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Consider 9-mm surgical margins for MIS
WAIKOLOA, HAWAII – The widely utilized 5-mm surgical margins for excision of melanoma in situ are inadequate in many cases, Christopher B. Zachary, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“You probably should be considering more like 9- or 10-mm margins for melanoma in situ,” advised Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.
This has been a controversial matter. The recommendation for the long-standard 5-mm margins for excision of melanoma in situ (MIS) date back to a 1992 consensus opinion. Since then, however, persuasive data have emerged showing that 5-mm margins are often inadequate for clearance, and the latest American Academy of Dermatology guidelines for the management of primary cutaneous melanoma recommend margins of 5-10 mm (J Am Acad Dermatol. 2019 Jan;80[1]:208-50).
Dr. Zachary’s advice to go on the high side of that 5- to 10-mm zone is based in large part on studies led by John A Zitelli, MD, of the University of Pittsburgh. More than 20 years ago, Dr. Zitelli and his coinvestigators published a provocative prospective series of 535 patients whose melanomas – in situ or invasive – were excised via Mohs micrographic surgery with frozen section examination of the margins. A 9-mm margin successfully removed 95% of the melanomas, a 12-mm margin removed 97%, and a 6-mm margin successfully excised only 83% of the lesions (J Am Acad Dermatol. 1997 Sep;37(3 Pt 1):422-9).
In a follow-up study, Dr. Zitelli and his colleagues reported on a prospective series of 1,072 patients with 1,120 MIS, all excised by Mohs micrographic surgery with frozen sections (J Am Acad Dermatol. 2012 Mar;66[3]:438-44). They determined that 86% of the MIS were completely cleared using a 6-mm margin, compared with 98.9% excised with a 9 mm margin, a statistically significant difference (P less than .001).
Support for Dr. Zitelli’s stance that 5-mm margins for MIS are inadequate was provided by dermatologic surgeons at the Mayo Clinic in Scottsdale, Ariz. Of 46 patients who underwent Mohs micrographic surgery with immunostaining for excision of MIS, margins of 6 mm achieved clearance in only half of them. Surgical excision margins of 15 mm were required to successfully clear 96% of the MIS (Dermatol Surg. 2000 Aug;26[8]:771-84).
Quite a few hands shot up when Dr. Zachary asked how many members of his audience utilize 5-mm margins for surgical excision of MIS.
“That had been my practice as well until quite recently,” he said.
Dr. Zachary reported having no financial conflicts of interest regarding his presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
WAIKOLOA, HAWAII – The widely utilized 5-mm surgical margins for excision of melanoma in situ are inadequate in many cases, Christopher B. Zachary, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“You probably should be considering more like 9- or 10-mm margins for melanoma in situ,” advised Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.
This has been a controversial matter. The recommendation for the long-standard 5-mm margins for excision of melanoma in situ (MIS) date back to a 1992 consensus opinion. Since then, however, persuasive data have emerged showing that 5-mm margins are often inadequate for clearance, and the latest American Academy of Dermatology guidelines for the management of primary cutaneous melanoma recommend margins of 5-10 mm (J Am Acad Dermatol. 2019 Jan;80[1]:208-50).
Dr. Zachary’s advice to go on the high side of that 5- to 10-mm zone is based in large part on studies led by John A Zitelli, MD, of the University of Pittsburgh. More than 20 years ago, Dr. Zitelli and his coinvestigators published a provocative prospective series of 535 patients whose melanomas – in situ or invasive – were excised via Mohs micrographic surgery with frozen section examination of the margins. A 9-mm margin successfully removed 95% of the melanomas, a 12-mm margin removed 97%, and a 6-mm margin successfully excised only 83% of the lesions (J Am Acad Dermatol. 1997 Sep;37(3 Pt 1):422-9).
In a follow-up study, Dr. Zitelli and his colleagues reported on a prospective series of 1,072 patients with 1,120 MIS, all excised by Mohs micrographic surgery with frozen sections (J Am Acad Dermatol. 2012 Mar;66[3]:438-44). They determined that 86% of the MIS were completely cleared using a 6-mm margin, compared with 98.9% excised with a 9 mm margin, a statistically significant difference (P less than .001).
Support for Dr. Zitelli’s stance that 5-mm margins for MIS are inadequate was provided by dermatologic surgeons at the Mayo Clinic in Scottsdale, Ariz. Of 46 patients who underwent Mohs micrographic surgery with immunostaining for excision of MIS, margins of 6 mm achieved clearance in only half of them. Surgical excision margins of 15 mm were required to successfully clear 96% of the MIS (Dermatol Surg. 2000 Aug;26[8]:771-84).
Quite a few hands shot up when Dr. Zachary asked how many members of his audience utilize 5-mm margins for surgical excision of MIS.
“That had been my practice as well until quite recently,” he said.
Dr. Zachary reported having no financial conflicts of interest regarding his presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
WAIKOLOA, HAWAII – The widely utilized 5-mm surgical margins for excision of melanoma in situ are inadequate in many cases, Christopher B. Zachary, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“You probably should be considering more like 9- or 10-mm margins for melanoma in situ,” advised Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.
This has been a controversial matter. The recommendation for the long-standard 5-mm margins for excision of melanoma in situ (MIS) date back to a 1992 consensus opinion. Since then, however, persuasive data have emerged showing that 5-mm margins are often inadequate for clearance, and the latest American Academy of Dermatology guidelines for the management of primary cutaneous melanoma recommend margins of 5-10 mm (J Am Acad Dermatol. 2019 Jan;80[1]:208-50).
Dr. Zachary’s advice to go on the high side of that 5- to 10-mm zone is based in large part on studies led by John A Zitelli, MD, of the University of Pittsburgh. More than 20 years ago, Dr. Zitelli and his coinvestigators published a provocative prospective series of 535 patients whose melanomas – in situ or invasive – were excised via Mohs micrographic surgery with frozen section examination of the margins. A 9-mm margin successfully removed 95% of the melanomas, a 12-mm margin removed 97%, and a 6-mm margin successfully excised only 83% of the lesions (J Am Acad Dermatol. 1997 Sep;37(3 Pt 1):422-9).
In a follow-up study, Dr. Zitelli and his colleagues reported on a prospective series of 1,072 patients with 1,120 MIS, all excised by Mohs micrographic surgery with frozen sections (J Am Acad Dermatol. 2012 Mar;66[3]:438-44). They determined that 86% of the MIS were completely cleared using a 6-mm margin, compared with 98.9% excised with a 9 mm margin, a statistically significant difference (P less than .001).
Support for Dr. Zitelli’s stance that 5-mm margins for MIS are inadequate was provided by dermatologic surgeons at the Mayo Clinic in Scottsdale, Ariz. Of 46 patients who underwent Mohs micrographic surgery with immunostaining for excision of MIS, margins of 6 mm achieved clearance in only half of them. Surgical excision margins of 15 mm were required to successfully clear 96% of the MIS (Dermatol Surg. 2000 Aug;26[8]:771-84).
Quite a few hands shot up when Dr. Zachary asked how many members of his audience utilize 5-mm margins for surgical excision of MIS.
“That had been my practice as well until quite recently,” he said.
Dr. Zachary reported having no financial conflicts of interest regarding his presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
REPORTING FROM SDEF HAWAII DERMATOLOGY SEMINAR
The 39th ASLMS meeting is now underway
WASHINGTON – At the annual meeting of the American Academy of Dermatology, the taking place March 27-31, 2019, in Denver.
“ASLMS is always an amazing meeting, and it’s a unique meeting,” said past president Mathew Avram, MD, director of the Dermatology Laser & Cosmetic Center at Massachusetts General Hospital, Boston. “At its core, it’s a scientific meeting ... you can take things back to your practice that change the practice of medicine.”
Current ASLMS president Eric Bernstein, MD, of Main Line Center for Laser Surgery, Ardmore, Pa., pointed out that, in addition to doctors and other health care practitioners, other available and accessible attendees include the engineers who build the lasers. And this year, injectables are being incorporated into the program.
MDedge reporter Doug Brunk will be reporting from the meeting.
WASHINGTON – At the annual meeting of the American Academy of Dermatology, the taking place March 27-31, 2019, in Denver.
“ASLMS is always an amazing meeting, and it’s a unique meeting,” said past president Mathew Avram, MD, director of the Dermatology Laser & Cosmetic Center at Massachusetts General Hospital, Boston. “At its core, it’s a scientific meeting ... you can take things back to your practice that change the practice of medicine.”
Current ASLMS president Eric Bernstein, MD, of Main Line Center for Laser Surgery, Ardmore, Pa., pointed out that, in addition to doctors and other health care practitioners, other available and accessible attendees include the engineers who build the lasers. And this year, injectables are being incorporated into the program.
MDedge reporter Doug Brunk will be reporting from the meeting.
WASHINGTON – At the annual meeting of the American Academy of Dermatology, the taking place March 27-31, 2019, in Denver.
“ASLMS is always an amazing meeting, and it’s a unique meeting,” said past president Mathew Avram, MD, director of the Dermatology Laser & Cosmetic Center at Massachusetts General Hospital, Boston. “At its core, it’s a scientific meeting ... you can take things back to your practice that change the practice of medicine.”
Current ASLMS president Eric Bernstein, MD, of Main Line Center for Laser Surgery, Ardmore, Pa., pointed out that, in addition to doctors and other health care practitioners, other available and accessible attendees include the engineers who build the lasers. And this year, injectables are being incorporated into the program.
MDedge reporter Doug Brunk will be reporting from the meeting.
REPORTING FROM AAD 2019
FDA panel calls for changes to breast implant rupture screening
A Food and Drug Administration advisory panel urged the agency to switch its recommended screening method for silent breast implant ruptures from MRI to ultrasound and to push the first screening examination back from the current 3 years post implant to 5 years.
Members of the FDA’s General and Plastic Surgery Advisory Panel also made suggestions to the FDA regarding how it might improve communication about the risks of breast implants to the public in general and to people considering implants in particular.
The panel also discussed the sort of safety and efficacy assessments the FDA should require for acellular dermal matrix (ADM), also known as mesh, to add the material’s label for use during breast reconstruction or implant augmentation. Surgeons have used mesh routinely as a surgical aid at other body sites, such as the abdomen. Although ADM is now also widely used during breast surgery, it has never undergone testing or labeling for use in that setting.
The FDA convened the advisory committee meeting largely to assess and discuss data and concerns about two recently appreciated complications of breast implant placement – breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) and a still poorly defined and described constellation of autoimmune and rheumatoid-like symptoms reported anecdotally by some breast implant recipients called Breast Implant Illness (BII). But agency officials asked the panel to also address these other issues related to the safety of breast implants and implant surgery.
The revised screening recommendations were primarily a response to a lack of compliance with current FDA recommendations to screen for breast implant rupture with MRI starting 3 years after placement and then every 2 years.
The problem is that a screening MRI costs about $1,500-$2,000 and is generally not covered by insurance when done for this purpose, although it is often covered when used to investigate a suspected rupture. The result is that less than 5% of implanted patients comply with the recommended screening schedule, noted committee chair Frank R. Lewis Jr., MD, executive director, emeritus, of the American Board of Surgery in Philadelphia.
“Effectively it’s a useless recommendation,” he said. “Ultrasound is far easier, quicker, and cheaper” and seems effective for screening.
The advisory panel recommended starting ultrasound screening 5 years after implantation, based on MRI screening data showing that virtually all ruptures don’t occur until after 5 years, and then following with ultrasound screening every 3 years after that. The panel recommended using MRI when the ultrasound result is equivocal or when the patient has symptoms suggesting rupture.
After hearing testimony during the sessions from several dozen women who told horror stories of the complications they experienced from breast implants, panel member Karen E. Burke, MD, PhD, spoke for many on the panel when she said “no doubt patients feel that the informed consent process failed them, that they were not aware of the risks.”
Dr. Burke suggested that patients must be informed so that they realize that breast implants are not static objects that will always sit unchanged in their body for the rest of their lives, that certain factors such as allergy or family history of tissue disease might predispose them to autoimmune-type reactions and that the diverse symptoms described for BII are possible sequelae.
A black box warning for the potential of developing anaplastic large-cell lymphoma should also go into the label, said Dr. Burke, a dermatologist who practices in New York City.
Dr. Lewis ridiculed the information booklets that implant manufacturers currently provide for patients as too long and dense. “They were not constructed to inform patients in the best way; they were constructed to provide legal protection.” He called for creating a two- or three-page list of potential adverse effects and points to consider.
Other panel members suggested public service advertisements similar to what is used to inform consumers about the risk from cigarettes. Dr. Burke recommended getting the word out about BII to other medical specialties that are more likely to see affected patients first, such as rheumatologists, immunologists, and dermatologists. She vowed to speak about these complications at an upcoming meeting of the American Academy of Dermatology. But other panel members noted that BII right now remains without any official medical definition nor clear causal link to breast implants.
The question of exactly what safety and efficacy data the FDA might require from manufacturers seeking a breast surgery indication for ADM was less clear.
Binita Ashar, MD, director of the FDA’s Division of Surgical Devices, highlighted the agency’s dilemma about considering data for a breast surgery indication. “The challenge for us is that we can’t expect a control arm because everyone today is using” mesh, she explained. “We’re looking for guidance on how to understand the risk-to-benefit profile” of ADM.
A plastic surgeon on the advisory panel, Pierre M. Chevray, MD, PhD, from Houston Methodist Hospital summarized the way ADM mesh reached its current niche in routine, U.S. breast surgery.
About 20 years ago, plastic surgeons began using mesh during implant surgery to improve eventual breast cosmesis. Surgeons began to wrap the implant in mesh and then attached the mesh to the pectoral muscle so that the implant could go on top of the muscle and not beneath it. It greatly diminished capsular contraction around the implant over time, reduced the risk for implant movement, and allowed for more natural positioning of the breast with the implant inside, he said.
Another factor in the growing use of mesh was heavy promotion by manufacturers to a generation of plastic surgeons, Dr. Chevray said. But use of ADM may also lead to a slightly increased rate of seromas and infections.
“The benefit from mesh is hard to prove and is questionable” because it largely depends on a subjective assessment by a surgeon or patient, Dr. Chevray said. “The cost [of ADM] is substantial, but no data have shown that outcomes are better” with its use. Despite that, “nearly every surgeon uses mesh” these days, he noted.
A Food and Drug Administration advisory panel urged the agency to switch its recommended screening method for silent breast implant ruptures from MRI to ultrasound and to push the first screening examination back from the current 3 years post implant to 5 years.
Members of the FDA’s General and Plastic Surgery Advisory Panel also made suggestions to the FDA regarding how it might improve communication about the risks of breast implants to the public in general and to people considering implants in particular.
The panel also discussed the sort of safety and efficacy assessments the FDA should require for acellular dermal matrix (ADM), also known as mesh, to add the material’s label for use during breast reconstruction or implant augmentation. Surgeons have used mesh routinely as a surgical aid at other body sites, such as the abdomen. Although ADM is now also widely used during breast surgery, it has never undergone testing or labeling for use in that setting.
The FDA convened the advisory committee meeting largely to assess and discuss data and concerns about two recently appreciated complications of breast implant placement – breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) and a still poorly defined and described constellation of autoimmune and rheumatoid-like symptoms reported anecdotally by some breast implant recipients called Breast Implant Illness (BII). But agency officials asked the panel to also address these other issues related to the safety of breast implants and implant surgery.
The revised screening recommendations were primarily a response to a lack of compliance with current FDA recommendations to screen for breast implant rupture with MRI starting 3 years after placement and then every 2 years.
The problem is that a screening MRI costs about $1,500-$2,000 and is generally not covered by insurance when done for this purpose, although it is often covered when used to investigate a suspected rupture. The result is that less than 5% of implanted patients comply with the recommended screening schedule, noted committee chair Frank R. Lewis Jr., MD, executive director, emeritus, of the American Board of Surgery in Philadelphia.
“Effectively it’s a useless recommendation,” he said. “Ultrasound is far easier, quicker, and cheaper” and seems effective for screening.
The advisory panel recommended starting ultrasound screening 5 years after implantation, based on MRI screening data showing that virtually all ruptures don’t occur until after 5 years, and then following with ultrasound screening every 3 years after that. The panel recommended using MRI when the ultrasound result is equivocal or when the patient has symptoms suggesting rupture.
After hearing testimony during the sessions from several dozen women who told horror stories of the complications they experienced from breast implants, panel member Karen E. Burke, MD, PhD, spoke for many on the panel when she said “no doubt patients feel that the informed consent process failed them, that they were not aware of the risks.”
Dr. Burke suggested that patients must be informed so that they realize that breast implants are not static objects that will always sit unchanged in their body for the rest of their lives, that certain factors such as allergy or family history of tissue disease might predispose them to autoimmune-type reactions and that the diverse symptoms described for BII are possible sequelae.
A black box warning for the potential of developing anaplastic large-cell lymphoma should also go into the label, said Dr. Burke, a dermatologist who practices in New York City.
Dr. Lewis ridiculed the information booklets that implant manufacturers currently provide for patients as too long and dense. “They were not constructed to inform patients in the best way; they were constructed to provide legal protection.” He called for creating a two- or three-page list of potential adverse effects and points to consider.
Other panel members suggested public service advertisements similar to what is used to inform consumers about the risk from cigarettes. Dr. Burke recommended getting the word out about BII to other medical specialties that are more likely to see affected patients first, such as rheumatologists, immunologists, and dermatologists. She vowed to speak about these complications at an upcoming meeting of the American Academy of Dermatology. But other panel members noted that BII right now remains without any official medical definition nor clear causal link to breast implants.
The question of exactly what safety and efficacy data the FDA might require from manufacturers seeking a breast surgery indication for ADM was less clear.
Binita Ashar, MD, director of the FDA’s Division of Surgical Devices, highlighted the agency’s dilemma about considering data for a breast surgery indication. “The challenge for us is that we can’t expect a control arm because everyone today is using” mesh, she explained. “We’re looking for guidance on how to understand the risk-to-benefit profile” of ADM.
A plastic surgeon on the advisory panel, Pierre M. Chevray, MD, PhD, from Houston Methodist Hospital summarized the way ADM mesh reached its current niche in routine, U.S. breast surgery.
About 20 years ago, plastic surgeons began using mesh during implant surgery to improve eventual breast cosmesis. Surgeons began to wrap the implant in mesh and then attached the mesh to the pectoral muscle so that the implant could go on top of the muscle and not beneath it. It greatly diminished capsular contraction around the implant over time, reduced the risk for implant movement, and allowed for more natural positioning of the breast with the implant inside, he said.
Another factor in the growing use of mesh was heavy promotion by manufacturers to a generation of plastic surgeons, Dr. Chevray said. But use of ADM may also lead to a slightly increased rate of seromas and infections.
“The benefit from mesh is hard to prove and is questionable” because it largely depends on a subjective assessment by a surgeon or patient, Dr. Chevray said. “The cost [of ADM] is substantial, but no data have shown that outcomes are better” with its use. Despite that, “nearly every surgeon uses mesh” these days, he noted.
A Food and Drug Administration advisory panel urged the agency to switch its recommended screening method for silent breast implant ruptures from MRI to ultrasound and to push the first screening examination back from the current 3 years post implant to 5 years.
Members of the FDA’s General and Plastic Surgery Advisory Panel also made suggestions to the FDA regarding how it might improve communication about the risks of breast implants to the public in general and to people considering implants in particular.
The panel also discussed the sort of safety and efficacy assessments the FDA should require for acellular dermal matrix (ADM), also known as mesh, to add the material’s label for use during breast reconstruction or implant augmentation. Surgeons have used mesh routinely as a surgical aid at other body sites, such as the abdomen. Although ADM is now also widely used during breast surgery, it has never undergone testing or labeling for use in that setting.
The FDA convened the advisory committee meeting largely to assess and discuss data and concerns about two recently appreciated complications of breast implant placement – breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) and a still poorly defined and described constellation of autoimmune and rheumatoid-like symptoms reported anecdotally by some breast implant recipients called Breast Implant Illness (BII). But agency officials asked the panel to also address these other issues related to the safety of breast implants and implant surgery.
The revised screening recommendations were primarily a response to a lack of compliance with current FDA recommendations to screen for breast implant rupture with MRI starting 3 years after placement and then every 2 years.
The problem is that a screening MRI costs about $1,500-$2,000 and is generally not covered by insurance when done for this purpose, although it is often covered when used to investigate a suspected rupture. The result is that less than 5% of implanted patients comply with the recommended screening schedule, noted committee chair Frank R. Lewis Jr., MD, executive director, emeritus, of the American Board of Surgery in Philadelphia.
“Effectively it’s a useless recommendation,” he said. “Ultrasound is far easier, quicker, and cheaper” and seems effective for screening.
The advisory panel recommended starting ultrasound screening 5 years after implantation, based on MRI screening data showing that virtually all ruptures don’t occur until after 5 years, and then following with ultrasound screening every 3 years after that. The panel recommended using MRI when the ultrasound result is equivocal or when the patient has symptoms suggesting rupture.
After hearing testimony during the sessions from several dozen women who told horror stories of the complications they experienced from breast implants, panel member Karen E. Burke, MD, PhD, spoke for many on the panel when she said “no doubt patients feel that the informed consent process failed them, that they were not aware of the risks.”
Dr. Burke suggested that patients must be informed so that they realize that breast implants are not static objects that will always sit unchanged in their body for the rest of their lives, that certain factors such as allergy or family history of tissue disease might predispose them to autoimmune-type reactions and that the diverse symptoms described for BII are possible sequelae.
A black box warning for the potential of developing anaplastic large-cell lymphoma should also go into the label, said Dr. Burke, a dermatologist who practices in New York City.
Dr. Lewis ridiculed the information booklets that implant manufacturers currently provide for patients as too long and dense. “They were not constructed to inform patients in the best way; they were constructed to provide legal protection.” He called for creating a two- or three-page list of potential adverse effects and points to consider.
Other panel members suggested public service advertisements similar to what is used to inform consumers about the risk from cigarettes. Dr. Burke recommended getting the word out about BII to other medical specialties that are more likely to see affected patients first, such as rheumatologists, immunologists, and dermatologists. She vowed to speak about these complications at an upcoming meeting of the American Academy of Dermatology. But other panel members noted that BII right now remains without any official medical definition nor clear causal link to breast implants.
The question of exactly what safety and efficacy data the FDA might require from manufacturers seeking a breast surgery indication for ADM was less clear.
Binita Ashar, MD, director of the FDA’s Division of Surgical Devices, highlighted the agency’s dilemma about considering data for a breast surgery indication. “The challenge for us is that we can’t expect a control arm because everyone today is using” mesh, she explained. “We’re looking for guidance on how to understand the risk-to-benefit profile” of ADM.
A plastic surgeon on the advisory panel, Pierre M. Chevray, MD, PhD, from Houston Methodist Hospital summarized the way ADM mesh reached its current niche in routine, U.S. breast surgery.
About 20 years ago, plastic surgeons began using mesh during implant surgery to improve eventual breast cosmesis. Surgeons began to wrap the implant in mesh and then attached the mesh to the pectoral muscle so that the implant could go on top of the muscle and not beneath it. It greatly diminished capsular contraction around the implant over time, reduced the risk for implant movement, and allowed for more natural positioning of the breast with the implant inside, he said.
Another factor in the growing use of mesh was heavy promotion by manufacturers to a generation of plastic surgeons, Dr. Chevray said. But use of ADM may also lead to a slightly increased rate of seromas and infections.
“The benefit from mesh is hard to prove and is questionable” because it largely depends on a subjective assessment by a surgeon or patient, Dr. Chevray said. “The cost [of ADM] is substantial, but no data have shown that outcomes are better” with its use. Despite that, “nearly every surgeon uses mesh” these days, he noted.
AT AN FDA ADVISORY PANEL MEETING
Use time-appropriate scar improvement sequencing
WAIKOLOA, HAWAII – , according to American Academy of Dermatology President-elect George J. Hruza, MD – and he’s got a raft of them.
“There are going to be situations where your scars aren’t going to be as wonderful as you’d like, or even if they’re pretty good, you might improve them further if you do some modifications,” he observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
He became convinced of the importance of having a large toolbox for scar improvement in part as a result of an Australian prospective study of 576 patients surveyed 6-9 months following skin cancer surgery. Far and away the most important factor influencing patients’ overall perception of their experience wasn’t the cost, pain, quality of nursing care, complications, wait time prior to surgery, or gratitude that they’d successfully had a cancer removed. It was their perception of the scar (J Am Acad Dermatol. 2007 Sep;57[3]:445-53).
To be effective, interventions for scar improvement need to be timed in sync with the three phases of cellular activity involved in wound healing. For example, neurotoxin injections are effective during the first few days of the initial acute inflammation period, when cellular migration is active. Silicone and taping are of value when employed long term, starting at about 1 month and continuing for 3-6 months, throughout the neovascularization/granulation phase, then the time of fibroblast proliferation and matrix formation that follows, and even beyond. Pulsed dye and fractionated ablative lasers are best utilized to reshape matrix formation, starting at about 2 weeks. Intervention using dermabrasion or fillers has to wait for the scar to be a bit more mature, at about 2 months; utilized earlier these can cause dehiscence, explained Dr. Hruza of St. Louis University.
He shared what he called his “scar improvement hierarchy,” the sequence of interventions he turns to from the most to least often. But he began with prevention, noting that more than 2 decades ago, he and his coinvestigators demonstrated that running horizontal mattress sutures for primary closures of facial wounds provide better cosmetic results, with a final scar that’s smoother and flatter than the more commonly used simple running sutures (Dermatol Surg. 2005 Oct;31[10]:1313-6).
Scar improvement sequence
Massage. “I recommend this to almost every patient. I have them start at about 6 weeks and do it for several months. It’s really more like kneading dough, not rubbing. You want the skin pressing on the bone underneath,” according to Dr. Hruza. Various investigators have suggested that scar massage works by increasing hydration and capillary proliferation, while promoting desensitization, but the evidence is really anecdotal.
“I think it’s mainly tincture of time. Scars get better on their own,” he observed. Regardless, massage allows patients the satisfaction of actively participating in their own recovery.
Intralesional triamcinolone. Dr. Hruza calls this “our big friend.”
“I find that 90% of the time when you look at a thickened scar and you think, ‘Oh gee, I’m going to have to do some scar revision, the intralesional triamcinolone takes care of the problem,” he said. He usually injects the site at about 6 weeks post surgery using 10 mg/mL. If the response is inadequate he reinjects about a month later using 20 mg/mL. He generally avoids going to 40 mg/mL for facial scars. The goal is to make therapeutic use of the steroid’s major side effect – atrophy – to shrink the thickened scar. But because this can be a tricky business, of late he has turned increasingly to intralesional triamcinolone and 5-fluorouracil (5-FU).
Intralesional triamcinolone plus 5-FU. This combination causes less atrophy, hypopigmentation, and telangiectasias than full-on triamcinolone. He injects 0.9 mL of 5-FU at 50 mg/mL and 0.1 mL of triamcinolone at 40 mg/mL into and under the scar. The 5-FU inhibits fibroblast proliferation. It is rated pregnancy category D, so he avoids using it in women of childbearing age.
Spot dermabrasion. “To me, this is the go-to. After my intralesional steroids, if the scar hasn’t fully smoothed out, then I go to dermabrasion or the spot CO2 laser,” Dr. Hruza said.
“Dermabrasion is an old technology, but it’s actually still very useful,” he continued. “Do it at 6-10 weeks; that’s the sweet spot. Do it sooner and you can get into problems with dehiscence. And if you do it later than 10 weeks the improvement is much less because everything is stabilized and the collagen is set.” He uses a diamond fraise to abrade and sculpt, rather than sandpaper, which doesn’t allow him to go sufficiently deep once bleeding starts and the sandpaper gets wet.
Spot conventional CO2 or Er:YAG laser resurfacing. “I really find in my hands these ablative techniques are much more effective than using a fractionated laser, which only gives you a little bit of improvement,” he said.
Pulsed dye laser. Very effective for red, thickened scars. Dr. Hruza does two to four treatments at 4-week intervals. At wavelengths of 585-595 nm, a pulse of 0.5-1.5 millisecs, and 4-5 Joules/cm2, there is only minimal purpura.
The pulsed dye laser can also be employed preventively starting at the time of suture removal and then again at 4-6 weeks in order to reduce hypertrophy. “It’s something to consider in areas like the chest, upper back, and shoulders, where you’re trying to prevent problems. The only danger is occasionally patients have dehiscence,” according to the dermatologic surgeon.
Fractionated nonablative laser. Four or five treatments are typically required in order to achieve significant resurfacing.
Micropore tape. Dr. Hruza finds this works just as well as topical silicone gel sheets, rolls, and gels, all of which are quite expensive. A roll of micropore tape costs only a few dollars and will last a patient for a couple months. Patients are taught to apply the tape at the time of suture removal in a line parallel to the suture line, replacing the tape when it begins to peel off. As with the vastly more expensive silicone products, the tape needs to be left on 12-24 hours per day for 3-6 months in order to achieve a flat white scar. The benefit is thought to come from relief of mechanical stress coupled with occlusion.
Botulinum toxin A and other neurotoxins. Inject into muscle near the wound edges right after closing the wound, using 1-3 units at 1- to 3-cm intervals in order to prevent scar formation, Dr. Hruza advised. If the wound is on one side of the face, the other side needs to receive injections as well in order to spare the patient from several months of cosmetically undesirable asymmetry. However, Dr. Hruza rarely utilizes neurotoxin injections. “It’s a cost issue. I’m in the Midwest, where a lot of insurers are unwilling to pay for it,” he explained.
Flap defatting. Here the surgeon opens the flap and keeps digging with scalpel and scissors until the scar is slightly depressed, since there is likely to be some recurrence. Then it’s time to resuture the flap.
Technical scar revision procedures. The simplest of these is Z-plasty, which entails making two skin incisions to create a Z-shaped incision, then flipping the two sides to reorient the scar. The Z-plasty has two major uses: correction of a retracted lip or medial canthus webbing. “If you get either of these, Z-plasty is the way to go,” Dr. Hruza said.
Fillers for atrophic scars. “To me, this is the last thing to go to. The reason is that, if a patient has skin cancer surgery, they don’t expect to pay extra to improve that scar. And I can do dermabrasion with no incremental product cost to the practice,” he commented. The technique entails making a subcision to create a pocket for the filler. The products marketed as Restylane Silk, Belotero, and Radiesse all yield good results, he said.
Dr. Hruza reported having no financial conflicts of interest regarding his presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
WAIKOLOA, HAWAII – , according to American Academy of Dermatology President-elect George J. Hruza, MD – and he’s got a raft of them.
“There are going to be situations where your scars aren’t going to be as wonderful as you’d like, or even if they’re pretty good, you might improve them further if you do some modifications,” he observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
He became convinced of the importance of having a large toolbox for scar improvement in part as a result of an Australian prospective study of 576 patients surveyed 6-9 months following skin cancer surgery. Far and away the most important factor influencing patients’ overall perception of their experience wasn’t the cost, pain, quality of nursing care, complications, wait time prior to surgery, or gratitude that they’d successfully had a cancer removed. It was their perception of the scar (J Am Acad Dermatol. 2007 Sep;57[3]:445-53).
To be effective, interventions for scar improvement need to be timed in sync with the three phases of cellular activity involved in wound healing. For example, neurotoxin injections are effective during the first few days of the initial acute inflammation period, when cellular migration is active. Silicone and taping are of value when employed long term, starting at about 1 month and continuing for 3-6 months, throughout the neovascularization/granulation phase, then the time of fibroblast proliferation and matrix formation that follows, and even beyond. Pulsed dye and fractionated ablative lasers are best utilized to reshape matrix formation, starting at about 2 weeks. Intervention using dermabrasion or fillers has to wait for the scar to be a bit more mature, at about 2 months; utilized earlier these can cause dehiscence, explained Dr. Hruza of St. Louis University.
He shared what he called his “scar improvement hierarchy,” the sequence of interventions he turns to from the most to least often. But he began with prevention, noting that more than 2 decades ago, he and his coinvestigators demonstrated that running horizontal mattress sutures for primary closures of facial wounds provide better cosmetic results, with a final scar that’s smoother and flatter than the more commonly used simple running sutures (Dermatol Surg. 2005 Oct;31[10]:1313-6).
Scar improvement sequence
Massage. “I recommend this to almost every patient. I have them start at about 6 weeks and do it for several months. It’s really more like kneading dough, not rubbing. You want the skin pressing on the bone underneath,” according to Dr. Hruza. Various investigators have suggested that scar massage works by increasing hydration and capillary proliferation, while promoting desensitization, but the evidence is really anecdotal.
“I think it’s mainly tincture of time. Scars get better on their own,” he observed. Regardless, massage allows patients the satisfaction of actively participating in their own recovery.
Intralesional triamcinolone. Dr. Hruza calls this “our big friend.”
“I find that 90% of the time when you look at a thickened scar and you think, ‘Oh gee, I’m going to have to do some scar revision, the intralesional triamcinolone takes care of the problem,” he said. He usually injects the site at about 6 weeks post surgery using 10 mg/mL. If the response is inadequate he reinjects about a month later using 20 mg/mL. He generally avoids going to 40 mg/mL for facial scars. The goal is to make therapeutic use of the steroid’s major side effect – atrophy – to shrink the thickened scar. But because this can be a tricky business, of late he has turned increasingly to intralesional triamcinolone and 5-fluorouracil (5-FU).
Intralesional triamcinolone plus 5-FU. This combination causes less atrophy, hypopigmentation, and telangiectasias than full-on triamcinolone. He injects 0.9 mL of 5-FU at 50 mg/mL and 0.1 mL of triamcinolone at 40 mg/mL into and under the scar. The 5-FU inhibits fibroblast proliferation. It is rated pregnancy category D, so he avoids using it in women of childbearing age.
Spot dermabrasion. “To me, this is the go-to. After my intralesional steroids, if the scar hasn’t fully smoothed out, then I go to dermabrasion or the spot CO2 laser,” Dr. Hruza said.
“Dermabrasion is an old technology, but it’s actually still very useful,” he continued. “Do it at 6-10 weeks; that’s the sweet spot. Do it sooner and you can get into problems with dehiscence. And if you do it later than 10 weeks the improvement is much less because everything is stabilized and the collagen is set.” He uses a diamond fraise to abrade and sculpt, rather than sandpaper, which doesn’t allow him to go sufficiently deep once bleeding starts and the sandpaper gets wet.
Spot conventional CO2 or Er:YAG laser resurfacing. “I really find in my hands these ablative techniques are much more effective than using a fractionated laser, which only gives you a little bit of improvement,” he said.
Pulsed dye laser. Very effective for red, thickened scars. Dr. Hruza does two to four treatments at 4-week intervals. At wavelengths of 585-595 nm, a pulse of 0.5-1.5 millisecs, and 4-5 Joules/cm2, there is only minimal purpura.
The pulsed dye laser can also be employed preventively starting at the time of suture removal and then again at 4-6 weeks in order to reduce hypertrophy. “It’s something to consider in areas like the chest, upper back, and shoulders, where you’re trying to prevent problems. The only danger is occasionally patients have dehiscence,” according to the dermatologic surgeon.
Fractionated nonablative laser. Four or five treatments are typically required in order to achieve significant resurfacing.
Micropore tape. Dr. Hruza finds this works just as well as topical silicone gel sheets, rolls, and gels, all of which are quite expensive. A roll of micropore tape costs only a few dollars and will last a patient for a couple months. Patients are taught to apply the tape at the time of suture removal in a line parallel to the suture line, replacing the tape when it begins to peel off. As with the vastly more expensive silicone products, the tape needs to be left on 12-24 hours per day for 3-6 months in order to achieve a flat white scar. The benefit is thought to come from relief of mechanical stress coupled with occlusion.
Botulinum toxin A and other neurotoxins. Inject into muscle near the wound edges right after closing the wound, using 1-3 units at 1- to 3-cm intervals in order to prevent scar formation, Dr. Hruza advised. If the wound is on one side of the face, the other side needs to receive injections as well in order to spare the patient from several months of cosmetically undesirable asymmetry. However, Dr. Hruza rarely utilizes neurotoxin injections. “It’s a cost issue. I’m in the Midwest, where a lot of insurers are unwilling to pay for it,” he explained.
Flap defatting. Here the surgeon opens the flap and keeps digging with scalpel and scissors until the scar is slightly depressed, since there is likely to be some recurrence. Then it’s time to resuture the flap.
Technical scar revision procedures. The simplest of these is Z-plasty, which entails making two skin incisions to create a Z-shaped incision, then flipping the two sides to reorient the scar. The Z-plasty has two major uses: correction of a retracted lip or medial canthus webbing. “If you get either of these, Z-plasty is the way to go,” Dr. Hruza said.
Fillers for atrophic scars. “To me, this is the last thing to go to. The reason is that, if a patient has skin cancer surgery, they don’t expect to pay extra to improve that scar. And I can do dermabrasion with no incremental product cost to the practice,” he commented. The technique entails making a subcision to create a pocket for the filler. The products marketed as Restylane Silk, Belotero, and Radiesse all yield good results, he said.
Dr. Hruza reported having no financial conflicts of interest regarding his presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
WAIKOLOA, HAWAII – , according to American Academy of Dermatology President-elect George J. Hruza, MD – and he’s got a raft of them.
“There are going to be situations where your scars aren’t going to be as wonderful as you’d like, or even if they’re pretty good, you might improve them further if you do some modifications,” he observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
He became convinced of the importance of having a large toolbox for scar improvement in part as a result of an Australian prospective study of 576 patients surveyed 6-9 months following skin cancer surgery. Far and away the most important factor influencing patients’ overall perception of their experience wasn’t the cost, pain, quality of nursing care, complications, wait time prior to surgery, or gratitude that they’d successfully had a cancer removed. It was their perception of the scar (J Am Acad Dermatol. 2007 Sep;57[3]:445-53).
To be effective, interventions for scar improvement need to be timed in sync with the three phases of cellular activity involved in wound healing. For example, neurotoxin injections are effective during the first few days of the initial acute inflammation period, when cellular migration is active. Silicone and taping are of value when employed long term, starting at about 1 month and continuing for 3-6 months, throughout the neovascularization/granulation phase, then the time of fibroblast proliferation and matrix formation that follows, and even beyond. Pulsed dye and fractionated ablative lasers are best utilized to reshape matrix formation, starting at about 2 weeks. Intervention using dermabrasion or fillers has to wait for the scar to be a bit more mature, at about 2 months; utilized earlier these can cause dehiscence, explained Dr. Hruza of St. Louis University.
He shared what he called his “scar improvement hierarchy,” the sequence of interventions he turns to from the most to least often. But he began with prevention, noting that more than 2 decades ago, he and his coinvestigators demonstrated that running horizontal mattress sutures for primary closures of facial wounds provide better cosmetic results, with a final scar that’s smoother and flatter than the more commonly used simple running sutures (Dermatol Surg. 2005 Oct;31[10]:1313-6).
Scar improvement sequence
Massage. “I recommend this to almost every patient. I have them start at about 6 weeks and do it for several months. It’s really more like kneading dough, not rubbing. You want the skin pressing on the bone underneath,” according to Dr. Hruza. Various investigators have suggested that scar massage works by increasing hydration and capillary proliferation, while promoting desensitization, but the evidence is really anecdotal.
“I think it’s mainly tincture of time. Scars get better on their own,” he observed. Regardless, massage allows patients the satisfaction of actively participating in their own recovery.
Intralesional triamcinolone. Dr. Hruza calls this “our big friend.”
“I find that 90% of the time when you look at a thickened scar and you think, ‘Oh gee, I’m going to have to do some scar revision, the intralesional triamcinolone takes care of the problem,” he said. He usually injects the site at about 6 weeks post surgery using 10 mg/mL. If the response is inadequate he reinjects about a month later using 20 mg/mL. He generally avoids going to 40 mg/mL for facial scars. The goal is to make therapeutic use of the steroid’s major side effect – atrophy – to shrink the thickened scar. But because this can be a tricky business, of late he has turned increasingly to intralesional triamcinolone and 5-fluorouracil (5-FU).
Intralesional triamcinolone plus 5-FU. This combination causes less atrophy, hypopigmentation, and telangiectasias than full-on triamcinolone. He injects 0.9 mL of 5-FU at 50 mg/mL and 0.1 mL of triamcinolone at 40 mg/mL into and under the scar. The 5-FU inhibits fibroblast proliferation. It is rated pregnancy category D, so he avoids using it in women of childbearing age.
Spot dermabrasion. “To me, this is the go-to. After my intralesional steroids, if the scar hasn’t fully smoothed out, then I go to dermabrasion or the spot CO2 laser,” Dr. Hruza said.
“Dermabrasion is an old technology, but it’s actually still very useful,” he continued. “Do it at 6-10 weeks; that’s the sweet spot. Do it sooner and you can get into problems with dehiscence. And if you do it later than 10 weeks the improvement is much less because everything is stabilized and the collagen is set.” He uses a diamond fraise to abrade and sculpt, rather than sandpaper, which doesn’t allow him to go sufficiently deep once bleeding starts and the sandpaper gets wet.
Spot conventional CO2 or Er:YAG laser resurfacing. “I really find in my hands these ablative techniques are much more effective than using a fractionated laser, which only gives you a little bit of improvement,” he said.
Pulsed dye laser. Very effective for red, thickened scars. Dr. Hruza does two to four treatments at 4-week intervals. At wavelengths of 585-595 nm, a pulse of 0.5-1.5 millisecs, and 4-5 Joules/cm2, there is only minimal purpura.
The pulsed dye laser can also be employed preventively starting at the time of suture removal and then again at 4-6 weeks in order to reduce hypertrophy. “It’s something to consider in areas like the chest, upper back, and shoulders, where you’re trying to prevent problems. The only danger is occasionally patients have dehiscence,” according to the dermatologic surgeon.
Fractionated nonablative laser. Four or five treatments are typically required in order to achieve significant resurfacing.
Micropore tape. Dr. Hruza finds this works just as well as topical silicone gel sheets, rolls, and gels, all of which are quite expensive. A roll of micropore tape costs only a few dollars and will last a patient for a couple months. Patients are taught to apply the tape at the time of suture removal in a line parallel to the suture line, replacing the tape when it begins to peel off. As with the vastly more expensive silicone products, the tape needs to be left on 12-24 hours per day for 3-6 months in order to achieve a flat white scar. The benefit is thought to come from relief of mechanical stress coupled with occlusion.
Botulinum toxin A and other neurotoxins. Inject into muscle near the wound edges right after closing the wound, using 1-3 units at 1- to 3-cm intervals in order to prevent scar formation, Dr. Hruza advised. If the wound is on one side of the face, the other side needs to receive injections as well in order to spare the patient from several months of cosmetically undesirable asymmetry. However, Dr. Hruza rarely utilizes neurotoxin injections. “It’s a cost issue. I’m in the Midwest, where a lot of insurers are unwilling to pay for it,” he explained.
Flap defatting. Here the surgeon opens the flap and keeps digging with scalpel and scissors until the scar is slightly depressed, since there is likely to be some recurrence. Then it’s time to resuture the flap.
Technical scar revision procedures. The simplest of these is Z-plasty, which entails making two skin incisions to create a Z-shaped incision, then flipping the two sides to reorient the scar. The Z-plasty has two major uses: correction of a retracted lip or medial canthus webbing. “If you get either of these, Z-plasty is the way to go,” Dr. Hruza said.
Fillers for atrophic scars. “To me, this is the last thing to go to. The reason is that, if a patient has skin cancer surgery, they don’t expect to pay extra to improve that scar. And I can do dermabrasion with no incremental product cost to the practice,” he commented. The technique entails making a subcision to create a pocket for the filler. The products marketed as Restylane Silk, Belotero, and Radiesse all yield good results, he said.
Dr. Hruza reported having no financial conflicts of interest regarding his presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
REPORTING FROM SDEF HAWAII DERMATOLOGY SEMINAR
31-GEP test predicts likelihood of metastasis for cutaneous melanoma
WASHINGTON – The for accurately predicting recurrence-free survival and distant metastasis-free survival and melanoma-specific survival, according to results presented by Bradley N. Greenhaw, MD, at a late-breaking research session at the annual meeting of the American Academy of Dermatology.
Dr. Greenhaw, a dermatologist affiliated with the North Mississippi Medical Center-Tupelo, and his colleagues pooled together 1,268 patients from the following studies that analyzed results from melanoma patients who had their disease classified with the 31-gene expression profile (31-GEP) test.
- A single-center study, conducted by Dr. Greenhaw and his associates (Greenhaw BN et al. Dermatol Surg. 2018 Dec. doi: 10.1097/DSS.0000000000001588.
- A multicenter prospective study (J Hematol Oncol. 2017 Aug. doi: 10.1186/s13045-017-0520-1.
- A retrospective archival study (J Am Acad Dermatol. 2019 Jan. doi: 10.1016/j.jaad.2018.07.028.
The 31-GEP test stratifies an individual’s likelihood of developing metastasis within 5 years as low and high risk. In the three studies, the test was used to identify tumors with low-risk (class 1A, class 1B), higher-risk (class 2A), and highest-risk (class 2B) melanoma based on tumor gene expression. In these individual studies, class 2B melanoma independently predicted recurrence-free survival (RFS), distant metastasis–free, and melanoma-specific survival.
Dr. Greenhaw and colleagues performed a meta-analysis of 1,268 patients with stage I through stage III melanoma from those three studies, using fixed and random effects weighting to account for study differences and heterogeneity, respectively. For class 2B tumors, they found a 2.96 increased risk for recurrent metastases and a 2.88 increased risk for distant metastases. The researchers also found no heterogeneity across the studies.
Melanoma-specific survival was not included in the meta-analysis because one paper did not contain any mortality events in class 1A melanoma patients.
“The meta-analysis demonstrated that the GEP test was able to accurately identify those melanoma patients who were at higher risk of metastasis, and we saw a consistent effect across multiple studies,” Dr. Greenhaw said.
Since publication of the 2019 JAAD paper, there were an additional 211 patients who met inclusion criteria and were included in an additional meta-analysis to determine whether inclusion of these patients affected the results. Dr. Greenhaw and colleagues found a 91.4% recurrence-free survival rate and a 94.1% distant metastasis–free survival rate for class 1A melanomas, compared with 45.7% and 55.5% , respectively, for class 2B tumors.
“You can see a big divergence,” Dr. Greenhaw said at the meeting. “Just by using this one test, it’s able to separate out melanomas that otherwise may be grouped in together under current AJCC [American Joint Committee on Cancer] staging,” he added. “The class 2B designation really did confirm a higher risk for recurrence in distant metastasis.”
The researchers used the SORT method to rate the quality of the data across all three studies. Level 1 evidence under the SORT method represents a systematic review or meta-analysis of good-quality studies and/or a prospective study with good follow-up, while an A-level recommendation represents good, quality evidence. Based on the meta-analysis results, the 31-GEP test meets level 1A evidence under the SORT method, Dr. Greenhaw said.
As a prognostic tool, 31-GEP has the potential to change how dermatologists manage their patients with regard to follow-up and adjuvant therapy. “It is being used not just as this novel test that gives us more information, it’s being used clinically,” said Dr. Greenhaw, who noted he regularly uses the 31-GEP test in his practice.
This is the first time that a meta-analysis has been performed for this test, he noted.
Dr. Greenhaw reports a pending relationship with Castle Biosciences.
SOURCE: Greenhaw BN et al. AAD 19. Session F055, Abstract 11370.
WASHINGTON – The for accurately predicting recurrence-free survival and distant metastasis-free survival and melanoma-specific survival, according to results presented by Bradley N. Greenhaw, MD, at a late-breaking research session at the annual meeting of the American Academy of Dermatology.
Dr. Greenhaw, a dermatologist affiliated with the North Mississippi Medical Center-Tupelo, and his colleagues pooled together 1,268 patients from the following studies that analyzed results from melanoma patients who had their disease classified with the 31-gene expression profile (31-GEP) test.
- A single-center study, conducted by Dr. Greenhaw and his associates (Greenhaw BN et al. Dermatol Surg. 2018 Dec. doi: 10.1097/DSS.0000000000001588.
- A multicenter prospective study (J Hematol Oncol. 2017 Aug. doi: 10.1186/s13045-017-0520-1.
- A retrospective archival study (J Am Acad Dermatol. 2019 Jan. doi: 10.1016/j.jaad.2018.07.028.
The 31-GEP test stratifies an individual’s likelihood of developing metastasis within 5 years as low and high risk. In the three studies, the test was used to identify tumors with low-risk (class 1A, class 1B), higher-risk (class 2A), and highest-risk (class 2B) melanoma based on tumor gene expression. In these individual studies, class 2B melanoma independently predicted recurrence-free survival (RFS), distant metastasis–free, and melanoma-specific survival.
Dr. Greenhaw and colleagues performed a meta-analysis of 1,268 patients with stage I through stage III melanoma from those three studies, using fixed and random effects weighting to account for study differences and heterogeneity, respectively. For class 2B tumors, they found a 2.96 increased risk for recurrent metastases and a 2.88 increased risk for distant metastases. The researchers also found no heterogeneity across the studies.
Melanoma-specific survival was not included in the meta-analysis because one paper did not contain any mortality events in class 1A melanoma patients.
“The meta-analysis demonstrated that the GEP test was able to accurately identify those melanoma patients who were at higher risk of metastasis, and we saw a consistent effect across multiple studies,” Dr. Greenhaw said.
Since publication of the 2019 JAAD paper, there were an additional 211 patients who met inclusion criteria and were included in an additional meta-analysis to determine whether inclusion of these patients affected the results. Dr. Greenhaw and colleagues found a 91.4% recurrence-free survival rate and a 94.1% distant metastasis–free survival rate for class 1A melanomas, compared with 45.7% and 55.5% , respectively, for class 2B tumors.
“You can see a big divergence,” Dr. Greenhaw said at the meeting. “Just by using this one test, it’s able to separate out melanomas that otherwise may be grouped in together under current AJCC [American Joint Committee on Cancer] staging,” he added. “The class 2B designation really did confirm a higher risk for recurrence in distant metastasis.”
The researchers used the SORT method to rate the quality of the data across all three studies. Level 1 evidence under the SORT method represents a systematic review or meta-analysis of good-quality studies and/or a prospective study with good follow-up, while an A-level recommendation represents good, quality evidence. Based on the meta-analysis results, the 31-GEP test meets level 1A evidence under the SORT method, Dr. Greenhaw said.
As a prognostic tool, 31-GEP has the potential to change how dermatologists manage their patients with regard to follow-up and adjuvant therapy. “It is being used not just as this novel test that gives us more information, it’s being used clinically,” said Dr. Greenhaw, who noted he regularly uses the 31-GEP test in his practice.
This is the first time that a meta-analysis has been performed for this test, he noted.
Dr. Greenhaw reports a pending relationship with Castle Biosciences.
SOURCE: Greenhaw BN et al. AAD 19. Session F055, Abstract 11370.
WASHINGTON – The for accurately predicting recurrence-free survival and distant metastasis-free survival and melanoma-specific survival, according to results presented by Bradley N. Greenhaw, MD, at a late-breaking research session at the annual meeting of the American Academy of Dermatology.
Dr. Greenhaw, a dermatologist affiliated with the North Mississippi Medical Center-Tupelo, and his colleagues pooled together 1,268 patients from the following studies that analyzed results from melanoma patients who had their disease classified with the 31-gene expression profile (31-GEP) test.
- A single-center study, conducted by Dr. Greenhaw and his associates (Greenhaw BN et al. Dermatol Surg. 2018 Dec. doi: 10.1097/DSS.0000000000001588.
- A multicenter prospective study (J Hematol Oncol. 2017 Aug. doi: 10.1186/s13045-017-0520-1.
- A retrospective archival study (J Am Acad Dermatol. 2019 Jan. doi: 10.1016/j.jaad.2018.07.028.
The 31-GEP test stratifies an individual’s likelihood of developing metastasis within 5 years as low and high risk. In the three studies, the test was used to identify tumors with low-risk (class 1A, class 1B), higher-risk (class 2A), and highest-risk (class 2B) melanoma based on tumor gene expression. In these individual studies, class 2B melanoma independently predicted recurrence-free survival (RFS), distant metastasis–free, and melanoma-specific survival.
Dr. Greenhaw and colleagues performed a meta-analysis of 1,268 patients with stage I through stage III melanoma from those three studies, using fixed and random effects weighting to account for study differences and heterogeneity, respectively. For class 2B tumors, they found a 2.96 increased risk for recurrent metastases and a 2.88 increased risk for distant metastases. The researchers also found no heterogeneity across the studies.
Melanoma-specific survival was not included in the meta-analysis because one paper did not contain any mortality events in class 1A melanoma patients.
“The meta-analysis demonstrated that the GEP test was able to accurately identify those melanoma patients who were at higher risk of metastasis, and we saw a consistent effect across multiple studies,” Dr. Greenhaw said.
Since publication of the 2019 JAAD paper, there were an additional 211 patients who met inclusion criteria and were included in an additional meta-analysis to determine whether inclusion of these patients affected the results. Dr. Greenhaw and colleagues found a 91.4% recurrence-free survival rate and a 94.1% distant metastasis–free survival rate for class 1A melanomas, compared with 45.7% and 55.5% , respectively, for class 2B tumors.
“You can see a big divergence,” Dr. Greenhaw said at the meeting. “Just by using this one test, it’s able to separate out melanomas that otherwise may be grouped in together under current AJCC [American Joint Committee on Cancer] staging,” he added. “The class 2B designation really did confirm a higher risk for recurrence in distant metastasis.”
The researchers used the SORT method to rate the quality of the data across all three studies. Level 1 evidence under the SORT method represents a systematic review or meta-analysis of good-quality studies and/or a prospective study with good follow-up, while an A-level recommendation represents good, quality evidence. Based on the meta-analysis results, the 31-GEP test meets level 1A evidence under the SORT method, Dr. Greenhaw said.
As a prognostic tool, 31-GEP has the potential to change how dermatologists manage their patients with regard to follow-up and adjuvant therapy. “It is being used not just as this novel test that gives us more information, it’s being used clinically,” said Dr. Greenhaw, who noted he regularly uses the 31-GEP test in his practice.
This is the first time that a meta-analysis has been performed for this test, he noted.
Dr. Greenhaw reports a pending relationship with Castle Biosciences.
SOURCE: Greenhaw BN et al. AAD 19. Session F055, Abstract 11370.
REPORTING FROM AAD 19
Simple treatments can address bleeding in dermatologic surgery
WAIKOLOA, HAWAII – “Nothing can ruin your day more than a lot of bleeding,” said Mohs surgeon Daniel Siegel, MD, clinical professor of dermatology at the State University of New York Downstate Medical Center, New York.
“Part of planning for surgery is to prevent that sort of problem,” and fortunately, and some are very inexpensive. There’s even a “fancy form of potato starch” that can be left in the wound and sewn over, he said in an interview at the Hawaii Dermatology Seminar, provided by Global Academy for Medical Education/Skin Disease Education Foundation.
During the interview, Dr. Siegel described several options and how to use them. They are good products to have on hand in the clinic, just in case, he said.
SDEF/Global Academy for Medical Education and this news organization and are owned by the same parent company.
WAIKOLOA, HAWAII – “Nothing can ruin your day more than a lot of bleeding,” said Mohs surgeon Daniel Siegel, MD, clinical professor of dermatology at the State University of New York Downstate Medical Center, New York.
“Part of planning for surgery is to prevent that sort of problem,” and fortunately, and some are very inexpensive. There’s even a “fancy form of potato starch” that can be left in the wound and sewn over, he said in an interview at the Hawaii Dermatology Seminar, provided by Global Academy for Medical Education/Skin Disease Education Foundation.
During the interview, Dr. Siegel described several options and how to use them. They are good products to have on hand in the clinic, just in case, he said.
SDEF/Global Academy for Medical Education and this news organization and are owned by the same parent company.
WAIKOLOA, HAWAII – “Nothing can ruin your day more than a lot of bleeding,” said Mohs surgeon Daniel Siegel, MD, clinical professor of dermatology at the State University of New York Downstate Medical Center, New York.
“Part of planning for surgery is to prevent that sort of problem,” and fortunately, and some are very inexpensive. There’s even a “fancy form of potato starch” that can be left in the wound and sewn over, he said in an interview at the Hawaii Dermatology Seminar, provided by Global Academy for Medical Education/Skin Disease Education Foundation.
During the interview, Dr. Siegel described several options and how to use them. They are good products to have on hand in the clinic, just in case, he said.
SDEF/Global Academy for Medical Education and this news organization and are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR
Fine-tune staging for better SCC risk stratification
ORLANDO – When caring for individuals with sun-damaged skin, dermatologists need comfort with the full spectrum of photo-related skin disease. From assessment and treatment of actinic keratoses (AKs) and field cancerization, to long-term follow-up of cutaneous squamous cell carcinomas (SCCs), appropriate treatment and staging can improve patient quality of life and reduce health care costs, Vishal Patel, MD, said at the Orlando Dermatology Aesthetic and Clinical Conference.
said Dr. Patel, director of cutaneous oncology at George Washington University Cancer Center, Washington. On the other hand, he added, “field disease can be a marker for invasive squamous cell carcinoma risk, and it requires field treatment.” Treatment that reduces field disease is primary prevention because it decreases the formation of invasive SCC, he noted.
“But this level of disease – AKs and SCC in situ – doesn’t kill people,” he emphasized. “I want to leave you with an ability to stage this disease,” said Dr. Patel, noting that SCC mortality may eventually surpass melanoma mortality as deaths from the latter decline and numbers of older Americans with high ultraviolet light exposure and other risk factors climb.
While the majority of AKs regress within 5 years, he looks at the total burden of AKs as a marker for field cancerization “because having less than five in situ or actinic lesions puts you at less than a 1% risk of squamous cell carcinoma formation. Having more than 20 increases that risk 20-fold to 20%,” he said. “That’s the way we need to start thinking about this: Is this a disease – or a symptom?”
Rather than thinking of each AK or SCC in situ as a separate disease event, “the disease we need to be focusing on and treating is field cancerization,” he continued. Within this context, “we should not be thinking that … we need to be aggressive in our management,” which is what results in high costs.
“The reality is that this is a big quality of life issue for our patients. So what do we do?” Field treatment is appropriate for field disease, he said. Dr. Patel said that at GW only field treatment is used; destructive treatment for AKs and SCC in situ is not used. In the absence of patient and lesion characteristics that elevate risk,“surgery is really not the standard of care for in situ lesions for us,” he commented.
“We start by discerning the field disease from the invasive disease” with an initial round of field treatment and, if needed, adjunctive oral chemoprophylaxis. “We lather, rinse, and repeat” the field therapy, continuously if needed, Dr. Patel said.
“We like to do that because we can then identify those specific lesions we want to go after. No cryosurgery, no destructive therapy, because we run the risk of burying those tumors under the scar. They may recur and make it more difficult to accurately stage them in the future,” he noted.
“I like to be more sophisticated in thinking about our approach to the outcomes of these individual lesions,” he said. When it comes to excising lesions that have been biopsied and show invasive SCC, “disc excision may be a more cost-effective way to treat many low-risk SCCs,” he noted. In any case, “removal with clear surgical margins is key.”
Primary tumors with such low-risk attributes as diameter under a centimeter and thickness under 2 mm; well-defined borders; location on the trunk, neck, or extremities; well-differentiated histology; and lack of perineural invasion can all be considered for a disc technique, especially if the patient is immunocompetent without background chronic inflammation or a history of prior radiation therapy.
Staging SCCs, said Dr. Patel, is where things really get tricky. Older staging systems for SCC “led us to overtreat nonaggressive disease and undertreat aggressive disease. I think we have the responsibility to lead the charge to having a more sophisticated approach.” For example, patients whose tumors were staged T2 in the American Joint Commission on Cancer (AJCC) 7 classification system were most likely to have poor outcomes – in part because so few tumors were staged higher – which meant AJCC 7 didn’t provide adequate differentiation for useful risk prognostication.
A group of researchers at the Brigham and Women’s Hospital (BWH), Boston, “came up with a better system to better differentiate those T2 tumors into a high-risk and a low-risk subtype,” according to Dr. Patel.
With use of validated risk factors, the investigators applied a long list of risk factors to 2,000 tumors to see which risk factors, taken individually, were really contributing to poor outcomes. Eventually, four risk factors that made the most difference were identified: size greater than 2 cm, poor tumor differentiation, perineural invasion greater than 0.1 mm in diameter, and tumor invasion beyond subcutaneous fat. “I really want to highlight the size portion of those risk factors,” said Dr. Patel. “Something I’d like you to do in your clinical practice is to measure and document the size of the lesion. … That really, clearly helps” with risk prognostication.
These four factors were then used to break out a T2a stage for tumors with one risk factor and a T2b stage for tumors with two or three risk factors. Tumors with no risk factors are stage T1, and those with all four risk factors are stage T3. In situ SCC is T0.
Applying this new staging system to a 2,000-patient cohort with SCC yielded clear separation in outcomes including recurrence, nodal metastasis, disease-specific death, and overall survival between patients with the T2a and T2b tumors (P less than .001 for all; J Clin Oncol. 2014 Feb 1;32[4]:327-34).
While AJCC 8 is “significantly better” than AJCC 7 in its incorporation of meaningful risk factors into the SCC staging system, “it still underperforms in comparison” with the BWH staging system using the 2000 patient cohort, he said. Recent work has shown the BWH classification system to have superior specificity and positive predictive value in detecting nodal metastasis and disease-specific death in higher-grade tumors. But both BWH and AJCC 8 need further refinement.
“So what are the staging pearls to take home?” Dr. Patel asked. “First, utilize a staging system.” “Staging of SCC utilizing should be done routinely. Most data seems to suggest that the BWH system appears to outperform AJCC 8, and it is what we currently use routinely at GW,” he said.
Patients who are T1 by BWH criteria, with no risk factors, are at low or even no risk, he noted. He pointed out that of the nearly 1,400 patients who met T1 criteria, there were just eight local recurrences, one nodal metastasis, and no distant metastases or deaths. Knowing this should guide physicians on a treatment path that will reduce costs and provide patients with peace of mind, he said.
In the BWH schema, T2a patients fared almost as well, with a 2% risk of nodal metastasis and an overall 1% risk of disease-specific death. “T2a disease is low risk, in my mind. Most of these patients will go on to do well,” he said.
By contrast, “there may be a number of tumors that you are missing” that are candidates for close follow-up if the BWH criteria are not being used, said Dr. Patel. These are the T2b tumors. “For those patients, we want to aggressively follow them and think about a more aggressive management plan.”
The bottom line is that BWH T2b and T3 tumors are both high risk, and management needs to acknowledge this, he said. The current protocol in our cutaneous oncology program includes using routine radiologic nodal staging in patients with BWH stage 2b and above SCCs and considering sentinel lymph node biopsy for certain individuals.
For patients with BWH T2b and T3 tumors, dermatologists should give consideration to tertiary care or cancer center referrals so they have access to the full spectrum of diagnostic and therapeutic modalities and the opportunity to participate in clinical trials, Dr. Patel said.
Dr. Patel reported that he is a speaker for Regeneron/Sanofi and a cofounder of the Skin Cancer Outcomes (SCOUT) consortium.
This article was updated 2/9/2019
ORLANDO – When caring for individuals with sun-damaged skin, dermatologists need comfort with the full spectrum of photo-related skin disease. From assessment and treatment of actinic keratoses (AKs) and field cancerization, to long-term follow-up of cutaneous squamous cell carcinomas (SCCs), appropriate treatment and staging can improve patient quality of life and reduce health care costs, Vishal Patel, MD, said at the Orlando Dermatology Aesthetic and Clinical Conference.
said Dr. Patel, director of cutaneous oncology at George Washington University Cancer Center, Washington. On the other hand, he added, “field disease can be a marker for invasive squamous cell carcinoma risk, and it requires field treatment.” Treatment that reduces field disease is primary prevention because it decreases the formation of invasive SCC, he noted.
“But this level of disease – AKs and SCC in situ – doesn’t kill people,” he emphasized. “I want to leave you with an ability to stage this disease,” said Dr. Patel, noting that SCC mortality may eventually surpass melanoma mortality as deaths from the latter decline and numbers of older Americans with high ultraviolet light exposure and other risk factors climb.
While the majority of AKs regress within 5 years, he looks at the total burden of AKs as a marker for field cancerization “because having less than five in situ or actinic lesions puts you at less than a 1% risk of squamous cell carcinoma formation. Having more than 20 increases that risk 20-fold to 20%,” he said. “That’s the way we need to start thinking about this: Is this a disease – or a symptom?”
Rather than thinking of each AK or SCC in situ as a separate disease event, “the disease we need to be focusing on and treating is field cancerization,” he continued. Within this context, “we should not be thinking that … we need to be aggressive in our management,” which is what results in high costs.
“The reality is that this is a big quality of life issue for our patients. So what do we do?” Field treatment is appropriate for field disease, he said. Dr. Patel said that at GW only field treatment is used; destructive treatment for AKs and SCC in situ is not used. In the absence of patient and lesion characteristics that elevate risk,“surgery is really not the standard of care for in situ lesions for us,” he commented.
“We start by discerning the field disease from the invasive disease” with an initial round of field treatment and, if needed, adjunctive oral chemoprophylaxis. “We lather, rinse, and repeat” the field therapy, continuously if needed, Dr. Patel said.
“We like to do that because we can then identify those specific lesions we want to go after. No cryosurgery, no destructive therapy, because we run the risk of burying those tumors under the scar. They may recur and make it more difficult to accurately stage them in the future,” he noted.
“I like to be more sophisticated in thinking about our approach to the outcomes of these individual lesions,” he said. When it comes to excising lesions that have been biopsied and show invasive SCC, “disc excision may be a more cost-effective way to treat many low-risk SCCs,” he noted. In any case, “removal with clear surgical margins is key.”
Primary tumors with such low-risk attributes as diameter under a centimeter and thickness under 2 mm; well-defined borders; location on the trunk, neck, or extremities; well-differentiated histology; and lack of perineural invasion can all be considered for a disc technique, especially if the patient is immunocompetent without background chronic inflammation or a history of prior radiation therapy.
Staging SCCs, said Dr. Patel, is where things really get tricky. Older staging systems for SCC “led us to overtreat nonaggressive disease and undertreat aggressive disease. I think we have the responsibility to lead the charge to having a more sophisticated approach.” For example, patients whose tumors were staged T2 in the American Joint Commission on Cancer (AJCC) 7 classification system were most likely to have poor outcomes – in part because so few tumors were staged higher – which meant AJCC 7 didn’t provide adequate differentiation for useful risk prognostication.
A group of researchers at the Brigham and Women’s Hospital (BWH), Boston, “came up with a better system to better differentiate those T2 tumors into a high-risk and a low-risk subtype,” according to Dr. Patel.
With use of validated risk factors, the investigators applied a long list of risk factors to 2,000 tumors to see which risk factors, taken individually, were really contributing to poor outcomes. Eventually, four risk factors that made the most difference were identified: size greater than 2 cm, poor tumor differentiation, perineural invasion greater than 0.1 mm in diameter, and tumor invasion beyond subcutaneous fat. “I really want to highlight the size portion of those risk factors,” said Dr. Patel. “Something I’d like you to do in your clinical practice is to measure and document the size of the lesion. … That really, clearly helps” with risk prognostication.
These four factors were then used to break out a T2a stage for tumors with one risk factor and a T2b stage for tumors with two or three risk factors. Tumors with no risk factors are stage T1, and those with all four risk factors are stage T3. In situ SCC is T0.
Applying this new staging system to a 2,000-patient cohort with SCC yielded clear separation in outcomes including recurrence, nodal metastasis, disease-specific death, and overall survival between patients with the T2a and T2b tumors (P less than .001 for all; J Clin Oncol. 2014 Feb 1;32[4]:327-34).
While AJCC 8 is “significantly better” than AJCC 7 in its incorporation of meaningful risk factors into the SCC staging system, “it still underperforms in comparison” with the BWH staging system using the 2000 patient cohort, he said. Recent work has shown the BWH classification system to have superior specificity and positive predictive value in detecting nodal metastasis and disease-specific death in higher-grade tumors. But both BWH and AJCC 8 need further refinement.
“So what are the staging pearls to take home?” Dr. Patel asked. “First, utilize a staging system.” “Staging of SCC utilizing should be done routinely. Most data seems to suggest that the BWH system appears to outperform AJCC 8, and it is what we currently use routinely at GW,” he said.
Patients who are T1 by BWH criteria, with no risk factors, are at low or even no risk, he noted. He pointed out that of the nearly 1,400 patients who met T1 criteria, there were just eight local recurrences, one nodal metastasis, and no distant metastases or deaths. Knowing this should guide physicians on a treatment path that will reduce costs and provide patients with peace of mind, he said.
In the BWH schema, T2a patients fared almost as well, with a 2% risk of nodal metastasis and an overall 1% risk of disease-specific death. “T2a disease is low risk, in my mind. Most of these patients will go on to do well,” he said.
By contrast, “there may be a number of tumors that you are missing” that are candidates for close follow-up if the BWH criteria are not being used, said Dr. Patel. These are the T2b tumors. “For those patients, we want to aggressively follow them and think about a more aggressive management plan.”
The bottom line is that BWH T2b and T3 tumors are both high risk, and management needs to acknowledge this, he said. The current protocol in our cutaneous oncology program includes using routine radiologic nodal staging in patients with BWH stage 2b and above SCCs and considering sentinel lymph node biopsy for certain individuals.
For patients with BWH T2b and T3 tumors, dermatologists should give consideration to tertiary care or cancer center referrals so they have access to the full spectrum of diagnostic and therapeutic modalities and the opportunity to participate in clinical trials, Dr. Patel said.
Dr. Patel reported that he is a speaker for Regeneron/Sanofi and a cofounder of the Skin Cancer Outcomes (SCOUT) consortium.
This article was updated 2/9/2019
ORLANDO – When caring for individuals with sun-damaged skin, dermatologists need comfort with the full spectrum of photo-related skin disease. From assessment and treatment of actinic keratoses (AKs) and field cancerization, to long-term follow-up of cutaneous squamous cell carcinomas (SCCs), appropriate treatment and staging can improve patient quality of life and reduce health care costs, Vishal Patel, MD, said at the Orlando Dermatology Aesthetic and Clinical Conference.
said Dr. Patel, director of cutaneous oncology at George Washington University Cancer Center, Washington. On the other hand, he added, “field disease can be a marker for invasive squamous cell carcinoma risk, and it requires field treatment.” Treatment that reduces field disease is primary prevention because it decreases the formation of invasive SCC, he noted.
“But this level of disease – AKs and SCC in situ – doesn’t kill people,” he emphasized. “I want to leave you with an ability to stage this disease,” said Dr. Patel, noting that SCC mortality may eventually surpass melanoma mortality as deaths from the latter decline and numbers of older Americans with high ultraviolet light exposure and other risk factors climb.
While the majority of AKs regress within 5 years, he looks at the total burden of AKs as a marker for field cancerization “because having less than five in situ or actinic lesions puts you at less than a 1% risk of squamous cell carcinoma formation. Having more than 20 increases that risk 20-fold to 20%,” he said. “That’s the way we need to start thinking about this: Is this a disease – or a symptom?”
Rather than thinking of each AK or SCC in situ as a separate disease event, “the disease we need to be focusing on and treating is field cancerization,” he continued. Within this context, “we should not be thinking that … we need to be aggressive in our management,” which is what results in high costs.
“The reality is that this is a big quality of life issue for our patients. So what do we do?” Field treatment is appropriate for field disease, he said. Dr. Patel said that at GW only field treatment is used; destructive treatment for AKs and SCC in situ is not used. In the absence of patient and lesion characteristics that elevate risk,“surgery is really not the standard of care for in situ lesions for us,” he commented.
“We start by discerning the field disease from the invasive disease” with an initial round of field treatment and, if needed, adjunctive oral chemoprophylaxis. “We lather, rinse, and repeat” the field therapy, continuously if needed, Dr. Patel said.
“We like to do that because we can then identify those specific lesions we want to go after. No cryosurgery, no destructive therapy, because we run the risk of burying those tumors under the scar. They may recur and make it more difficult to accurately stage them in the future,” he noted.
“I like to be more sophisticated in thinking about our approach to the outcomes of these individual lesions,” he said. When it comes to excising lesions that have been biopsied and show invasive SCC, “disc excision may be a more cost-effective way to treat many low-risk SCCs,” he noted. In any case, “removal with clear surgical margins is key.”
Primary tumors with such low-risk attributes as diameter under a centimeter and thickness under 2 mm; well-defined borders; location on the trunk, neck, or extremities; well-differentiated histology; and lack of perineural invasion can all be considered for a disc technique, especially if the patient is immunocompetent without background chronic inflammation or a history of prior radiation therapy.
Staging SCCs, said Dr. Patel, is where things really get tricky. Older staging systems for SCC “led us to overtreat nonaggressive disease and undertreat aggressive disease. I think we have the responsibility to lead the charge to having a more sophisticated approach.” For example, patients whose tumors were staged T2 in the American Joint Commission on Cancer (AJCC) 7 classification system were most likely to have poor outcomes – in part because so few tumors were staged higher – which meant AJCC 7 didn’t provide adequate differentiation for useful risk prognostication.
A group of researchers at the Brigham and Women’s Hospital (BWH), Boston, “came up with a better system to better differentiate those T2 tumors into a high-risk and a low-risk subtype,” according to Dr. Patel.
With use of validated risk factors, the investigators applied a long list of risk factors to 2,000 tumors to see which risk factors, taken individually, were really contributing to poor outcomes. Eventually, four risk factors that made the most difference were identified: size greater than 2 cm, poor tumor differentiation, perineural invasion greater than 0.1 mm in diameter, and tumor invasion beyond subcutaneous fat. “I really want to highlight the size portion of those risk factors,” said Dr. Patel. “Something I’d like you to do in your clinical practice is to measure and document the size of the lesion. … That really, clearly helps” with risk prognostication.
These four factors were then used to break out a T2a stage for tumors with one risk factor and a T2b stage for tumors with two or three risk factors. Tumors with no risk factors are stage T1, and those with all four risk factors are stage T3. In situ SCC is T0.
Applying this new staging system to a 2,000-patient cohort with SCC yielded clear separation in outcomes including recurrence, nodal metastasis, disease-specific death, and overall survival between patients with the T2a and T2b tumors (P less than .001 for all; J Clin Oncol. 2014 Feb 1;32[4]:327-34).
While AJCC 8 is “significantly better” than AJCC 7 in its incorporation of meaningful risk factors into the SCC staging system, “it still underperforms in comparison” with the BWH staging system using the 2000 patient cohort, he said. Recent work has shown the BWH classification system to have superior specificity and positive predictive value in detecting nodal metastasis and disease-specific death in higher-grade tumors. But both BWH and AJCC 8 need further refinement.
“So what are the staging pearls to take home?” Dr. Patel asked. “First, utilize a staging system.” “Staging of SCC utilizing should be done routinely. Most data seems to suggest that the BWH system appears to outperform AJCC 8, and it is what we currently use routinely at GW,” he said.
Patients who are T1 by BWH criteria, with no risk factors, are at low or even no risk, he noted. He pointed out that of the nearly 1,400 patients who met T1 criteria, there were just eight local recurrences, one nodal metastasis, and no distant metastases or deaths. Knowing this should guide physicians on a treatment path that will reduce costs and provide patients with peace of mind, he said.
In the BWH schema, T2a patients fared almost as well, with a 2% risk of nodal metastasis and an overall 1% risk of disease-specific death. “T2a disease is low risk, in my mind. Most of these patients will go on to do well,” he said.
By contrast, “there may be a number of tumors that you are missing” that are candidates for close follow-up if the BWH criteria are not being used, said Dr. Patel. These are the T2b tumors. “For those patients, we want to aggressively follow them and think about a more aggressive management plan.”
The bottom line is that BWH T2b and T3 tumors are both high risk, and management needs to acknowledge this, he said. The current protocol in our cutaneous oncology program includes using routine radiologic nodal staging in patients with BWH stage 2b and above SCCs and considering sentinel lymph node biopsy for certain individuals.
For patients with BWH T2b and T3 tumors, dermatologists should give consideration to tertiary care or cancer center referrals so they have access to the full spectrum of diagnostic and therapeutic modalities and the opportunity to participate in clinical trials, Dr. Patel said.
Dr. Patel reported that he is a speaker for Regeneron/Sanofi and a cofounder of the Skin Cancer Outcomes (SCOUT) consortium.
This article was updated 2/9/2019
EXPERT ANALYSIS FROM ODAC 2019
Antibiotic use in dermatology declining, with one exception
Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.
In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.
The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.
John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.
“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”
However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.
The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.
Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.
“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.
The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.
SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.
Reducing antibiotic prescribing in dermatology – as in so many other areas of medical practice – is a challenge, but there are a number of strategies that can help.
The first is to take a wait-and-see approach, which has been shown to be effective for childhood otitis media. Communication training for physicians can also help them to manage patient requests for antibiotics by working out the patient’s level of understanding of their condition and treatment options, and their expectations, and getting them to agree to keep antibiotics as a contingency plan. There are clinical decision support tools available to help physicians identify high-risk surgical patients who may require postoperative antibiotics.
It will help to have alternative treatment options for conditions such as acne and rosacea, such as better topical therapies, and an increase in clinical trials for these therapies will hopefully provide more options for patients.
Joslyn S. Kirby, MD, and Jordan S. Lim, MB, are in the department of dermatology, Penn State University, Hershey. These comments are taken from an accompanying editorial (JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4877). They had no disclosures.
Reducing antibiotic prescribing in dermatology – as in so many other areas of medical practice – is a challenge, but there are a number of strategies that can help.
The first is to take a wait-and-see approach, which has been shown to be effective for childhood otitis media. Communication training for physicians can also help them to manage patient requests for antibiotics by working out the patient’s level of understanding of their condition and treatment options, and their expectations, and getting them to agree to keep antibiotics as a contingency plan. There are clinical decision support tools available to help physicians identify high-risk surgical patients who may require postoperative antibiotics.
It will help to have alternative treatment options for conditions such as acne and rosacea, such as better topical therapies, and an increase in clinical trials for these therapies will hopefully provide more options for patients.
Joslyn S. Kirby, MD, and Jordan S. Lim, MB, are in the department of dermatology, Penn State University, Hershey. These comments are taken from an accompanying editorial (JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4877). They had no disclosures.
Reducing antibiotic prescribing in dermatology – as in so many other areas of medical practice – is a challenge, but there are a number of strategies that can help.
The first is to take a wait-and-see approach, which has been shown to be effective for childhood otitis media. Communication training for physicians can also help them to manage patient requests for antibiotics by working out the patient’s level of understanding of their condition and treatment options, and their expectations, and getting them to agree to keep antibiotics as a contingency plan. There are clinical decision support tools available to help physicians identify high-risk surgical patients who may require postoperative antibiotics.
It will help to have alternative treatment options for conditions such as acne and rosacea, such as better topical therapies, and an increase in clinical trials for these therapies will hopefully provide more options for patients.
Joslyn S. Kirby, MD, and Jordan S. Lim, MB, are in the department of dermatology, Penn State University, Hershey. These comments are taken from an accompanying editorial (JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4877). They had no disclosures.
Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.
In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.
The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.
John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.
“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”
However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.
The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.
Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.
“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.
The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.
SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.
Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.
In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.
The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.
John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.
“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”
However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.
The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.
Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.
“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.
The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.
SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.
FROM JAMA DERMATOLOGY
Key clinical point: Antibiotic prescriptions by dermatologists have decreased since 2008.
Major finding: Between 2008 and 2016, antibiotic prescriptions by dermatologists dropped by 36.6%.
Study details: Cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists from 2008 to 2016.
Disclosures: The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. The authors had no disclosures.
Source: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.
How, and when, to use fat grafting for scars
BOSTON – according to Benjamin Levi, MD, director of the burn/wound and regenerative medicine laboratory at the University of Michigan, Ann Arbor.
Some corners of the Internet tout it as “some sort of magic stem cell surgery,” Dr. Levi said, but in reality, for scar surgeons, it’s just another useful tool in the armamentarium, one that excels at filling skin depressions due to underlying tissue loss, whether from burns, trauma, or surgery. Unlike hyaluronic acid and other options, fat grafts last; about half of injected adipocytes remain indefinitely. Fat grafting might also help soften scars, he said.
To get the most out of the procedure, of course, it has to be done correctly, so Dr. Levi took a few minutes at the annual clinical congress of the American College of Surgeons to share his tips on harvesting and spinning down fat grafts, injecting adipocytes, and other matters. Although the concepts of fat grafting are straightforward, the techniques are a bit tricky. Dr. Levi hoped his treatment pearls would help other physicians, especially those considering adding fat grafting to their practice.
BOSTON – according to Benjamin Levi, MD, director of the burn/wound and regenerative medicine laboratory at the University of Michigan, Ann Arbor.
Some corners of the Internet tout it as “some sort of magic stem cell surgery,” Dr. Levi said, but in reality, for scar surgeons, it’s just another useful tool in the armamentarium, one that excels at filling skin depressions due to underlying tissue loss, whether from burns, trauma, or surgery. Unlike hyaluronic acid and other options, fat grafts last; about half of injected adipocytes remain indefinitely. Fat grafting might also help soften scars, he said.
To get the most out of the procedure, of course, it has to be done correctly, so Dr. Levi took a few minutes at the annual clinical congress of the American College of Surgeons to share his tips on harvesting and spinning down fat grafts, injecting adipocytes, and other matters. Although the concepts of fat grafting are straightforward, the techniques are a bit tricky. Dr. Levi hoped his treatment pearls would help other physicians, especially those considering adding fat grafting to their practice.
BOSTON – according to Benjamin Levi, MD, director of the burn/wound and regenerative medicine laboratory at the University of Michigan, Ann Arbor.
Some corners of the Internet tout it as “some sort of magic stem cell surgery,” Dr. Levi said, but in reality, for scar surgeons, it’s just another useful tool in the armamentarium, one that excels at filling skin depressions due to underlying tissue loss, whether from burns, trauma, or surgery. Unlike hyaluronic acid and other options, fat grafts last; about half of injected adipocytes remain indefinitely. Fat grafting might also help soften scars, he said.
To get the most out of the procedure, of course, it has to be done correctly, so Dr. Levi took a few minutes at the annual clinical congress of the American College of Surgeons to share his tips on harvesting and spinning down fat grafts, injecting adipocytes, and other matters. Although the concepts of fat grafting are straightforward, the techniques are a bit tricky. Dr. Levi hoped his treatment pearls would help other physicians, especially those considering adding fat grafting to their practice.
EXPERT ANALYSIS FROM THE ACS CLINICAL CONGRESS
Re-excision unnecessary in moderately dysplastic nevi with positive margins
ORLANDO – Re-excisions are not needed when clinically excised moderately dysplastic nevi have positive histologic margins, based on results of a retrospective study of 438 patients who were treated at nine academic medical centers in the United States.
Not a single patient in the study developed melanoma at the excision site after an average follow-up of 6.9 years, and at least 3 years in all cases, said Elizabeth G. Berry, MD, of Emory University, Atlanta, and Atlanta Veterans Administration Medical Center, one of the study investigators.
The finding “really has the potential to change how we manage these lesions. You don’t need to cut [these patients] again. You can watch them. Close observation with routine skin surveillance is reasonable,” Dr. Berry said at the International Investigative Dermatology meeting.
Routine skin exams are essential for patients with a history of dysplastic nevi as these patients are at risk for developing melanoma. Indeed, in this study, 100 patients (22.8%) subsequently developed melanomas at a site other than the location of their biopsy.
The study included 438 patients who had 467 biopsies that indicated incomplete excision of a moderately dysplastic nevus from 1990 to 2014. Patients were at least 18 years old and were an average of 47 years old. About half had a history of dysplastic nevi, and a third had a history of melanoma.
All of their biopsies for moderately dysplastic nevi had positive margins, but patients had no clinically apparent residual pigment at their excision sites. Lesions were equally as likely to be removed by shave and punch biopsies, and the majority of the nevi were located on the trunk. Complete excision was the intent in all cases.
To control for interobserver variability, the centers submitted a total of 40 slides for central dermatopathology review, which found agreement in 35 cases (87.8%). Two of the remaining five cases were downgraded to mild dysplasia, two were upgraded to severe, and one patient was upgraded to melanoma in situ, but hasn’t had a recurrence after 5 years of follow-up.
Controlling for age, sex, and family history, a patient history of dysplastic nevus prior to the biopsy doubled the risk of a subsequent melanoma (P = .017), and a history of melanoma increased it almost eightfold (P less than .001).
Knowing these risk factors, patients with a history of dysplastic nevi “need to have more frequent total body skin exams. What that frequency is, we don’t know,” Dr. Berry said.
The investigators reported they had no relevant disclosures.
SOURCE: Kim CC et al. IID 2018, Abstract 571.
ORLANDO – Re-excisions are not needed when clinically excised moderately dysplastic nevi have positive histologic margins, based on results of a retrospective study of 438 patients who were treated at nine academic medical centers in the United States.
Not a single patient in the study developed melanoma at the excision site after an average follow-up of 6.9 years, and at least 3 years in all cases, said Elizabeth G. Berry, MD, of Emory University, Atlanta, and Atlanta Veterans Administration Medical Center, one of the study investigators.
The finding “really has the potential to change how we manage these lesions. You don’t need to cut [these patients] again. You can watch them. Close observation with routine skin surveillance is reasonable,” Dr. Berry said at the International Investigative Dermatology meeting.
Routine skin exams are essential for patients with a history of dysplastic nevi as these patients are at risk for developing melanoma. Indeed, in this study, 100 patients (22.8%) subsequently developed melanomas at a site other than the location of their biopsy.
The study included 438 patients who had 467 biopsies that indicated incomplete excision of a moderately dysplastic nevus from 1990 to 2014. Patients were at least 18 years old and were an average of 47 years old. About half had a history of dysplastic nevi, and a third had a history of melanoma.
All of their biopsies for moderately dysplastic nevi had positive margins, but patients had no clinically apparent residual pigment at their excision sites. Lesions were equally as likely to be removed by shave and punch biopsies, and the majority of the nevi were located on the trunk. Complete excision was the intent in all cases.
To control for interobserver variability, the centers submitted a total of 40 slides for central dermatopathology review, which found agreement in 35 cases (87.8%). Two of the remaining five cases were downgraded to mild dysplasia, two were upgraded to severe, and one patient was upgraded to melanoma in situ, but hasn’t had a recurrence after 5 years of follow-up.
Controlling for age, sex, and family history, a patient history of dysplastic nevus prior to the biopsy doubled the risk of a subsequent melanoma (P = .017), and a history of melanoma increased it almost eightfold (P less than .001).
Knowing these risk factors, patients with a history of dysplastic nevi “need to have more frequent total body skin exams. What that frequency is, we don’t know,” Dr. Berry said.
The investigators reported they had no relevant disclosures.
SOURCE: Kim CC et al. IID 2018, Abstract 571.
ORLANDO – Re-excisions are not needed when clinically excised moderately dysplastic nevi have positive histologic margins, based on results of a retrospective study of 438 patients who were treated at nine academic medical centers in the United States.
Not a single patient in the study developed melanoma at the excision site after an average follow-up of 6.9 years, and at least 3 years in all cases, said Elizabeth G. Berry, MD, of Emory University, Atlanta, and Atlanta Veterans Administration Medical Center, one of the study investigators.
The finding “really has the potential to change how we manage these lesions. You don’t need to cut [these patients] again. You can watch them. Close observation with routine skin surveillance is reasonable,” Dr. Berry said at the International Investigative Dermatology meeting.
Routine skin exams are essential for patients with a history of dysplastic nevi as these patients are at risk for developing melanoma. Indeed, in this study, 100 patients (22.8%) subsequently developed melanomas at a site other than the location of their biopsy.
The study included 438 patients who had 467 biopsies that indicated incomplete excision of a moderately dysplastic nevus from 1990 to 2014. Patients were at least 18 years old and were an average of 47 years old. About half had a history of dysplastic nevi, and a third had a history of melanoma.
All of their biopsies for moderately dysplastic nevi had positive margins, but patients had no clinically apparent residual pigment at their excision sites. Lesions were equally as likely to be removed by shave and punch biopsies, and the majority of the nevi were located on the trunk. Complete excision was the intent in all cases.
To control for interobserver variability, the centers submitted a total of 40 slides for central dermatopathology review, which found agreement in 35 cases (87.8%). Two of the remaining five cases were downgraded to mild dysplasia, two were upgraded to severe, and one patient was upgraded to melanoma in situ, but hasn’t had a recurrence after 5 years of follow-up.
Controlling for age, sex, and family history, a patient history of dysplastic nevus prior to the biopsy doubled the risk of a subsequent melanoma (P = .017), and a history of melanoma increased it almost eightfold (P less than .001).
Knowing these risk factors, patients with a history of dysplastic nevi “need to have more frequent total body skin exams. What that frequency is, we don’t know,” Dr. Berry said.
The investigators reported they had no relevant disclosures.
SOURCE: Kim CC et al. IID 2018, Abstract 571.
REPORTING FROM IID 2018