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2024 Journal Club Archive

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2024

 

December 2024

Click for meeting recording and notes
  • Article 1 take home points:
    • N/A
  • Article 2 take home points:
    • N/A
  • Article 3 take home points:
    • N/A

 

Annie Wang (Hofstra University) presents the best dermatologic surgery relevant literature from the December Journals:

November 2024

Click for meeting recording and notes
  • Article 1 take home points:
    • DFSP incidence is 2-fold higher among Black individuals
    • Risk of DFSP metastasis is significantly increased with tumor size < 3 cm and located on head and neck, and genitalia
    • Larger tumor size (< 3 cm), regardless of location, and age (< 60 years) are the most important prognostic indicators of survival
  • Article 2 take home points:
    • See the Carroll manuscript for IHC validation tips.
    • See the Etzkorn manuscript for operational tips.
    • Repetitions with an experienced colleague helps perceive the trees (criteria) and forest (all together) of margin analysis.
    • High quality slides and stain necessary for margin analysis accuracy.
  • Article 3 take home points:
    • Early water exposure in the immediate postoperative period does not lead to increased risk of infection, hematoma, or bruising
    • Scar cosmesis is not compromised
    • No significant difference in QoL
    • Development of better evidence-based guidelines for immediate post-op care is needed
  • Article 4 take home points:
    • TM51614 in combination with nivolumab has an overall response rate of 25.9%
    • It is well tolerated in anti-PD-1 Ab-refractory unresectable melanoma cohort
    • Larger sample size and longer follow-up is needed for better assessment

 

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

October 2024

Click for meeting recording and notes
  • Article 1 take home points:
    • RT+cemiplimab significantly improved PFS vs. cemiplimab alone in patients with la/mCSCC
    • Further research needed to validate data from real-world studies
  • Article 2 take home points:
    • Save this article and study it before boards.
  • Article 3 take home points:
    • Skin grafts provide a versatile, reliable, and simple approach for reconstructing scalp defects
    • FTSG can be used on exposed calvarium
    • FTSG has increased graft take and decreased wound complications on exposed calvarium and intact pericranium vs. STSG
    • Risk factors affecting outcomes: Grafting exposed bone, larger graft sizes, previous exposure to head and neck radiation, and immunosuppression
    • Similar to study of Jiang et al analyzing FTSG on LE wounds after Mohs where 72/80 cases (90%) had full graft survival, 6/80 (7.5%) had partial failure, and 2/80 (2.5%) had complete failure. Complications included infections in 9/80 (11%) cases and hematoma formation in 2/80 (2.5%).
  • Article 4 take home points:
    • TXA safely reduced postoperative ecchymosis and edema
    • Clinical superiority suggested with IV dosing
    • Improved Early-Postoperative Experience
      • Lower levels of postoperative edema and ecchymosis
      • Faster recovery time
    • Enhance patient satisfaction
    • Intraoperative hemostasis
      • Helps control bleeding during surgery
      • Ensures a clear surgical field
    • No adverse effects
      • IV doses 1000mg

 

Dr. Igor Kapetanovic (University of Minnesota), Dr. Ian Maher (University of Minnesota), Dr. Adam Mattox (University of Minnesota), and Dr. Kathryn Shahwan (Ohio State University) present the best dermatologic surgery relevant literature from the October Journals.:

September 2024

Click for meeting recording and notes
  • Article 1 take home points:
    • Findings suggest that a running SQ may result in a less noticeable scar when compared to a running HM at 3 months.
      • Superior observer and patient overall opinion scores
    • However, there were no significant differences in patient or observer POSAS scores
      • The decision of suture technique should remain dependent on surgeon and patient preference.
    • Maybe deep layer quality is a more significant contributor
  • Article 2 take home points:
    • Patients diagnosed with AFX/PDS had an increased risk of developing subsequent SC when compared to the general population, especially SCC and BD and to a lesser extent BCC.
    • Might reflect the similar pathogenesis of SCC/BD and AFX/PDS.
    • Emphasizes the importance of proper instruction on UV-protection, self-examination and routine total body skin examination in patients with AFX/PDS, particularly in those with a history of SC.
  • Article 3 take home points:
    • There is no evidence that prior WLE meaningfully impacts SLNB in terms of false-negative findings or recurrence.
    • There is mixed anecdotal data on the impact of large rotation flaps on SLNB accuracy.
    • Further trials needed to evaluate this notion, especially with larger rotation flaps on the trunk.
  • Article 4 take home points:
    • NIT is given more selectively to clinical stage III patients with more advanced N category disease
    • Despite significant differences in N category between groups there was no difference in OS observed at 3 years
    • In subgroup analysis, NIT was associated with a survival advantage among N2/N3 patients
    • The national data support the continued usage and study of NIT approaches in patients with high-risk resectable melanoma
  • Article 5 take home points:
    • SRT/eBT may very well have role in the skin cancer armamentarium
    • They themselves are cheaper than traditional radiotherapy, can be offered in outpatient settings, and may offer a good alternative for non-surgical candidates
    • However, in practice they are commonly bundled with codes of questionable value to patient care (e.g. ultrasound, hyperthermia, etc.)
    • There is a limited amount of healthcare resources and a small number of individuals are going to make life tougher for the rest of us.

 

Dr. Igor Kapetanovic (University of Minnesota) and Dr. Adam Mattox (University of Minnesota) present the best dermatologic surgery relevant literature from the September Journals.:

August 2024

Click for meeting recording and notes
  • Article 1 take home points:
    • MMS seems to be the best active management strategy
      • Lowest rate of recurrence or persistence in this review
      • Majority of DTE on the face
      • Frozen histology helpful in cases where BCC and MAC cannot be ruled out.
    • Larger-scale studies necessary to improve understanding on outcomes of DTEs
  • Article 2 take home points:
    • BWM is a viable technique for nasal reconstruction after Mohs
      • Can achieve definitive coverage in soft-tissue defects much larger than previously described.
    • The use of ADM as an adequate departure from the traditional algorithm for nasal reconstruction.
      • Patient selection important, must be accepting of a granulating wound scar.
    • Helps to preserve future autologous reconstruction options
    • Promotes tissue scaffolding that can facilitate reepithelization by secondary intent, or accept a subsequent skin graft, even in defects with exposed cartilage.
    • Plan ahead as insurance coverage in the outpatient setting is varibale.
  • Article 3 take home points:
    • AI applications currently being assessed for integration into MMS and dermatologic surgery for NMSC have the potential to improve the accuracy of tumor detection and enhance surgical planning
    • Extent of these benefits is contingent upon the specific AI models, their integration into clinical workflows, and the quality of the underlying data sets.
    • Methodological transparency of AI needed (disclosure of inclusion criteria of data sets, clear descriptions of the diversity and representativeness of this data with acknowledgement of potential biases, and a thorough assessment of performance metrics)
    • Further research is warranted to establish standardized protocols and validate these findings across diverse clinical environments
  • Article 4 take home points:
    • Mohs surgeons steadily integrating IHC into clinical practice across all regions
    • Adoption rates higher in the Northeast but volume greatest in the South and West
    • Significantly higher utilization rates among ACMS members, recipients of MDS certification, and those in academics likely highlights the importance of formalized training and exposures in improving IHC comfort
    • Recent IHC trends may permit approximation of future IHC adoption rates and further encourage training and educational experiences to drive comfort and proficiency among Mohs surgeons

 

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

July 2024

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  • Article 1 take home points:
    • Longer course based on ID literature showing lower bacterial counts with longer courses
    • Could be useful in very compliant patients
  • Article 2 take home points:
    • MRI most common modality for detecting perineural spread, with high sensitivity
    • CT most common for detecting bony invasion with high specificity and relatively high sensitivity
    • US, PET-CT, and CT most commonly used to detect NM
    • All perform reasonably well, but CT has the highest sensitivity and specificity
    • US: low-risk and cost-effective, but highly operator dependent and less able to detect deeper nodes
    • Imaging for DM is poorly studied
    • Overall, imaging in CSCC appears to change management and improve outcomes
    • Additional research is needed to develop practice guidelines
  • Article 3 take home points:
    • Watchful waiting for SCCIS with a clinically resolved biopsy site has a local recurrence rate of 4%
    • Exercise caution in solid organ transplant recipients, tumors on the head/neck (especially vermilion lip or ear), and with positive deep biopsy margins
  • Article 4 take home points:
    • Local recurrence of invasive melanoma is significantly lower after MMS and staged excision with IHC as opposed to without IHC
    • No statistical difference between IHC and H&E in regards to nodal or distal recurrence and disease-specific mortality
    • Efforts should be made to implement IHC with MMS to improve patient outcomes and decrease local recurrence
    • Prospective studies with uniform reporting and long-term follow-up needed

 

Dr. Ian Maher (University of Minnesota), Dr. Katie Shahwan (The Ohio State University) and Dr. Andrea Tan (The Ohio State University) present the best dermatologic surgery relevant literature from the July Journals.:

June 2024

Click for meeting recording and notes
  • Article 1 take home points:
    • This doesn't count settlements which are the vast majority
    • Consistent with previous studies risk points are:
      • Being a male dermatologist
      • Doing cosmetic procedures
    • Doctors who are well liked by their patients are FAR less likely to be sued
  • Article 2 take home points:
    • MIS on head and neck requires larger margins to achieve clearance
    • Cheek associated with larger subclinical spread
    • Reinforces previous data
    • Subtle differences expected with single center studies
  • Article 3 take home points:
    • Peer comparison and intervention can influence outliers
    • Still relatively sticky. Not much movement.
    • 0.16 stages/case improvement in outliers
    • Also reduced stages in non-outliers
    • Gross savings in inliers ~4x that in outliers.
    • Even these marginal gains resulted in big $$ savings
      • $80m over three-year period
  • Article 4 take home points:
    • Significant risk of SCC metastases for SOTR within 2 years of index SCC
    • Holds with previous risk factors
    • Clinical finding of ulceration also associated with risk
    • Combination of ulceration and high stage had additive negative effect
    • Identifies patients who should be monitored closely
    • Potential area for study of interventions to improve outcomes for these patients

 

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

May 2024

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  • Article 1 take home points:
    • Updated staging during MMS is important
      • Central debulks for cSCC >= 2 cm, poor diff, IS patients
    • Upstaging during MMS occurs more commonly in SOC tumors
      • Greater subclinical extension, results in more MMS layers
    • No difference in rate of high-risk features in SOC cSCC
  • Article 2 take home points:
    • Subq TXA without waiting period significantly decreases post-op ecchymosis in eyelid surgery but not intra-op bleeding
      • The effect of TXA on non-ecchymosis bleeding complications are unknown
    • Local TXA + 15 minute waiting period may reduce intra-op bleeding
    • AEs/complications are extremely rare with subq TXA
  • Article 3 take home points:
    • Large lip repairs can be safely and effectively done under local anesthesia 
    • Complication rate ~8% actually low for literature averages
      • Durable in smokers
      • Durable to radiation
    • Design keys flap width = defect height. Spilling past MLF > making the flap too narrow
    • Really only need full thickness to ~oral commissure then just incise to prefascial plane ergo no risk of motor nerve injury
  • Article 4 take home points:
    • While a nicely presented article with rational approach, Dr. Demer's concerns about use of SRT for skin cancer treatment in the US persist
    • Despite careful pt/tumor selection: recurrence rate 10%+ at 10 years
    • Cost-effectiveness significantly overestimated
    • If performed, consider: low risk tumor, elderly patient, non-surgical candidate, careful counseling, and hypofractionated course without image guidance
  • Article 5 take home points:
    • In otherwise immunocompetent patients with non-inflamed skin, prophylactic antibiotics may not be necessary
    • There are no RCTs assessing the efficacy of antibiotic prophylaxis for prevention of bacteremia, IE, or PJI.
    • Data is limited to small case series and prospective studies, many of which were published several decades ago.
    • There is a need for further research and updated guidelines.

 

Dr. Anderson (University of Minnesota), Dr. Demer (Mayo Clinic College of Medicine and Science), Dr. Mattox (University of Minnesota), and Dr. Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the May Journals.:

April 2024

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  • Article 1 take home points:
    • Discordance in interpretation of IS and variance of IS/VS diagnosis suggest that reviewing IS and VS is something that is reasonable to consider.
    • The nastier something is on vertical sections the more likely you are to have to chase it on layers
    • Learners like more information
    • We’re always challenged to review each slide without bias
  • Article 2 take home points:
    • Staph aureus and Pseudomonas aeruginosa are the most common isolates and can occur in clinically infected or non-clinically infected wounds. Supports that these bacteria can be colonizers in some.
    • Exception - MRSA was seen in only clinically infected wounds.
    • Some clinically infected wounds just grew normal flora.
    • Authors recommend that culture be collected if a wound is clinically infected, but not treat with oral antibiotics initially unless clinical concern for cellulitis. Authors suggest topical antibiotics (mupirocin and gentamicin) until culture data has returned.
  • Article 3 take home points:
    • Overall, patient-centered communication skills, referral to the surgeon by the patient’s physician or family and friends, and staff members who made a favorable impression were some of the most notable factors associated with patients’ confidence.
    • Identifying characteristics that foster confidence can provide ways to strengthen patient–physician relationships (and health outcomes).
  • Article 4 take home points:
    • If you’re already doing CK-7 for EMPD, the protocol is the same for Sebaceous Carcinoma.
    • Knowing the tumor’s CK-7 staining pattern on the original biopsy can help you determine its utility in each case.
    • If CK-7 is not available on the biopsy tissue, a sharp debulk could be used as control tissue.
    • Staining and lack of staining may aid in confirming positive and negative margins.
  • Article 5 take home points:
    • Mail vs mail + phone call had similar level of patients’ sense of preparedness
    • Higher satisfaction ratings if additional pre-op phone call but satisfaction still high without phone call
    • If it’s vital that patient has a driver home, might be worth while to have phone call in addition to mailed materials

 

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

March 2024

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  • Article 1 take home points:
    • mBCC is rare
    • Consider salvage surgery + radiation for nodal mets
      • 50% chance of CR
    • For distant mets Hhi and immunotherapy are the first options in that order
      • Long course
      • Remission is unlikely
  • Article 2 take home points:
    • Useful tool for counseling patients
    • Good reminder of MCC risk factors for those that have to take exams
  • Article 3 take home points:
    • Upstaging of cutaneous melanoma during MMS occurs at a low rate (2.3%)
      • Authors say unclear why their rate is lower than previously published literature. Possibly earlier detection of melanoma, more accurate initial biopsies, or expedited surgery.
    • Majority of those upstaged had either base transected or positive peripheral margin on original biopsy.
    • No statistically significant demographic or tumor-specific risk factors for upstaging were identified.
  • Article 4 take home points:
    • No significant difference in scar outcomes when comparing sutures vs sutures + cyanoacrylate
    • No difference in rates of adverse events
    • Not statistically significant but patients tended to prefer wound care on the cyanoacrylate side
  • Article 5 take home points:
    • Injection of a mixture of bleomycin and triamcinolone seems to be an effective therapy for treatment-resistant keloids. About 80% of patients had an excellent response.
    • Very low recurrence rate (3.3%) at 6 months
    • One-third of patients each experienced ulceration, hyperpigmentation, post-operative pain, and/or infection

 

Dr. Laura Archibald (University of Minnesota) and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the March Journals.:

February 2024

Click for meeting recording and notes
  • Article 1 take home points:
    • Our current staging systems can be used to predict poor outcomes for non-head and neck CSCC
      • Its performance is on-par with what is seen for head and neck CSCC
  • Article 2 take home points:
    • Delay of PORT is associated with increased LRR, usually outside radiation field
      • Each week is a 20% increase in the rate of LRR
    • Starting PORT within 8 weeks (ideally 2-3 weeks) reduces rate of LRR and DSD
  • Article 3 take home points:
    • N/A
  • Article 4 take home points:
    • N/A

 

Dr. Aatman Shah and Dr. Kyle Rismiller present the best dermatologic surgery relevant literature from the February Journals.:

January 2024

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  • Article 1 take home points:
    • Excision of SCCIS with 5 mm margin has very high cure rates
    • Rate of clearance with 4 weeks of 5-FU was 85% (c/w past literature)
    • Non-inferiority studies need to be big to achieve a useful margin of non-inferiority
    • Topical 5-FU remains a reasonable treatment options for low risk tumors in patients willing to accept a lower cure rate to avoid surgery
    • Doing this with 2 groups would have improved the non-inferiority margin (also would have made a positive study less likely)
  • Article 2 take home points:
    • NOAC monotherapy does not have an increased bleeding risk
    • Combo therapy does
    • Supports continuation of therapy
    • ~1/1000 risk of serious event if discontinue anticoagulation
    • Potential tailoring of regiment should be done in consultation with prescribing doctor
  • Article 3 take home points:
    • CAPABLE survey offers a succinct, practical method to assess multiple aspects of the postoperative patient experience
    • Incorporation of the CAPABLE survey in Mohs surgical centers has the potential to improve patient experience and satisfaction
  • Article 4 take home points:
    • Both STSG and SIH can be great options for defects on the cartilaginous ear.
      • Favorable scar outcomes, minimal complications, well-tolerated
    • Patients who underwent STSG had increased pain in the first 3 days after surgery but had faster healing time compared to SIH
      • For majority of patients with STSG, pain still only mild to moderate

 

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