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Mohs Archives | ODAC Dermatology, Aesthetic and Surgical Conference

Deciding When to Perform Mohs: ODAC Q&A

By | ODAC Sessions, Surgical Dermatology | No Comments
Patel at ODAC Mohs

Source: The Dermatologist

The following is an excerpt from The Dermatologist as coverage from ODAC Dermatology, Aesthetic & Surgical 2020 where Sailesh Konda, MD, and Vishal Patel, MD, reviewed the guidelines and discussed considerations for when and when not to perform MMS.

Mohs micrographic surgery (MMS) is considered the gold standard of treatment for many skin cancers. However, this option is not always appropriate for every situation and every patient. Several factors should be considered when determining which option to use, including tumor size, patient age, and aesthetic outcomes, for treating skin cancer.

The Dermatologist: What are the guidelines for determining what tumors should and should not be treated with MMS?

Dr Konda: The appropriate use criteria (AUC) for MMS was developed in 2012 by an ad hoc task force.2 In general, MMS may be considered as a treatment option for tumors on the head, neck, hands, feet, pretibial surface, ankles, and genitalia; aggressive tumors of any location; tumors greater than 2 cm on trunk or extremities; recurrent tumors, and tumors arising in patients with a history of immunosuppression, radiation, or genetic syndromes.

An AUC score is assigned to tumors based on their characteristics. Tumors with scores of 7 to 9 are appropriate, 4 to 6 are uncertain (in extenuating circumstances, MMS may be considered), and 1 to 3 are inappropriate.

However, practitioners should remember that these are only guidelines! Even if a tumor meets criteria for MMS, the physician and patient should still discuss all available treatment options—both surgical and nonsurgical— and take into consideration associated cure rates; long-term clinical and aesthetic outcome; the patient’s age and comorbidities; and risks, benefits, and adverse effects before deciding on a treatment.

The Dermatologist: What tumors often deemed appropriate for MMS might not actually require MMS, and why?

Dr Konda: Superficial basal cell carcinoma and squamous cell carcinoma in situ are tumors that have been deemed appropriate for MMS. However, these tumors may also be treated with topical therapy (imiquimod and 5-fluorouracil), local destruction, fusiform or disc excision, photodynamic therapy, and lasers (CO2 +/- diode for follicular extension). These treatment modalities may provide cure rates lower than but approaching those of MMS, and may be preferred by physicians and patients in certain circumstances. When discussing treatment options, patients should be made aware of any therapies that may be used off-label or are not FDA-approved.

Additionally, lentigo maligna (melanoma in situ) and lentigo maligna melanoma may be treated with either MMS (frozen sections), staged excision with central debulk and complete margin assessment (permanent sections), or wide local excision (permanent sections).

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Sentinel Lymph Node Biopsy for Melanoma

By | Medical Dermatology, ODAC Sessions, Surgical Dermatology | No Comments
Dr. Zitelli Presenting at ODAC

Source: Next Steps in Derm

Backed by a mountain of evidence, Dr. Zitelli walked us through the new and changing role of sentinel lymph node biopsy for melanoma in a riveting 20-minute talk presented at the 16th annual ODAC conference. Here are the highlights.

“Let’s separate what’s really evidence based from what you’ve been told.”

Before delving in, Dr. Zitelli skillfully laid the framework for his lecture. The crux of sentinel lymph node biopsy is based on the theory of orderly progressionin which malignant melanoma cells leave the tumor and preferentially enter the lymphatics and the first lymph node. This theory is rivaled by the anatomic pathway, in which malignant melanoma cells may enter the lymphatics or  the blood stream, resulting in simultaneous dissemination.

Which theory is correct?

The overwhelming preponderance of evidence supports the latter anatomic theory – melanoma cells may enter the blood stream directly or the lymphatics, potentially bypassing the sentinel node. This anatomic theory is evidence based. It refutes the theory of orderly progression that the concept of sentinel lymph node biopsy is based on. Another common misconception is that lymph nodes are filters – they are not. Lymph nodes are sampling organs, sampling antigens in order to initiate an immune response.

With the groundwork laid, Dr. Zitelli went on to summarize the emerging evidence for sentinel lymph node biopsy. “This is what you need to know when you counsel a patient in order to obtain true informed consent.”

What you’ve been told: Sentinel lymph node biopsy improves survival
What the evidence shows: There is not a single solid tumor for which sentinel lymph node biopsy has been shown to provide a survival benefit.

We’ve been told that sentinel lymph node biopsy improves survival in intermediate thickness melanoma, because subclinical deposits are removed from the lymph nodes before they can grow. In fact, 33% of patients who underwent sentinel lymph node biopsy, did so because they thought it would improve their survival. Yet, there is not a single solid tumor – melanoma, gastric, renal, thyroid or otherwise – where electively removing normal lymph nodes, even in the case of microscopic involvement, has shown a survival benefit.

A cornerstone trial, the Multicenter Selective Lymphadenectomy Trial (MSLT-1), set out to prove the survival benefit of sentinel lymph node biopsy in melanoma. However, sentinel lymph node biopsy failed to improve melanoma specific survival. Subsequently, MSLT-2 looked at whether removing positive lymph nodes further down the line would improve survival in patients who had positive sentinel lymph nodes – this was also a negative study.

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Fine Tune Staging Risk for SCC

By | Medical Dermatology, ODAC Sessions | No Comments
Patel at ODAC Mohs

Source: Dermatology News

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.

“Actinic keratosis/squamous cell carcinoma in situ is not a disease; it’s a symptom of cutaneous carcinogenesis or field cancerization,” 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.

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