Appropriate use of Mohs micrographic surgery in immunocompromised patients is high, and published indications for Mohs decrease inappropriate use

To the Editor: The number of immunosuppressed patients continues to rise,1Zwald F.O. Brown M. Skin cancer in solid organ transplant recipients: advances therapy and management: part I. Epidemiology skin recipients.J Am Acad Dermatol. 2011; 65 (quiz 62): 253-261Abstract Full Text PDF PubMed Scopus (154) Google Scholar they are at a significantly elevated risk cancer.2Garrett G.L. Blanc P.D. Boscardin J. et al.Incidence factors for recipients United States.JAMA 2017; 153: 296-303Crossref (128) Inappropriate use Mohs micrographic surgery (MMS) may be more common patients.3Ruiz E.S. Karia P.S. Morgan F.C. Liang C.A. Schmults C.D. Multiple is most reason divergence from appropriate criteria: single institution retrospective cohort study.J 2016; 75: 830-831Abstract (5) impact published MMS criteria (AUC) on rate inappropriate utilization population uncertain. An institutional review board–approved retrospective, single-center study was performed evaluate appropriateness treat cancers University Pennsylvania July 2005 through March 2016. Data all were prospectively entered an electronic database time surgery. following data extracted: age, sex, recurrent status, histologic diagnosis, anatomic location, preoperative size, subclinical spread (defined as requiring >1 stage achieve tumor-free margins), duration immunosuppression. Anatomic locations grouped into categories established by AUC4Ad Hoc Task F. Connolly S.M. Baker D.R. al.AAD/ACMS/ASDSA/ASMS 2012 surgery: report American Academy Dermatology, College Surgery, Society Dermatologic Surgery Association, Surgery.J 2012; 67: 531-550Abstract (260) follows: area H, which includes “mask areas” face (central face, eyelids, eyebrows, nose, lips, chin, ear, periauricular skin/sulci, temple), genitalia, hands, feet, nail units, ankles, nipples/areola; M, cheeks, forehead, scalp, neck, jawline, pretibial surface; L, trunk extremities. Each tumor scored using Dermatology's AUC app.5Mohs Appropriate Use Criteria.2014Google considered (score, 7-9), uncertain 4-6), or 1-3). primary outcome measure frequency MMS. Frequencies according before (2005-2012) after (2013-2016) publication MMS4Ad compared 2-tailed Fisher exact test (with P < .05 statistically significant). Univariate logistic regression used identify clinicopathologic characteristics associated with AUC. Odds ratios, 95% confidence intervals, values generated secondary spread. A total 680 3012 included (Table I). appropriately 95.7% tumors (2881 3012). improved (1660 1748) 96.6% (1221 1264) (P .05). Younger female immunosuppression least 10 years, location proximal extremities scores II). 22.3% (671 3012) did not differ rating > .05).Table ICharacteristics cohortPatient demographics (N = 680)ValueSex, n (%) Male518 (76.2%) Female162 (23.8%)Average age surgery, y (range, SD)62.7 (range 25-96, SD 10.75)Duration immunosuppression, <10 y398 (54.7%) ≥10 y257 (35.3%) Unknown72 (9.9%)Reason Organ transplant419 (61.6%) Nontransplant immunocompromised states∗Nontransplant medical conditions include autoimmune/inflammatory diseases, HIV infection/primary immune deficiencies, chronic lymphocytic leukemia, other hematologic malignancies, well active chemotherapy.261 (38.4%)Tumor date, (%)2005-2012 (before AUC)1748 (42.0%)2013-2016 (after AUC)1264 (58.0%) App AUC, (%)†With regard score 7 9, specific indication generally acceptable. With 4 6, indication, although its Uncertainty implies that research needed classify definitively. 1 3, acceptable.47-9 (appropriate)2881 (95.65%)4-6 (uncertain)123 (4.08%)1-3 (inappropriate)8 (0.27%) Tumor type, (%)Basal cell carcinoma742 (24.6%)Squamous carcinoma2236 (74.2%)Melanoma20 (0.7%)Other cutaneous malignancy14 (0.5%) (%)‡Area H M L extremities.AUC H1091 (36.2%)AUC M1257 (41.7%)AUC L664 (22.0%) Recurrent lesions, (%)175 (5.8%) Preoperative sizeAverage length, cm (range)1.59 (.10-17.00)Average width, (range)1.32 (0.10-11.80) Postoperative (range)2.51 (0.2-52)Average (range)2.12 (0.3-14.2)Average stages, (range)1.28 (1-7)AUC, Criteria; MMS, surgery; SD, standard deviation.∗ chemotherapy.† acceptable.4Ad Scholar‡ Area Open table new tab Table IIInfluence clinical variables likelihood MMSVariableOR∗All ORs significant .001.95% CIAge surgery1.031.008-1.044Female sex0.450.31-0.67Immunosuppression y0.530.41-0.68AUC L†Area (excluding surface, ankles).40.00350.0007-0.018CI, Confidence interval; OR, odds ratio.∗ All .001.† ankles).4Ad deviation. CI, ratio. declined suggesting guidelines influence rates. However, absolute decrease small (1.6%), overwhelming majority both guideline publication. Subclinical present patients, supporting utility these tumors. Although state “the ultimate decision regarding should determined expertise experience physician,”4Ad inform future increase awareness populations common.