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Implementation of Mohs micrographic surgery at the VA New York Manhattan Harbor Healthcare System eliminated need for re-excision and decreased time to treatment: A retrospective and prospective cohort study

Himeles, Jaclyn Rosenthal; Steuer, Alexa Beth; Sally, Rachel; Gutierrez, Daniel; Zampella, John G; Stevenson, Mary L; Carucci, John A; Lee, Nayoung
PMID: 38149943
ISSN: 1097-6787
CID: 5623592

Family Planning Experiences and Challenges of Mohs Fellowship Trainees

Kuo, Alyce M; Dusza, Stephen W; Minkis, Kira; Pugliano-Mauro, Melissa; Stevenson, Mary; Yu, Siegrid; Lee, Erica H
BACKGROUND:There is a paucity of literature describing family planning challenges faced by Mohs fellows. OBJECTIVE:To characterize perceptions about and experiences with family planning, fertility, lactation, and parental leave and identify ways to support parental health and family planning for Mohs fellows. MATERIALS AND METHODS/METHODS:A voluntary, anonymous survey was distributed to Mohs surgeons who recently completed fellowship. RESULTS:In total, 116 Mohs surgeons completed the survey. Their mean age was 34.5 years old, and more were female (n = 81, 69.8%) than male (n = 35, 30.2%). Most had children before completion of their Mohs training (n = 73, 62.9%). The most significant barrier to having children during fellowship was "loss of education or training time." Over 20% (n = 23) of respondents or their partner had experienced infertility. Half of the 20 respondents (n = 10) who breastfed or pumped did not have a convenient place to do so. CONCLUSION/CONCLUSIONS:This study elucidates trainee perceptions and gaps in parental support for Mohs fellowship trainees. In addition, barriers to implementing a universal family planning policy in Mohs surgery are discussed.
PMID: 38147436
ISSN: 1524-4725
CID: 5623502

Evaluating Delays to Surgery for Melanomas Treated With Mohs Micrographic Surgery in the United States

Cheraghlou, Shayan; Criscito, Maressa C; Stevenson, Mary L; Carucci, John A
PMID: 37606888
ISSN: 1524-4725
CID: 5598382

Defining and quantifying histopathologic risk factors for regional and distant metastases in a large cohort of vulvar squamous cell carcinomas

Cheraghlou, Shayan; Doudican, Nicole A; Criscito, Maressa C; Stevenson, Mary L; Carucci, John A
BACKGROUND:Vulvar squamous cell carcinoma (vSCC) is a rare tumor with a good prognosis when treated at a localized stage. However, once regional/distant metastasis occurs, vSCC can be rapidly fatal. Thus, it is important to identify tumor prognostic features so that high-risk cases can be prioritized for further diagnostic workup and treatment. OBJECTIVE:To estimate the risk of regional/distant metastasis at presentation and sentinel lymph node status for vSCC based on histopathologic characteristics. METHODS:A retrospective cohort study of 15,188 adult vSCC cases from the National Cancer Database diagnosed from 2012 to 2019. RESULTS:We provide specific estimates of the risk of clinically positive nodes and metastatic disease at presentation and sentinel lymph node positivity according to tumor size, moderate/poor tumor differentiation, and lymph-vascular invasion. These histopathologic factors were all significantly associated with the tested clinical outcomes in a multivariable analysis. Moderate (hazard ratio, 1.190; P < .001) and poor differentiation (hazard ratio, 1.204; P < .001) and lymph-vascular invasion (hazard ratio, 1.465; P < .001) were also associated with significantly poorer overall survival. LIMITATIONS/CONCLUSIONS:Data on disease-specific survival not available in the data set. CONCLUSIONS:We demonstrate the association of the histopathologic characteristics of vSCC with clinically important outcomes. These data may provide individualized information when discussing diagnostic/treatment recommendations, particularly regarding sentinel lymph node biopsy. These data may also guide future staging and risk stratification efforts for vSCC.
PMID: 37054818
ISSN: 1097-6787
CID: 5618742

Overall Survival After Mohs Surgery for Early-Stage Merkel Cell Carcinoma

Cheraghlou, Shayan; Doudican, Nicole A; Criscito, Maressa C; Stevenson, Mary L; Carucci, John A
IMPORTANCE:Merkel cell carcinoma (MCC) is a rare cutaneous malignant neoplasm with increasing incidence and high mortality. Although it is accepted that the optimal treatment for localized tumors is surgical, the data surrounding the optimal surgical approach are mixed, and current National Comprehensive Cancer Network guidelines state that Mohs micrographic surgery (MMS) and wide local excision (WLE) can both be used. The current National Comprehensive Cancer Network guidelines do not advocate a preference for MMS or WLE and suggest that they can be used interchangeably. OBJECTIVE:To evaluate the association of surgical approach with overall survival after excision of localized T1/T2 MCC. DESIGN, SETTING, AND PARTICIPANTS:This retrospective cohort study used the National Cancer Database to assess adults with T1/T2 MCC who were diagnosed between January 1, 2004, and December 31, 2018, with pathologically confirmed, negative regional lymph nodes and treated with surgery. The National Cancer Database includes all reportable cases from Commission on Cancer-accredited facilities. Data analysis was performed from October 2022 to May 2023. EXPOSURE:Surgical approach. MAIN OUTCOMES AND MEASURES:Overall survival. RESULTS:A total of 2313 patients (mean [SD] age, 71 [10.6] years; 1340 [57.9%] male) were included in the study. Excision with MMS had the best unadjusted survival, with mean (SE) survival rates of 87.4% (3.4%) at 3 years, 84.5% (3.9%) at 5 years, and 81.8% (4.6%) at 10 years vs 86.1% (0.9%) at 3 years, 76.9% (1.2%) at 5 years, and 60.9% (2.0%) at 10 years for patients treated with WLE. Patients treated with narrow-margin excision had similar survival as those treated with WLE, with mean (SE) survival rates of 84.8% (1.4%) at 3 years, 78.3% (1.7%) at 5 years, and 60.8% (3.6%) at 10 years. On multivariable survival analysis, excision with MMS was associated with significantly improved survival compared with WLE (hazard ratio, 0.59; 95% CI, 0.36-0.97; P = .04). High-volume MCC centers were significantly more likely to use MMS over WLE compared with other centers (odds ratio, 1.99; 95% CI, 1.63-2.44; P < .001). CONCLUSIONS AND RELEVANCE:In this cohort study, the use of MMS (compared with WLE) was associated with significantly improved survival for patients with localized MCC with pathologically confirmed negative lymph nodes treated with surgery. These data suggest that Mohs surgery may provide a more effective treatment for MCC primary tumors than conventional WLE, although the lack of randomization and potential for selection bias in this study highlight the need for future prospective work evaluating this issue.
PMID: 37610773
ISSN: 2168-6084
CID: 5598522

Diagnosis of perineural invasion during Mohs micrographic surgery guides clinical decision-making in the management of cutaneous squamous cell carcinoma

Steuer, Alexa B; Criscito, Maressa C; Doudican, Nicole; Carucci, John A; Stevenson, Mary L
PMID: 37169297
ISSN: 1097-6787
CID: 5544612

Characterizing cutaneous malignancies in patients with skin of color treated with Mohs micrographic surgery

Juarez, Michelle C; Criscito, Maressa C; Pulavarty, Akshay; Stevenson, Mary L; Carucci, John A
PMID: 36965670
ISSN: 1097-6787
CID: 5462992

Immunosuppressed patients are at increased risk of local recurrence, metastasis, and disease specific death from cutaneous squamous cell carcinoma

Lopez, Adriana; Babadzhanov, Marianna; Cheraghlou, Shayan; Canavan, Theresa; Doudican, Nicole; Stevenson, Mary; Carucci, John A
It is well established that immunosuppressed patients are at increased risk for poor outcomes (PO) from cutaneous squamous cell carcinoma (cSCC), including local recurrence (LR), nodal metastasis (NM), distant metastasis (DM), and disease-specific death (DSD). Defining PO risk is challenging but may be beneficial in guiding management. We aimed to define PO risk factors and evaluated their importance in immunosuppressed versus immunocompetent patients. We conducted a 4-year single-center retrospective review of patients with cSCC. Patient and tumor characteristics were evaluated in those that experienced PO. Immunosuppressed patients were ~ 11-fold more likely than immunocompetent patients to develop PO (10/85 vs. 15/1332, p < 0.0001). Among those with PO, immunosuppressed patients had diminished relapse free (p = 0.026) and progression free (p < 0.001) survival compared to immunocompetent. Immunosuppression was significantly associated with LR (p < 0.00001). Immunosuppressed patients were also more likely to develop NM, DM and experience DSD (p = 0.027). Mohs Appropriate Use Criteria was associated with NM, DM and DSD (p = 0.029), with area H tumors more likely to result in metastasis and death. In conclusion, immunosuppressed patients are more likely to develop LR, metastasis, and DSD from cSCC compared to immunocompetent patients. Immunosuppressed status was an independent risk factor for PO in this cohort and further considered for its inclusion in prognostication schema is warranted.
PMID: 36416979
ISSN: 1432-069x
CID: 5384242

Gender Differences in Clinical Practice and Medicare Reimbursement Among Mohs Surgeons

Motosko, Catherine C; Waldman, Abigail; Stevenson, Mary L; Council, M Laurin
OBJECTIVE:To evaluate Medicare reimbursement and clinical activity between male and female dermatologic surgeons. MATERIALS AND METHODS/METHODS:A retrospective review of the Medicare Provider Utilization and Payment data from 2018 was performed for all dermatologists performing MMS. Provider gender, place of service, number of services, and average payment per service was recorded for all relevant procedure codes. RESULTS:Women represented 31.5% of the 2,581 surgeons who performed MMS in 2018. Women were paid significantly less than men (mean difference, -$73,033). On average, women performed 123 fewer cases than their male counterparts. When surgeons were stratified by productivity, remuneration was the same. CONCLUSION/CONCLUSIONS:Remuneration from CMS was disparate between male and female dermatologic surgeons, which may be attributed to submission of fewer charges by women. Further efforts are necessary to better evaluate and address causes for this discrepancy, because greater parity of opportunity and pay would greatly benefit this subspecialty of dermatology.
PMID: 36877102
ISSN: 1524-4725
CID: 5432562

Assessing Rates of Positive Surgical Margins After Standard Excision of Vulvar Melanomas

Cheraghlou, Shayan; Doudican, Nicole A; Criscito, Maressa C; Stevenson, Mary L; Carucci, John A
BACKGROUND:Vulvar melanoma is a rare malignancy with frequent recurrence and poor prognosis. National guidelines recommend wide local excision of these tumors with allowances for narrower margins for anatomic and functional limitations, which are common on specialty sites. There is presently a lack of data of margin positivity after standard excision of vulvar melanomas. OBJECTIVE:We aim to evaluate the rate of positive margins after standard excision of vulvar melanomas. MATERIALS AND METHODS/METHODS:Retrospective cohort study of surgically excised vulvar melanomas from the NCDB diagnosed from 2004 to 2019. RESULTS:We identified a total of 2,226 cases. Across surgical approaches and tumor stages, 17.2% (Standard Error [SE]: 0.8%) of cases had positive surgical margins. Among tumor stages, T4 tumors were most commonly excised with positive margins (22.9%, SE: 1.5%). On multivariable survival analysis, excision with positive margins was associated with significantly poorer survival (Hazard Ratio 1.299, p = .015). CONCLUSION/CONCLUSIONS:We find that positive margin rates after standard excision of vulvar malignancies are higher than for other specialty site melanomas. Our data suggest that use of surgical approaches with complete margin assessment may improve local control and functional outcomes for patients with vulvar melanoma as they have for patients with other specialty site melanomas.
PMID: 36857160
ISSN: 1524-4725
CID: 5502312