This guidelines document is really helpful
- We obviously don't take care of the kids, but we take care of the parents
- There is serious early childhood disease that we should be alerting our patients of childbearing potential to

Dr. Ian Maher (University of Minnesota) and Dr. West Mori (University of Minnesota Fellow) present the best dermatologic surgery relevant literature from the February Journals.

January 2022

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Article 1 take home points:
- Comparison between bread-loafed biopsy margin and Mohs margin isn't a good one.
- Underlines the lack of reliability of biopsy margins
- ~1/5 of tumors "cleared" by biopsy will have residual tumor on exhaustive margin examination (at the surgical margin)
Article 2 take home points:
- Incidence of infection and all-cause postoperative morbidity appears to be lower for placental grafts versus flaps and FTSG
- Limitations:
  - Cohorts not randomized
  - Need for possibly frequent reapplication of placental graft, necessitating more postop visits
  - Placental grafts more expensive
  - Unclear degree of value-add compared to second intent as this was not studied
  - Did not use a standardized scale for measuring cosmetic appearance
Article 3 take home points:
- ALM subtype independently associated with higher risk of SLN positivity
- Higher risk in stage IB and II impacts clinical management
  - Much higher than 10% cut-off for offering SLN biopsy, per NCCN guidelines
- Patients should receive appropriate counseling about higher regional metastatic risk of their cancers
  - 26% with stage IB and 20% with stage II ALM did NOT undergo SLN biopsy
- Limitations
  - Not enough cases of stage IA ALM to allow analysis of SLN positivity rate or survival
Article 4 take home points:
- Mohs is great
- Can't use it for everything
- Value = Quality/cost
- When efficacy ~ equal, hard to argue for a more expensive treatment.
- We've made great progress.
- We shouldn't screw it up.

Dr. Ian Maher (University of Minnesota) and Dr. West Mori (Fellow, University of Minnesota) present the best dermatologic surgery relevant literature from the January Journals.

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