Dataset Information

Outcomes of Melanoma In Situ Treated With Mohs Micrographic Surgery Compared With Wide Local Excision.

ABSTRACT:

Importance

Melanoma in situ (MIS) is increasing in incidence, and expert consensus opinion recommends surgical excision for therapeutic management. Currently, wide local excision (WLE) is the standard of care. However, Mohs micrographic surgery (MMS) is now used to treat a growing subset of individuals with MIS. During MMS, unlike WLE, the entire cutaneous surgical margin is evaluated intraoperatively for tumor cells.

Objective

To assess the outcomes of patients with MIS treated with MMS compared with those treated with WLE.

Design, setting, and participants

Retrospective review of a prospective database. The study cohort consisted of 662 patients with MIS treated with MMS or WLE per standard of care in dermatology and surgery (general surgery, otolaryngology, plastics, oculoplastics, surgical oncology) at an academic tertiary care referral center from January 1, 1978, to December 31, 2013, with follow-up through 2015.

Exposure

Mohs micrographic surgery or WLE.

Main outcomes and measures

Recurrence, overall survival, and melanoma-specific survival.

Results

There were 277 patients treated with MMS (mean [SD] age, 64.0 [13.1] years; 62.1% male) and 385 treated with WLE (mean [SD] age, 58.5 [15.6] years; P?Conclusions and relevanceNo significant differences were found in the recurrence rate, overall survival, or melanoma-specific survival of patients with MIS treated with MMS compared with WLE.

SUBMITTER: Nosrati A

PROVIDER: S-EPMC5817486 | biostudies-literature | 2017 May

REPOSITORIES: biostudies-literature

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Publications

Outcomes of Melanoma In Situ Treated With Mohs Micrographic Surgery Compared With Wide Local Excision.

Nosrati Adi A Berliner Jacqueline G JG Goel Shilpa S McGuire Joseph J Morhenn Vera V de Souza Juliana R JR Yeniay Yildiray Y Singh Rasnik R Lee Kristina K Nakamura Mio M Wu Rachel R RR Griffin Ann A Grimes Barbara B Linos Eleni E Chren Mary Margaret MM Grekin Roy R Wei Maria L ML

JAMA dermatology 20170501 5

<h4>Importance</h4>Melanoma in situ (MIS) is increasing in incidence, and expert consensus opinion recommends surgical excision for therapeutic management. Currently, wide local excision (WLE) is the standard of care. However, Mohs micrographic surgery (MMS) is now used to treat a growing subset of individuals with MIS. During MMS, unlike WLE, the entire cutaneous surgical margin is evaluated intraoperatively for tumor cells.<h4>Objective</h4>To assess the outcomes of patients with MIS treated w ...[more]

PMID: 28241261

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Project description:ImportanceMohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness.ObjectiveTo evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally.Design, setting, and participantsThis nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery.InterventionsIndividualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group.Main outcomes and measuresThe primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated.ResultsOf the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, -1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, -0.19 to -0.09; P = .002). The total administrative cost of the intervention program was $150 000, and the estimated reduction in Medicare spending was $11.1 million.Conclusions and relevanceSharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.

Project description:BACKGROUND:Cyanoacrylate topical adhesives and fast absorbing gut sutures are increasingly utilized by dermatologic surgeons as they provide satisfactory surgical outcomes while eliminating an additional patient visit for suture removal. To date, no head-to-head studies have compared the wound healing characteristics of these epidermal closure techniques in the repair of facial wounds after Mohs micrographic surgery. OBJECTIVE:To compare the cosmetic outcome of epidermal closure by cyanoacrylate topical adhesive with fast absorbing gut suture in linear repairs of the face following Mohs micrographic surgery. METHODS:Fourteen patients with wound length greater than 3cm who underwent Mohs micrographic surgery for nonmelanoma skin cancer of the face were enrolled in this randomized right-left comparative study. Following placement of dermal sutures, half of the wound was randomly selected for closure with cyanoacrylate and the contralateral side with fast absorbing gut suture. Using photographs from the three-month postoperative visit, six blinded individuals rated the overall cosmetic outcome. RESULTS:The present study shows no significant difference in cosmetic outcomes between cyanoacrylate and fast absorbing gut suture for closure of linear facial wounds resulting from Mohs micrographic surgery. Cyanoacrylate tissue adhesive may not be as effective in achieving optimal cosmesis for wounds on the forehead or of longer repair lengths. The majority of patients did not have a preference for wound closure techniques, but when a preference was given, cyanoacrylate was significantly favored over sutures. CONCLUSION:Cyanoacrylate tissue adhesive and fast absorbing gut suture both result in comparable aesthetic outcomes for epidermal closure of linear facial wounds following Mohs micrographic surgery. Consideration should be given to factors such as need for eversion, hemostasis, and wound tension when selecting an epidermal wound closure method. (ClinicalTrials.gov, Identifier: NCT01298167, http://clinicaltrials.gov/show/NCT01298167).

Dataset Information

Outcomes of Melanoma In Situ Treated With Mohs Micrographic Surgery Compared With Wide Local Excision.

Importance

Objective

Design, setting, and participants

Exposure

Main outcomes and measures

Results

Publications

Outcomes of Melanoma In Situ Treated With Mohs Micrographic Surgery Compared With Wide Local Excision.

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