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The incidence of cutaneous squamous cell carcinoma (cSCC) continues to increase, and it is now predicted that the number of deaths from cSCC will surpass that of melanoma within the next 5 years. Although most cSCCs are successfully treated, there exists an important subset of high-risk tumors that have the highest propensity for local recurrence (LR), nodal metastasis (NM), and disease-specific death (DSD).We investigated the clinical outcomes of high-risk cSCCs treated with Mohs surgery (MS) alone, analyzing LR, NM, distant metastasis, and DSD. In addition, we analyzed progression-free survival and DSD in patients who underwent salvage head/neck dissection for regional NMs.Retrospective review of all high-risk cSCC treated in our clinics between January 1, 2000, and January 1, 2020, with follow-up through April 1, 2020.Two university-affiliated, private-practice MS referral centers.In total, 581 high-risk primary cSCCs were identified in 527 patients, of which follow-up data were obtained for 579 tumors. The 5-year disease-specific survival was 95.7%, with a mean survival time of 18.6 years. The 5-year LR-free survival was 96.9%, the regional NM-free survival was 93.8%, and the distant metastasis-free survival was 97.3%. The 5- and 10-year progression-free survival rates from metastatic disease were 92.6 and 90.0%, respectively. In patients who experienced regional NMs and underwent salvage head and neck dissection with or without radiation, the 2-year disease-specific survival was 90.5%.Our cohort, which is the largest high-risk cSCC cohort treated with MS to date, experienced lower rates of LR, NM, and DSD than those reported with historical reference controls using both the Brigham and Women's Hospital and American Joint Committee on Cancer, Eighth Edition, staging systems. We demonstrated that MS confers a disease-specific survival advantage over historical wide local excision for high-risk tumors. Moreover, by improving local tumor control, MS appears to reduce the frequency of regional metastatic disease and may confer a survival advantage even for patients who develop regional metastases.

Traditionally "aggressive" histologic subtypes (HSs) of basal cell carcinoma (BCC) are more likely to quantitatively exhibit subclinical extension (SCE), requiring more stages during Mohs micrographic surgery (MMS) and, therefore, larger margins upon excision. However, the tendency for SCE has never been compared between HSs of BCC in a prospective manner.To prospectively correlate the HS of BCC with the likelihood of SCE as defined by the number of MMS stages required to clear the tumor.In a prospective, multicenter study involving 17 Mohs surgeons in 16 different practices across the United States, data regarding 1686 cases of BCC undergoing MMS were collected. Patient demographics, tumor characteristics, number of MMS stages required for tumor clearance, and specific BCC subtypes noted on both index biopsy and the final MMS stage were recorded.Analysis of the average number of MMS stages for each HS required to clear tumor revealed 2 distinct degrees of SCE (P .0001): high (higher than average) risk of SCE (1.9 stages, 1.0 SD) and low (lower than average) risk of SCE (1.6 stages, 0.9 SD). Subtypes of BCC within the high category were morpheaform (2.1), infiltrative (1.9), metatypical (1.9), mixed (1.8), and superficial (1.8). The low category included BCC subtypes of basosquamous (1.6), micronodular (1.6), nodular (1.6), and unspecified (1.5). Three hundred twenty-four cases (22.0%) manifested HS drift or a change in subtype from index biopsy to the final MMS stage. Superficial BCC was the only subtype that showed an increase in prevalence from index biopsy to the final MMS stage (from 16.0% to 25.8%; P .0002).HSs from index biopsy may not be representative of all HSs present, resulting in sampling bias.SCE of superficial BCC was as likely as SCE of BCC subtypes that are considered "aggressive" and are deemed "appropriate" for MMS by the appropriate use criteria. Our study also found that when HS drift occurs, the most likely subtype to extend subclinically is superficial BCC.

Background There is a need to improve prognostic accuracy for patients with cutaneous melanoma (CM). A 31-gene expression profile (31-GEP) test uses the molecular biology of primary tumors to identify individual patient metastatic risk. Objective Develop a nomogram incorporating 31-GEP with relevant clinical factors to improve prognostic accuracy. Methods In an IRB-approved study, 1,124 patients from nine Mohs micrographic surgery centers were prospectively enrolled, treated with Mohs micrographic surgery, and had 31-GEP testing. Data from 684 of those patients with at least one-year follow-up or a metastatic event were included in nomogram development to predict metastatic risk. Results Logistic regression modeling of 31-GEP results and T stage provided the simplest nomogram with the lowest Bayesian information criteria score. Validation in an archival cohort (n=901) demonstrated a significant linear correlation between observed and nomogram-predicted risk of metastasis. The resulting nomogram more accurately predicts the risk for CM metastasis than T stage or 31-GEP alone. Limitations The patient population is representative of Mohs micrographic surgery centers. Sentinel lymph node biopsy was not performed for most patients and could not be used in the nomogram. Conclusions 31-GEP and T stage can be integrated to gain clinically useful prognostic information from data obtained non-invasively.

Evidence supports the safety of Mohs micrographic surgery for melanoma. Because of its potential benefits to the patient in terms of very low-recurrence rates and same-day histologic confirmation of tumor removal with reconstruction of tumor-free margins of potentially smaller wounds, it should be one of the treatment options considered. The informed consent process for the patient should not be complete without a discussion of the attributes of Mohs surgery for melanoma.

Background Microscopic evaluation of the entire surgical margin during excision of cutaneous malignancies results in the highest rates of complete excision and lowest rates of true local scar recurrence. Few studies demonstrate the outcomes of Mohs micrographic surgery specifically for invasive melanoma of the trunk and proximal portion of the extremities. Objective To evaluate the long-term efficacy of Mohs micrographic surgery for invasive melanoma of the trunk and proximal portion of the extremities, including true local scar recurrence rate, distant recurrence-free survival, and disease-specific survival. Methods Prospectively collected study of 1416 cases of invasive melanoma of the trunk and proximal portion of the extremities was performed to evaluate long-term outcomes. Results True local scar recurrences occurred in our cohort at a rate of 0.14% (2/1416), after a mean follow-up period of 75 months and were not associated with tumor depth. The rate of satellite/in-transit recurrences and the disease-specific survival stratified by tumor thickness were superior to historical control values. Limitations We used a nonrandomized, single institution, retrospective design. Conclusions Mohs micrographic surgery of primary cutaneous invasive melanoma on the trunk and proximal portion of the extremities resulted in local control of 99.86% of tumors and an overall disease-specific death rate superior to that of wide local excision.

Aim: To clinically validate the 40-gene expression profile (40-GEP) test for cutaneous squamous cell carcinoma patients and evaluate coupling the test with individual clinicopathologic risk factor-based assessment methods. Patients & methods: In a 33-site study, primary tumors with known patient outcomes were assessed under clinical testing conditions (n = 420). The 40-GEP results were integrated with clinicopathologic risk factors. Kaplan–Meier and Cox regression analyses were performed for metastasis. Results: The 40-GEP test demonstrated significant prognostic value. Risk classification was improved via integration of 40-GEP results with clinicopathologic risk factor-based assessment, with metastasis rates near the general cutaneous squamous cell carcinoma population for class 1 and ≥50% for class 2B. Conclusion: Combining molecular profiling with clinicopathologic risk factor assessment enhances stratification of cutaneous squamous cell carcinoma patients and may inform decision-making for risk-appropriate management strategies.

Background Merkel cell carcinoma (MCC) of the skin is most commonly treated with wide local excision (WLE) with or without adjuvant radiation therapy (RT). Mohs micrographic surgery (MMS) as monotherapy may offer an alternative treatment modality. The purpose of this study is to describe outcomes of patients with primary Stage I/II MCC treated with MMS alone and no RT. Methods A retrospectively collected sample of 56 MCCs treated with MMS was studied over an 18-year period. Tumor and treatment characteristics were described, and follow-up was assessed. Results A total of 56 primary Stage I/II MCCs in 53 patients were treated with MMS as monotherapy from April 2001 through July 2019. Patients were followed for an average of 4.6 years (median 2.7 years, range 0.8 to 16.9 years), of which 19 (33.9%) had follow-up of 5 years or more. There were no local recurrences due to inadequate excision. The 5-year Kaplan-Meier MCC-specific survival for AJCC8 Stage I and AJCC8 Stage IIA were 91.2% and 68.6%, respectively. Conclusion In comparison to historical controls, Mohs surgery offers a survival that is at least as good as WLE +/- RT, with the added benefits of no need for adjuvant RT or the need for further surgery for treatment of local recurrence.

Objective Over 50% of newly diagnosed cutaneous squamous cell carcinoma (cSCC) lesions occur in the head and neck (cSCC‐HN), and metastasis to nodal basins in this region further complicates surgical and adjuvant treatment. The current study addressed whether the 40‐gene expression profile (40‐GEP) test can predict metastatic risk in cSCC‐HN with improved accuracy and provide independent prognostic value to complement current risk assessment methods. Study Design Multicenter, retrospective cohort study. Methods Formalin‐fixed paraffin‐embedded primary tumor tissue and associated clinical data from patients with cSCC‐HN (n = 278) were collected from 33 independent centers. Samples were analyzed via the 40‐GEP test. Cases were staged per American Joint Committee on Cancer, Eighth Edition (AJCC8) and Brigham and Women's Hospital (BWH) criteria after comprehensive medical record and pathology report review. Metastasis‐free survival (MFS) rates were determined, and risk factors were analyzed via Cox regression. Results The 40‐GEP test classified the cohort into low (Class 1, n = 126; 45.3%), moderate (Class 2A, n = 134; 48.2%), and high (Class 2B, n = 18; 6.5%) metastatic risk at 3 years postdiagnosis. Regional/distant metastasis occurred in 54 patients (19.4%). MFS rates were 92.1% (Class 1), 76.1% (Class 2A), and 44.4% (Class 2B; p

Background Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence. Objective To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction. Methods This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at ≥80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval. Results Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid. Conclusion Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommendations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic.

Skin cancer is the most common malignancy affecting solid organ transplant recipients (SOTR), and SOTR experience increased skin cancer-associated morbidity and mortality. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. We conducted three rounds of Delphi method surveys with a panel of 84 U.S. dermatologists and transplant physicians to establish skin cancer screening recommendations for SOTR. The transplant team should risk stratify SOTR for screening, and dermatologists should perform skin cancer screening by full-body skin examination. SOTR with a history of skin cancer should continue regular follow-up with dermatology for skin cancer surveillance. High-risk transplant patients include thoracic organ recipients, SOTR age 50 and above, and male SOTR. High-risk Caucasian patients should be screened within 2 years after transplant, all Caucasian, Asian, Hispanic, and high-risk African American patients should be screened within 5 years after transplant. No consensus was reached regarding screening for low-risk African American SOTR. We propose a standardized approach to skin cancer screening in SOTR based on multidisciplinary expert consensus. These guidelines prioritize and emphasize the need for screening for SOTR at greatest risk for skin cancer.

Background There is little evidence to predict patient outcomes after the treatment of high-risk cutaneous SCC (hrSCC) using Mohs micrographic surgery (MMS). Objective We sought to report the rates of poor outcomes in patients with hrSCC treated by MMS alone and to determine if any specific clinical factors may be more predictive of these outcomes. Methods We conducted a retrospective chart review of all patients with hrSCC who were treated in our clinic between October 2011 and December 2015. Results We identified 647 hrSCC tumors that met the inclusion criteria. During the follow-up period, there were 19 local recurrences (2.9%), 31 nodal metastases (4.8%), 7 distant metastases (1.1%), and 7 disease-specific deaths (1.1%). Two factors, poor differentiation and invasion beyond the subcutaneous fat, were positively associated with local recurrence, nodal metastasis, and disease-specific death through multivariate analysis. Conclusions Invasion beyond the subcutaneous fat and poor histologic differentiation may carry a greater risk of poor outcomes than other factors in hrSCC. MMS alone provides excellent marginal control with low rates of local recurrence, nodal metastasis, and disease-specific death.

Background The efficacy of Mohs micrographic surgery (MMS) in treating cutaneous squamous cell carcinoma has been demonstrated. The cost effectiveness of MMS has rarely been studied to support the perceived higher cost. Objective Perform a cost-effectiveness analysis to determine whether MMS is cost effective over wide local excision (WLE) for Brigham and Women's Hospital tumor stage T2a cutaneous squamous cell carcinoma over a 5-year period. Methods A Markov model with a 5-year time horizon was created using variables from published data. Costs in United States dollars and quality-adjusted life-years (QALY) were calculated. Results MMS was $333.83 less expensive ($4365.57 [95% CI, $3664.68-$6901.66] vs $4699.41 [95% CI, $3782.94-$10,019.31]) than WLE. MMS gained 2.22 weeks of perfect health (3.776 QALY [95% CI, 3.774-3.777] for MMS and 3.733 QALY [95% CI, 3.728-3.777]) over 5 years. The incremental cost-effectiveness ratio was -$7,822.19. MMS had a 99.9% probability of being more cost effective than WLE. Annualized savings of choosing MMS over WLE would be $200 million and over 25,000 QALY. MMS could cost 3.1 times its current rate and remain cost effective. Limitations Relied on data from external retrospective sources. Conclusion MMS is less costly and more effective than WLE and should be strongly considered for stage T2a cSCC, given improvements in costs and QALY.

Background Current staging systems for cutaneous squamous cell carcinoma (cSCC) have limited positive predictive value for identifying patients who will experience metastasis. Objective To develop and validate a gene expression profile (GEP) test for predicting risk for metastasis in localized, high-risk cSCC with the goal of improving risk-directed patient management. Methods Archival formalin-fixed paraffin-embedded primary cSCC tissue and clinicopathologic data (n = 586) were collected from 23 independent centers in a prospectively designed study. A GEP signature was developed using a discovery cohort (n = 202) and validated in a separate, nonoverlapping, independent cohort (n = 324). Results A prognostic 40-GEP test was developed and validated, stratifying patients with high-risk cSCC into classes based on metastasis risk: class 1 (low risk), class 2A (high risk), and class 2B (highest risk). For the validation cohort, 3-year metastasis-free survival rates were 91.4%, 80.6%, and 44.0%, respectively. A positive predictive value of 60% was achieved for the highest-risk group (class 2B), an improvement over staging systems, and negative predictive value, sensitivity, and specificity were comparable to staging systems. Limitations Potential understaging of cases could affect metastasis rate accuracy. Conclusion The 40-GEP test is an independent predictor of metastatic risk that can complement current staging systems for patients with high-risk cSCC.

Background Cutaneous melanomas (CMs) with similar clinical and histopathologic features can harbor differing capacities for metastasis. A validated gene expression profile (GEP) test offers prognostic information by classifying CMs as low risk (Class 1A/1B) or high risk (Class 2A/2B) for metastasis. Objective The authors sought to perform an independent study of the predictive accuracy of the GEP test, to determine what clinical and histopathologic features predict high-risk classification, and to evaluate how intermediate classes (1B & 2A) performed clinically. Materials and methods Using our institution's prospectively collected melanoma registry, the authors identified patients who had been treated for CM within the last 5 years and undergone GEP testing. Clinical, histopathologic, and outcomes data were analyzed. A subcohort of patients with known metastatic disease were identified and tested. Results The GEP test accurately identified 77% of metastatic CMs as high risk (Class 2). The GEP had a negative predictive value of 99% for Class 1 CMs. Class 2 CMs were 22 times more likely to metastasize. Conclusion The GEP test's performance in our independent cohort corresponded with previous industry-sponsored studies and proved to be a helpful clinical prognostic tool with the potential to direct patient care protocols.

Background Extramammary Paget's disease (EMPD) is a rare intraepithelial malignancy with high recurrence rates following standard surgical treatments, ranging from 22% to 60% in large retrospective reviews. Objective To evaluate the local recurrence rate of Mohs micrographic surgery (MMS) supplemented with intraoperative immunohistochemistry for cytokeratin-7 (MMS + CK-7) for primary and recurrent EMPD. Materials and methods Retrospective, multi-center, cross-sectional study of patients treated using MMS + CK-7. Demographic, clinicopathologic, treatment, and follow-up data were obtained by chart review. Results The observed local recurrence rate for MMS + CK-7 is 3.3% (2/61 tumors) with a mean follow-up of 43.5 months (1-120 months). Local recurrence occurred in 2.3% (1/43) of primary tumors and 5.6% (1/18) of recurrent tumors. Kaplan-Meier 5-year tumor-free rates are 94.6% overall, 97.1% for primary tumors, and 80.0% for recurrent tumors. The Kaplan-Meier 5-year tumor-free rates for all EMPD tumors treated with MMS + CK-7 versus a historical cohort of MMS alone are 94.6% versus 72.0% (p = .012). Conclusion MMS + CK-7 is an effective treatment for EMPD, demonstrating improved outcomes compared with historical controls.

The incidence and diagnosis of cutaneous malignancies are steadily rising. In addition, with the aging population and increasing use of organ transplant and immunosuppressive medications, subsets of patients are now more susceptible to skin cancer. Mohs micrographic surgery (MMS) has become the standard of care for the treatment of high-risk nonmelanoma skin cancers and is increasingly used to treat melanoma. Mohs micrographic surgery has the highest cure rates, spares the maximal amount of normal tissue, and is cost-effective for the treatment of cutaneous malignancies. As in other medical fields, appropriate use criteria were developed for MMS and have become an evolving guideline for determining which patients and tumors are appropriate for referral to MMS. Patients with cutaneous malignancies often require multidisciplinary care. With the changing landscape of medicine and the rapidly increasing incidence of skin cancer, primary care providers and specialists who do not commonly manage cutaneous malignancies will need to have an understanding of MMS and its role in patient care. This review better familiarizes the medical community with the practice of MMS, its utilization and capabilities, differences from wide excision and vertical section pathology, and cost-effectiveness, and it guides practitioners in the process of appropriately evaluating and determining when patients with skin cancer might be appropriate candidates for MMS.

EMPD is an intraepidermal adenocarcinoma most often limited to the epidermis, with typical cases affecting genital skin in women and men. In patients with invasive disease, prognosis is based on the degree of invasion, with tumors less than 1 mm deep having very low mortality. Careful evaluation for an underlying malignancy should be carried out to exclude life-threatening disease, but the association of many coexistent malignancies is controversial. Reported underlying adnexal adenocarcinoma may, at least in some patients, represent invasive spread of primary epidermal disease. Mohs surgery has proven effective in the treatment of EMPD, and the implementation of CK7 immunostaining shows promise in further reducing the recurrence rate. Alternative treatments, including topical treatment with imiquimod and 5-fluorouracil as well as photodynamic therapy, may be effective in select cases of EMPD.

Background Outcomes for patients with cutaneous squamous cell carcinoma (CSCC) treated with Mohs micrographic surgery (MS) in the United States have never been prospectively defined. Risk factors as they relate to outcomes are primarily derived from single-institution, retrospective data without regard for treatment modality. The American Joint Committee on Cancer Staging Manual, Eighth Edition, and the Brigham and Women's Hospital T staging systems have not been prospectively validated. Objective To prospectively quantify outcomes by T stage and verify historically high-risk features as they pertain to outcomes in MS-treated CSCC. Methods A 5-year, prospective, multicenter analysis of patients undergoing MS for invasive CSCC was conducted. Results The study enrolled 647 patients with 745 tumors. The 5-year local recurrence (LR)-free survival, nodal metastasis (NM)-free survival, and disease-specific survival were 99.3%, 99.2%, and 99.4%, respectively. Both staging systems were predictive of NM, disease-specific death, and all-cause death; neither was predictive of LR. Although Breslow depth was statistically associated with LR, NM, and disease-specific death, incidental perineural invasion was not. Limitations The Brigham and Women's Hospital and the American Joint Committee on Cancer Staging Manual, Eighth Edition T staging systems were published after study enrollment, therefore T stages were retrospectively applied using the prospectively collected data. Conclusion MS is a highly effective treatment for CSCC and may mitigate factors typically considered high risk. Uniform reporting of Breslow depth should be considered in CSCC. The American Joint Committee on Cancer Staging Manual, Eighth Edition, and the Brigham and Women's Hospital staging system are useful prognosticators but are not predictive of LR after MS.

BACKGROUND The traditional paramedian forehead flap (FHF) is an axial flap based on the supratrochlear artery (STA). Doppler examination is often used to ensure inclusion of the STA within the flap. The authors hypothesized that a FHF pedicle design could be simplified to extend from the midline of the glabella to 1.2 cm lateral to the midline without compromising outcomes. OBJECTIVE To compare clinical outcomes and vessel densities of 2 FHF designs. METHODS Two FHF designs were used to repair fifty nasal defects. One was based on Doppler identification of the STA; the other on clinical measurements from the glabellar midline (with no effort to identify the STA). Clinical outcomes, complication rates, and pedicle vasculature of both groups were compared. RESULTS There was no significant difference in flap survival or complication rate. Forehead flaps designed on the paramidline glabella had more arteries within their pedicles than Doppler-based FHFs (p < .05). Small arteries predominated, whereas larger arteries were infrequent in both groups. Size and number of arteries were not related to flap survival. CONCLUSION A paramidline FHF has equivalent clinical outcomes as a flap based on the STA. A simple and reproducible design of the FHF using only surface landmarks is described.

Background Digital melanoma is commonly treated with amputation or wide local excision. Mohs micrographic surgery (MMS) may offer an alternative treatment modality. Objective To describe outcomes of digital melanomas treated with MMS over a 35-year period. Methods A retrospective series of digital melanomas treated with MMS was studied. Tumor and treatment characteristics were described and follow-up was assessed. Results Sixty-two digital (1.2%) tumors were identified from 4995 melanomas, of which 57 (91.9%) were primary and 5 (8.1%) were recurrent on enrollment. Melanocytic antigen recognized by cytotoxic T lymphocytes from melanoma patients (MART)-1 and HMB-45 immunostains were used in 34 (54.8%) and 14 (22.6%) cases, respectively. Five (8.2%) tumors recurred locally during the course of the study, none of which occurred with MART-1 use. Three (60.0%) local recurrences were salvaged with additional MMS. Local recurrence-free survival rates for primary melanomas at 5 and 10 years were 91.8% and 82.6%, respectively. Overall, 55 (96.5%) patients with primary digital melanomas avoided amputation. Five and 10-year melanoma-specific survival rates for all patients were 95.0% and 81.2%, respectively. Limitations A formal comparison group was not studied. Conclusion In the management of digital melanoma, MMS conserves function by avoiding amputation and offers a low local recurrence rate. Outcomes are improved with the use of MART-1.

Background Sentinel lymph node (SLN) status is reportedly a powerful prognosticator of survival. Breslow thickness alone provides significant prognostic information. Objective To assess overall survival (OS) according to tumor depth based on SLN status. Materials and Methods MEDLINE, EMBASE, and the Cochrane Central Database were searched for studies. Included studies evaluated overall survival according to SLNB results and were stratified according to Breslow thickness. Meta-analysis was performed if appropriate in each category for which three or more studies reported risk estimates and variability measurement. Results Twenty-nine articles met inclusion criteria. Six met the criteria for meta-analysis. In individuals with thin melanoma ( .99). Few studies were available for intermediate depths, and most reported worse survival in SLN–positive patients, although the difference was not statistically significant (p > .05). For thick melanoma (>4 mm), SLN positivity was related to worse prognosis (sign test, p = .004). Based on the pooled results of six studies of patients with tumors 4 mm thick or thicker, SLN–positive patients had a greater likelihood of dying (hazard ratio = 2.42, 95% confidence interval = 2.00–2.92). Conclusions Sentinel lymph node biopsy may not provide more-accurate prognostic information than Breslow thickness for most melanomas.

Background There have been few published case series of penile squamous cell carcinoma (SCC) removed with Mohs micrographic surgery (MMS). Of these case series, the published cure rates are between 68% and 74%. Objective To report 30 years of experience removing penile SCCs with MMS. Methods and materials Retrospective record review of 42 patients with 44 penile SCCs. Results There was one recurrence of the 19 primary SCCs in situ, resulting in a cure rate of 94.7%. There were no recurrences among the 10 primary invasive SCC. Of the 6 recurrent invasive SCCs, 2 recurred, resulting in an initial cure rate of 66.7%. These 2 recurrences were re-treated with MMS with no evidence of recurrence at 5 years. There were 4 patients with SCC in situ of the glans with extension down the urethra. While all 4 patients required urethral dilation postoperatively secondary to urethral stricture, none of these tumors recurred and normal function was restored in each case. Conclusion In conclusion, MMS may be preferred for patients with penile carcinoma by providing a high cure rate and tissue conservative alternative to partial or total penectomy and does not need to be limited to low-grade, small, superficial tumors.

Mohs micrographic surgery (MMS) with melanoma antigen recognized by T-cell (MART-1) immunostaining is an effective treatment of cutaneous melanoma.To determine the efficacy of MMS with MART-1 immunostain in the management of invasive and in situ melanoma.A retrospective cohort study evaluated 2,114 melanomas in 1,982 patients excised using MMS and MART-1 immunostain. The margins required for excision were calculated based on Breslow thickness, location, and size. Survival and local recurrence rates were calculated and compared with those of historical controls.The mean follow-up period was 3.73 years. Local recurrence was identified in 0.49% (7/1,419) of primary melanomas. Approximately 82% of melanomas were excised with ≤6-mm margins. The surgical margin was significantly related to tumor location and size but not to Breslow thickness. The five-year Kaplan-Meier local recurrence and disease-specific survival rates were 0.59 ± 0.30 and 98.53 ± 0.42, respectively. Mohs micrographic surgery with MART-1 immunostain achieved lower local recurrence rates and equivalent or higher Kaplan-Meier survival rates than conventional wide local excision.Mohs micrographic surgery with MART-1 immunostain is an effective treatment of melanoma as evidenced by low local recurrence rates. It offers the advantage of more tissue-conserving margins than those recommended for conventional excision.

Background Complications associated with Mohs surgery have been evaluated by single-surgeon studies. While these studies provide evidence for the safety of the procedure, prospective, multicenter studies afford a higher level of clinical evidence and establish further the safety profile of Mohs surgery in the ambulatory setting. Objective This study was designed to prospectively evaluate major and minor complications as well as postoperative pain associated with Mohs surgery. Methods A multicenter prospective cohort study was conducted evaluating the rate of major and minor complications as well as postoperative pain associated with the treatment of skin cancer using Mohs surgery in 1550 patients with 1792 tumors. Follow-up was obtained in 1709 of the 1792 tumors treated (95.3%). Results No major complications occurred during Mohs surgery or reconstruction. A total of 44 (2.6%) minor primary postoperative complications occurred during the study. On a scale from 0 to 10, the average peak postoperative pain level was 1.99. Limitations Limitations of the study include the variability of practice patterns across practice sites as well as the 4.7% of patients lost to follow-up. Conclusion Mohs surgery is performed with a high degree of safety and is well tolerated by patients.

Background With the continuing increase in the incidence of skin cancer, delivery of cost-efficient skin cancer treatment is a top priority. Objective To compare costs associated with removal of skin cancers using Mohs micrographic surgery (MMS) with that using standard surgical excision (SSE) with frozen or permanent margin control in the office or an ambulatory surgery center (ASC). Methods and Materials Costs for actual MMS and calculated costs for all SSE were recorded. The expense of treatment of incomplete excisions with subsequent reexcision and reconstruction and MMS on recurrent tumors were added to the final estimate. Results Four hundred six tumors were included in the study. An average tumor was cleared in 1.6 stages. MMS was the least expensive surgical procedure evaluated, at $805 per tumor. SSE with permanent margins ($1,026) was more expensive than MMS but less expensive than SSE with frozen margins ($1,200) and ASC-SSE with frozen margins ($2,507). Adjusted for inflation, the cost of MMS, inclusive of initial examination, biopsy, and 5-year follow-up, in 2009 ($1,376) was lower than in 1998 ($1,635). Conclusions This study confirms MMS as the cornerstone of cost-effective treatment, regardless of place of service or type of margin control pathology.

Background A controversy in the treatment of melanoma in situ is the required width of surgical margin. The currently accepted 5-mm margin is based on a 1992 consensus opinion, despite data since then showing this is inadequate. Objective We sought to develop guidelines for predetermined surgical margins for excision of melanoma in situ. Methods A prospectively collected series of 1072 patients with 1120 melanoma in situs was studied. All lesions were excised by Mohs micrographic surgery with frozen-section examination of the margin. The minimal surgical margin was 6 mm, and the total margin was calculated by adding an additional 3 mm for each subsequent stage required. The minimum surgical margin that would successfully remove 97% of all tumors was calculated. Local recurrence was also tabulated. Results In all, 86% of melanoma in situs were successfully excised with a 6-mm margin; 9 mm removed 98.9% of melanoma in situs. The superiority of 9-mm to 6-mm margins was significant ( P Limitations Margins less than 6 mm were not studied. This is a referral center for melanoma in situ and 10% of tumors were previously treated before presentation to our clinic. Conclusion The frequently recommended 5-mm margin for melanoma is inadequate. Standard surgical excision of melanoma in situ should include 9 mm of normal-appearing skin, similar to that recommended for early invasive melanoma.

BACKGROUND Residual melanoma and melanoma in situ (MIS), also referred to as marginally recurrent melanoma, continues to be a concern for all dermatologic surgeons. Little is known about the potential of these tumors to recur with a deeper invasive histology measured according to Breslow depth. OBJECTIVE To identify the clinical features and histologic, invasive potential of marginally recurrent melanoma and MIS. By having a more accurate understanding of marginally recurrent melanoma, we can better appreciate the consequence of inadequate excision and recognize the importance of improving initial treatments. MATERIALS AND METHODS An analysis was performed of 108 marginally recurrent melanoma and MIS cases based on prospective data collection. For each case, clinical data, including a comparison of Breslow depth from the time of primary treatment and salvage surgery for marginally recurrent tumor, were tabulated. RESULTS Of the 84 lesions initially treated as MIS, 19 (22.6%) recurred marginally with a histologically invasive component and a mean Breslow depth of 0.94 mm. Of the 24 patients diagnosed with invasive melanoma, eight (33.3%) had a deeper Breslow depth at the time of clinical recurrence than at the time of primary treatment. The change in Breslow depth for these eight cases was 1.53 to 2.83 mm. CONCLUSIONS Our findings demonstrate the invasive growth potential of MIS and invasive melanoma inadequately excised at the time of primary treatment. This finding illustrates the consequences of marginal recurrence and stresses the importance of accurate and complete removal of melanoma at the time of initial diagnosis and treatment.

BACKGROUND On-site pathology services are an integral part of many dermatology and surgical dermatology practices in the United States. OBJECTIVE Assess the effectiveness and advantages of on-site pathology services. METHODS Biopsy data from 7 practices with on-site pathology services were reviewed to determine the diagnostic accuracy of malignancies from all lesional biopsies. Patient preference and convenience were queried and measured with satisfaction surveys. RESULTS Of note, 1,052/1,379 (76.3%) of biopsies demonstrated a malignancy. Most patients underwent treatment of malignant lesions on a different day than the biopsy. Of the patients who scheduled a return visit for surgery on a later date, 42/246 (17.1%) reported incurring additional costs and 44/249 (17.7%) had a relative/friend who was inconvenienced. CONCLUSION On-site pathology services provide efficient, effective, and convenient care for skin cancer patients. Fellowship-trained dermatologic surgeons use on-site pathology services to diagnose and treat clinically relevant nonmelanoma skin cancer.

Background Evaluation of the entire surgical margin results in high rates of complete excision, low local recurrence rates, and maximal tissue conservation. Although well recognized for melanoma of the head and neck, few studies have focused exclusively on the trunk and proximal extremities. Objective We sought to evaluate the efficacy of Mohs micrographic surgery for melanoma in situ (MIS) of the trunk and proximal extremities, and determine adequate excision margins for MIS when total margin evaluation is not used. Methods Long-term outcomes in 882 cases of MIS treated with Mohs micrographic surgery were analyzed and compared with historical controls. Rates of complete excision were determined for increasing surgical margin intervals. Results One local recurrence occurred in our cohort (0.1%). Only 83% of MIS were excised with a 6-mm margin. Margins of 9 mm were needed to excise 97% of MIS, statistically equivalent to thin melanomas. Limitations We used a nonrandomized, single-institution, retrospective design. Conclusion Mohs micrographic surgery may cure the 17% of MIS that exceed traditional excision margins of 5 mm and is a valuable option for these patients. Surgical margins of at least 0.9 cm should be considered for MIS of the trunk and extremities when total margin evaluation is not used.

Background: Optimal treatment of primary Merkel cell carcinoma (MCC) is unknown. High local recurrence rates after excision alone compel some physicians to advocate postoperative radiation therapy to improve local control. Objective: We wondered whether marginal recurrence and survival rates differed between patients with primary MCC treated with Mohs surgery alone and those treated with Mohs surgery and adjuvant postoperative radiation. Methods: A collaborative retrospective study was performed; the study group consisted of 45 patients with stage I MCC who were histologically and clinically free of disease after Mohs excision. Twenty patients subsequently received elective postoperative radiation to the primary site, and 25 patients had no adjuvant radiation therapy. Results: One marginal recurrence (4%) and 3 in-transit metastases were observed in the Mohs surgery alone group, whereas none were observed in the Mohs surgery and radiation group. The proportion of patients with these events was not significantly different between treatment groups. Overall survival, relapse-free survival, and disease-free survival were not significantly different between treatment groups. Conclusion: Adjuvant radiation appears unessential to secure local control of primary MCC lesions completely excised with Mohs micrographic surgery. Adjuvant radiation is recommended for patients unable to have complete excision or if complete histologic margin control is unavailable and should be considered for patients with large or recurrent tumors. (J Am Acad Dermatol 2002;47:885-92.)

BACKGROUND The ear is a complex and intricate feature of the human face in which reconstruction after oncologic excision is predicated on the complete removal of skin cancer. Reconstructive strategies are based on an understanding of the hierarchy of aesthetic concerns for the ear. METHODS Review of the reconstructive strategies for reconstruction of the ear. RESULTS The 2 most important characteristics of the ear are its symmetrical projection from the head and the smooth curvature of the helix. With this in mind, the reconstructive plan must begin from the "inside out" with assessment of the cartilaginous frameworks followed by the cutaneous defect. CONCLUSION A reconstructive strategy that takes into account the hierarchy of aesthetic concerns for defects of the ear will optimize cosmesis, function, and patient's satisfaction.