Susan London

VANCOUVER, B.C. — Photographing cutaneous lesions before biopsy can help prevent wrong-site surgery when the lesions prove to be malignant and patients must undergo Mohs excision of the remaining tumor, according to an observational study of 271 biopsy sites.

Factors such as healing and actinic skin damage can make it difficult to identify biopsy sites at the time of Mohs surgery, Dr. Jamie L. McGinness, a dermatologic surgeon in Leawood, Kan., and Lee's Summit, Mo., said at the annual meeting of American College of Mohs Surgery.

In a previous survey of Mohs surgeons, other investigators found that 11% of the 300 respondents had been sued and that performing surgery on the wrong site was a leading reason for the malpractice claims, accounting for 14% (Dermatol. Surg. 2006;32:79-83).

For their study, Dr. McGinness and his coinvestigators enrolled patients who were undergoing Mohs surgery with any of four physicians at the center for a previously biopsied, malignant cutaneous lesion who could see their biopsy site using a mirror, and who had preoperative photographs of their biopsy site. Those with conditions that impair memory were excluded.

On the day of Mohs surgery, patients were given a mirror and asked to identify their biopsy site. Next, their Mohs surgeons were asked to identify the site using the anatomic information on the pathology report, the diagrammed location, and palpation. Neither the patient nor the physician was further assisted with the identification process.

In all, 271 biopsy sites were evaluated. Fully 16.6% of sites were incorrectly identified by patients and 5.9% were incorrectly identified by physicians. About 4.4% were incorrectly identified by both parties. In contrast, all sites were correctly identified with the use of preoperative photos. The results suggest that neither patients—even confident ones—nor diagrams are reliable means for identifying biopsy sites, Dr. McGinness said.

If a biopsy site cannot be identified at the time of surgery, the options are to proceed anyway—at the risk of wrong-site surgery—or to cancel surgery. "When surgeries are cancelled, this leads to higher patient inconvenience, untreated tumors that could metastasize, larger tumors when they again become observable, and increased patient morbidity," Dr. McGinness commented.

All of the patients underwent surgery an average of 2-3 weeks after biopsy, and he recommended that future research evaluate the role of this time interval. "With longer wait times between biopsy and surgery, lesions could heal and the rates [of incorrect identification] could actually be even higher," he explained.

Dr. McGinness reported no conflicts of interest related to the study.

Performing surgery on the wrong site was behind 14% of the lawsuits brought against Mohs surgeons. DR. MCGINNESS

Healing and actinic skin damage can make it hard to identify the biopsy site before surgery.

By using a prebiopsy photograph, the surgeon located the biopsy site and removed the tumor. Photos courtesy Dr. Jamie L. McGinness

VANCOUVER, B.C. — Photographing cutaneous lesions before biopsy can help prevent wrong-site surgery when the lesions prove to be malignant and patients must undergo Mohs excision of the remaining tumor, according to an observational study of 271 biopsy sites.

Factors such as healing and actinic skin damage can make it difficult to identify biopsy sites at the time of Mohs surgery, Dr. Jamie L. McGinness, a dermatologic surgeon in Leawood, Kan., and Lee's Summit, Mo., said at the annual meeting of American College of Mohs Surgery.

In a previous survey of Mohs surgeons, other investigators found that 11% of the 300 respondents had been sued and that performing surgery on the wrong site was a leading reason for the malpractice claims, accounting for 14% (Dermatol. Surg. 2006;32:79-83).

For their study, Dr. McGinness and his coinvestigators enrolled patients who were undergoing Mohs surgery with any of four physicians at the center for a previously biopsied, malignant cutaneous lesion who could see their biopsy site using a mirror, and who had preoperative photographs of their biopsy site. Those with conditions that impair memory were excluded.

On the day of Mohs surgery, patients were given a mirror and asked to identify their biopsy site. Next, their Mohs surgeons were asked to identify the site using the anatomic information on the pathology report, the diagrammed location, and palpation. Neither the patient nor the physician was further assisted with the identification process.

In all, 271 biopsy sites were evaluated. Fully 16.6% of sites were incorrectly identified by patients and 5.9% were incorrectly identified by physicians. About 4.4% were incorrectly identified by both parties. In contrast, all sites were correctly identified with the use of preoperative photos. The results suggest that neither patients—even confident ones—nor diagrams are reliable means for identifying biopsy sites, Dr. McGinness said.

If a biopsy site cannot be identified at the time of surgery, the options are to proceed anyway—at the risk of wrong-site surgery—or to cancel surgery. "When surgeries are cancelled, this leads to higher patient inconvenience, untreated tumors that could metastasize, larger tumors when they again become observable, and increased patient morbidity," Dr. McGinness commented.

All of the patients underwent surgery an average of 2-3 weeks after biopsy, and he recommended that future research evaluate the role of this time interval. "With longer wait times between biopsy and surgery, lesions could heal and the rates [of incorrect identification] could actually be even higher," he explained.

Dr. McGinness reported no conflicts of interest related to the study.

Performing surgery on the wrong site was behind 14% of the lawsuits brought against Mohs surgeons. DR. MCGINNESS

Healing and actinic skin damage can make it hard to identify the biopsy site before surgery.

By using a prebiopsy photograph, the surgeon located the biopsy site and removed the tumor. Photos courtesy Dr. Jamie L. McGinness

VANCOUVER, B.C. — Photographing cutaneous lesions before biopsy can help prevent wrong-site surgery when the lesions prove to be malignant and patients must undergo Mohs excision of the remaining tumor, according to an observational study of 271 biopsy sites.

Factors such as healing and actinic skin damage can make it difficult to identify biopsy sites at the time of Mohs surgery, Dr. Jamie L. McGinness, a dermatologic surgeon in Leawood, Kan., and Lee's Summit, Mo., said at the annual meeting of American College of Mohs Surgery.

In a previous survey of Mohs surgeons, other investigators found that 11% of the 300 respondents had been sued and that performing surgery on the wrong site was a leading reason for the malpractice claims, accounting for 14% (Dermatol. Surg. 2006;32:79-83).

For their study, Dr. McGinness and his coinvestigators enrolled patients who were undergoing Mohs surgery with any of four physicians at the center for a previously biopsied, malignant cutaneous lesion who could see their biopsy site using a mirror, and who had preoperative photographs of their biopsy site. Those with conditions that impair memory were excluded.

On the day of Mohs surgery, patients were given a mirror and asked to identify their biopsy site. Next, their Mohs surgeons were asked to identify the site using the anatomic information on the pathology report, the diagrammed location, and palpation. Neither the patient nor the physician was further assisted with the identification process.

In all, 271 biopsy sites were evaluated. Fully 16.6% of sites were incorrectly identified by patients and 5.9% were incorrectly identified by physicians. About 4.4% were incorrectly identified by both parties. In contrast, all sites were correctly identified with the use of preoperative photos. The results suggest that neither patients—even confident ones—nor diagrams are reliable means for identifying biopsy sites, Dr. McGinness said.

If a biopsy site cannot be identified at the time of surgery, the options are to proceed anyway—at the risk of wrong-site surgery—or to cancel surgery. "When surgeries are cancelled, this leads to higher patient inconvenience, untreated tumors that could metastasize, larger tumors when they again become observable, and increased patient morbidity," Dr. McGinness commented.

All of the patients underwent surgery an average of 2-3 weeks after biopsy, and he recommended that future research evaluate the role of this time interval. "With longer wait times between biopsy and surgery, lesions could heal and the rates [of incorrect identification] could actually be even higher," he explained.

Dr. McGinness reported no conflicts of interest related to the study.

Performing surgery on the wrong site was behind 14% of the lawsuits brought against Mohs surgeons. DR. MCGINNESS

Healing and actinic skin damage can make it hard to identify the biopsy site before surgery.

By using a prebiopsy photograph, the surgeon located the biopsy site and removed the tumor. Photos courtesy Dr. Jamie L. McGinness

VANCOUVER, B.C. — Fractional photothermolysis is superior to pulsed dye laser treatment for improving the cosmetic appearance of Mohs surgical scars and was preferred by all patients, despite being more painful, according to the first study comparing the two modalities.

The pulsed dye laser is the standard treatment for surgical scars, but it seems to primarily improve erythema, while fractional photothermolysis seems to mainly improve scar consistency, lead author Dr. Emily P. Tierney said in an interview.

It was surprising, then, to find that fractional photothermolysis outperformed the pulsed dye laser in reducing scar erythema. "My hypothesis in doing the study was that [fractional photothermolysis] would have improvements above and beyond the pulsed dye likely in terms of scar thickness and scar texture, but that the pulsed dye would have greater improvements in terms of the red component of scars," explained Dr. Tierney, a dermatologic surgeon with the Henry Ford Health System, Detroit.

The randomized, double-blind study, presented as a poster at the annual meeting of the American College of Mohs Surgery, involved 12 patients who had undergone Mohs surgery. All 12 scars were located on the face, neck, or chest, and 8 of them were hypopigmented.

In each patient, after application of lidocaine gel, half of each scar was treated with fractional photothermolysis (Fraxel SR, Reliant Technologies Inc.) and half treated with a pulsed dye laser (V-Beam, Candela Corp.). The patients received four treatments at 2-week intervals.

Dr. Tierney reported that she had no conflicts of interest in association with the research.

The same blinded physicians assessed the scars at each treatment and 1 month after the last treatment. All assessments were done in person, which permitted better evaluation of the scars' 3-D features. The physicians rated cosmetic outcomes using a quartile scale, so a one-quartile increase corresponded to a 25% improvement.

Compared with pulsed dye laser, fractional photothermolysis resulted in significantly greater improvements in scar thickness (mean improvement, 50%-75% vs. 0–25%), scar dyspigmentation (75% vs. 25%), color and texture of the subset of hypopigmented scars (50% vs. 0), and overall cosmetic outcome (75% vs. 50%). The two treatments both yielded a 50% improvement in scar texture.

Patients experienced significantly greater pain with the fractional photothermolysis than with the pulsed dye laser, according to Dr. Tierney, but neither treatment produced any other adverse effects.

At the end of the study, patients were offered additional treatment for the half of the scar with lesser improvement, and "uniformly, all of my 12 patients wanted the entire scar treated with Fraxel, so patients could see the significant difference between the two sides as well," she said, concluding that fractional photothermolysis appears to be the superior treatment and may expand the options available to patients.

All of the study patients started treatment 2–3 months after their surgery, but the best timing is unknown.

"That is something that we are going to have to look at in future studies—just where that optimal window is for scar remodeling," she commented. "Perhaps 2 months is too late or it may even be a little bit on the early side." To better define that optimal window, she and her colleagues are planning studies in which patients will be treated at varying times after surgery.

"The frequency of treatment is also an incredibly important variable in the success of both devices," she asserted, noting that treating patients every 2 weeks is very aggressive.

"I think the results that we got in terms of the before and after photos are greater than anything I have seen where people have treated with monthly or every-other-month types of intervals," Dr. Tierney concluded.

A scar is shown before being treated with pulsed dye (1) and Fraxel (2).

The same scar is shown after treatment using the two lasers as noted above. Photos courtesy Dr. Emily P. Tierney

VANCOUVER, B.C. — Fractional photothermolysis is superior to pulsed dye laser treatment for improving the cosmetic appearance of Mohs surgical scars and was preferred by all patients, despite being more painful, according to the first study comparing the two modalities.

The pulsed dye laser is the standard treatment for surgical scars, but it seems to primarily improve erythema, while fractional photothermolysis seems to mainly improve scar consistency, lead author Dr. Emily P. Tierney said in an interview.

It was surprising, then, to find that fractional photothermolysis outperformed the pulsed dye laser in reducing scar erythema. "My hypothesis in doing the study was that [fractional photothermolysis] would have improvements above and beyond the pulsed dye likely in terms of scar thickness and scar texture, but that the pulsed dye would have greater improvements in terms of the red component of scars," explained Dr. Tierney, a dermatologic surgeon with the Henry Ford Health System, Detroit.

The randomized, double-blind study, presented as a poster at the annual meeting of the American College of Mohs Surgery, involved 12 patients who had undergone Mohs surgery. All 12 scars were located on the face, neck, or chest, and 8 of them were hypopigmented.

In each patient, after application of lidocaine gel, half of each scar was treated with fractional photothermolysis (Fraxel SR, Reliant Technologies Inc.) and half treated with a pulsed dye laser (V-Beam, Candela Corp.). The patients received four treatments at 2-week intervals.

Dr. Tierney reported that she had no conflicts of interest in association with the research.

The same blinded physicians assessed the scars at each treatment and 1 month after the last treatment. All assessments were done in person, which permitted better evaluation of the scars' 3-D features. The physicians rated cosmetic outcomes using a quartile scale, so a one-quartile increase corresponded to a 25% improvement.

Compared with pulsed dye laser, fractional photothermolysis resulted in significantly greater improvements in scar thickness (mean improvement, 50%-75% vs. 0–25%), scar dyspigmentation (75% vs. 25%), color and texture of the subset of hypopigmented scars (50% vs. 0), and overall cosmetic outcome (75% vs. 50%). The two treatments both yielded a 50% improvement in scar texture.

Patients experienced significantly greater pain with the fractional photothermolysis than with the pulsed dye laser, according to Dr. Tierney, but neither treatment produced any other adverse effects.

At the end of the study, patients were offered additional treatment for the half of the scar with lesser improvement, and "uniformly, all of my 12 patients wanted the entire scar treated with Fraxel, so patients could see the significant difference between the two sides as well," she said, concluding that fractional photothermolysis appears to be the superior treatment and may expand the options available to patients.

All of the study patients started treatment 2–3 months after their surgery, but the best timing is unknown.

"That is something that we are going to have to look at in future studies—just where that optimal window is for scar remodeling," she commented. "Perhaps 2 months is too late or it may even be a little bit on the early side." To better define that optimal window, she and her colleagues are planning studies in which patients will be treated at varying times after surgery.

"The frequency of treatment is also an incredibly important variable in the success of both devices," she asserted, noting that treating patients every 2 weeks is very aggressive.

"I think the results that we got in terms of the before and after photos are greater than anything I have seen where people have treated with monthly or every-other-month types of intervals," Dr. Tierney concluded.

A scar is shown before being treated with pulsed dye (1) and Fraxel (2).

The same scar is shown after treatment using the two lasers as noted above. Photos courtesy Dr. Emily P. Tierney

VANCOUVER, B.C. — Fractional photothermolysis is superior to pulsed dye laser treatment for improving the cosmetic appearance of Mohs surgical scars and was preferred by all patients, despite being more painful, according to the first study comparing the two modalities.

The pulsed dye laser is the standard treatment for surgical scars, but it seems to primarily improve erythema, while fractional photothermolysis seems to mainly improve scar consistency, lead author Dr. Emily P. Tierney said in an interview.

It was surprising, then, to find that fractional photothermolysis outperformed the pulsed dye laser in reducing scar erythema. "My hypothesis in doing the study was that [fractional photothermolysis] would have improvements above and beyond the pulsed dye likely in terms of scar thickness and scar texture, but that the pulsed dye would have greater improvements in terms of the red component of scars," explained Dr. Tierney, a dermatologic surgeon with the Henry Ford Health System, Detroit.

The randomized, double-blind study, presented as a poster at the annual meeting of the American College of Mohs Surgery, involved 12 patients who had undergone Mohs surgery. All 12 scars were located on the face, neck, or chest, and 8 of them were hypopigmented.

In each patient, after application of lidocaine gel, half of each scar was treated with fractional photothermolysis (Fraxel SR, Reliant Technologies Inc.) and half treated with a pulsed dye laser (V-Beam, Candela Corp.). The patients received four treatments at 2-week intervals.

Dr. Tierney reported that she had no conflicts of interest in association with the research.

The same blinded physicians assessed the scars at each treatment and 1 month after the last treatment. All assessments were done in person, which permitted better evaluation of the scars' 3-D features. The physicians rated cosmetic outcomes using a quartile scale, so a one-quartile increase corresponded to a 25% improvement.

Compared with pulsed dye laser, fractional photothermolysis resulted in significantly greater improvements in scar thickness (mean improvement, 50%-75% vs. 0–25%), scar dyspigmentation (75% vs. 25%), color and texture of the subset of hypopigmented scars (50% vs. 0), and overall cosmetic outcome (75% vs. 50%). The two treatments both yielded a 50% improvement in scar texture.

Patients experienced significantly greater pain with the fractional photothermolysis than with the pulsed dye laser, according to Dr. Tierney, but neither treatment produced any other adverse effects.

At the end of the study, patients were offered additional treatment for the half of the scar with lesser improvement, and "uniformly, all of my 12 patients wanted the entire scar treated with Fraxel, so patients could see the significant difference between the two sides as well," she said, concluding that fractional photothermolysis appears to be the superior treatment and may expand the options available to patients.

All of the study patients started treatment 2–3 months after their surgery, but the best timing is unknown.

"That is something that we are going to have to look at in future studies—just where that optimal window is for scar remodeling," she commented. "Perhaps 2 months is too late or it may even be a little bit on the early side." To better define that optimal window, she and her colleagues are planning studies in which patients will be treated at varying times after surgery.

"The frequency of treatment is also an incredibly important variable in the success of both devices," she asserted, noting that treating patients every 2 weeks is very aggressive.

"I think the results that we got in terms of the before and after photos are greater than anything I have seen where people have treated with monthly or every-other-month types of intervals," Dr. Tierney concluded.

A scar is shown before being treated with pulsed dye (1) and Fraxel (2).

The same scar is shown after treatment using the two lasers as noted above. Photos courtesy Dr. Emily P. Tierney

VANCOUVER, B.C. — Cranial neuropathy may be the first sign or symptom of a skin cancer recurrence, and as such it is often misdiagnosed, a dermatologist/otolaryngologist said.

Neurotropic skin cancer is an uncommon but aggressive form of skin cancer, Dr. Joel W. Cook reported at the annual meeting of the American College of Mohs Surgery.

"Most of the neurotropic findings are histologic and any symptoms are reasonably unusual; most studies say that it's very rare. To have [patients] present to your office with neurologic findings as their sentinel event in the recognition of recurrent skin cancer is even rarer," he said.

In the retrospective study, Dr. Cook of the Medical University of South Carolina, Charleston, and his colleagues reviewed the charts of patients who had previously had skin cancer and were referred to the university's head and neck program between 1999 and 2007.

The chart review identified six patients in whom cranial neuropathy was the initial sign or symptom of recurrent skin cancer.

Five of the patients had previously undergone multiple excisions of skin cancer, and two had undergone Mohs surgery for a primary lesion, he said.

The cancer was squamous cell carcinoma in four cases and desmoplastic melanoma in two. "Importantly, none of the six patients" was a transplant patient, he noted.

"One had an indolent chronic myelogenous leukemia, but they were all reasonably immunocompetent," he said.

The majority of the patients had multiple cranial neuropathies; all had deficits of cranial nerve V, and half had deficits of cranial nerve VII.

The presenting symptoms were most commonly facial numbness; facial paralysis or weakness; facial pain; diplopia; and paresthesia.

Less common symptoms were formication and hearing loss. The symptoms had been present for 7 months, on average, before diagnosis.

In nearly all cases, the cranial neuropathy had been misdiagnosed as trigeminal neuralgia, Bell's palsy, or some other condition, said Dr. Cook.

Neurotropism was identified histologically in five patients who underwent surgery or biopsy, and cranial nerve involvement was confirmed in all patients by MRI.

"It's important to know what imaging study to order in these patients," Dr. Cook pointed out. "Although CT is an excellent method to image head and neck malignancies, … it cannot be used to evaluate for the presence or absence of neurotropic tumor. In that case or with that suspicion, you would want to get an MRI; this is by far the preferred imaging modality."

Five of the patients underwent treatment for their recurrence with various combinations of surgery, radiation therapy, and chemotherapy.

"As you can imagine, the surgery in these patients is salvage surgery and is amazingly extensive. These patients have to be counseled preoperatively, they have to be adequately staged, and they need multidisciplinary consultations," Dr. Cook said.

"But surgery is the only chance these patients have to survive," he added.

Three of the patients eventually died, with evidence of metastases. The other three, however, all of whom had undergone surgery, were still alive without evidence of disease 2.5–6 years after their operations.

Dr. Cook concluded that any time a patient is found to have a cranial neuropathy and that patient has previously undergone resection of a high-risk skin cancer, "you need to be very skeptical of an alternative diagnosis other than neurotropic recurrence."

He reported no disclosures in association with the study.

VANCOUVER, B.C. — Cranial neuropathy may be the first sign or symptom of a skin cancer recurrence, and as such it is often misdiagnosed, a dermatologist/otolaryngologist said.

Neurotropic skin cancer is an uncommon but aggressive form of skin cancer, Dr. Joel W. Cook reported at the annual meeting of the American College of Mohs Surgery.

"Most of the neurotropic findings are histologic and any symptoms are reasonably unusual; most studies say that it's very rare. To have [patients] present to your office with neurologic findings as their sentinel event in the recognition of recurrent skin cancer is even rarer," he said.

In the retrospective study, Dr. Cook of the Medical University of South Carolina, Charleston, and his colleagues reviewed the charts of patients who had previously had skin cancer and were referred to the university's head and neck program between 1999 and 2007.

The chart review identified six patients in whom cranial neuropathy was the initial sign or symptom of recurrent skin cancer.

Five of the patients had previously undergone multiple excisions of skin cancer, and two had undergone Mohs surgery for a primary lesion, he said.

The cancer was squamous cell carcinoma in four cases and desmoplastic melanoma in two. "Importantly, none of the six patients" was a transplant patient, he noted.

"One had an indolent chronic myelogenous leukemia, but they were all reasonably immunocompetent," he said.

The majority of the patients had multiple cranial neuropathies; all had deficits of cranial nerve V, and half had deficits of cranial nerve VII.

The presenting symptoms were most commonly facial numbness; facial paralysis or weakness; facial pain; diplopia; and paresthesia.

Less common symptoms were formication and hearing loss. The symptoms had been present for 7 months, on average, before diagnosis.

In nearly all cases, the cranial neuropathy had been misdiagnosed as trigeminal neuralgia, Bell's palsy, or some other condition, said Dr. Cook.

Neurotropism was identified histologically in five patients who underwent surgery or biopsy, and cranial nerve involvement was confirmed in all patients by MRI.

"It's important to know what imaging study to order in these patients," Dr. Cook pointed out. "Although CT is an excellent method to image head and neck malignancies, … it cannot be used to evaluate for the presence or absence of neurotropic tumor. In that case or with that suspicion, you would want to get an MRI; this is by far the preferred imaging modality."

Five of the patients underwent treatment for their recurrence with various combinations of surgery, radiation therapy, and chemotherapy.

"As you can imagine, the surgery in these patients is salvage surgery and is amazingly extensive. These patients have to be counseled preoperatively, they have to be adequately staged, and they need multidisciplinary consultations," Dr. Cook said.

"But surgery is the only chance these patients have to survive," he added.

Three of the patients eventually died, with evidence of metastases. The other three, however, all of whom had undergone surgery, were still alive without evidence of disease 2.5–6 years after their operations.

Dr. Cook concluded that any time a patient is found to have a cranial neuropathy and that patient has previously undergone resection of a high-risk skin cancer, "you need to be very skeptical of an alternative diagnosis other than neurotropic recurrence."

He reported no disclosures in association with the study.

VANCOUVER, B.C. — Cranial neuropathy may be the first sign or symptom of a skin cancer recurrence, and as such it is often misdiagnosed, a dermatologist/otolaryngologist said.

Neurotropic skin cancer is an uncommon but aggressive form of skin cancer, Dr. Joel W. Cook reported at the annual meeting of the American College of Mohs Surgery.

"Most of the neurotropic findings are histologic and any symptoms are reasonably unusual; most studies say that it's very rare. To have [patients] present to your office with neurologic findings as their sentinel event in the recognition of recurrent skin cancer is even rarer," he said.

In the retrospective study, Dr. Cook of the Medical University of South Carolina, Charleston, and his colleagues reviewed the charts of patients who had previously had skin cancer and were referred to the university's head and neck program between 1999 and 2007.

The chart review identified six patients in whom cranial neuropathy was the initial sign or symptom of recurrent skin cancer.

Five of the patients had previously undergone multiple excisions of skin cancer, and two had undergone Mohs surgery for a primary lesion, he said.

The cancer was squamous cell carcinoma in four cases and desmoplastic melanoma in two. "Importantly, none of the six patients" was a transplant patient, he noted.

"One had an indolent chronic myelogenous leukemia, but they were all reasonably immunocompetent," he said.

The majority of the patients had multiple cranial neuropathies; all had deficits of cranial nerve V, and half had deficits of cranial nerve VII.

The presenting symptoms were most commonly facial numbness; facial paralysis or weakness; facial pain; diplopia; and paresthesia.

Less common symptoms were formication and hearing loss. The symptoms had been present for 7 months, on average, before diagnosis.

In nearly all cases, the cranial neuropathy had been misdiagnosed as trigeminal neuralgia, Bell's palsy, or some other condition, said Dr. Cook.

Neurotropism was identified histologically in five patients who underwent surgery or biopsy, and cranial nerve involvement was confirmed in all patients by MRI.

"It's important to know what imaging study to order in these patients," Dr. Cook pointed out. "Although CT is an excellent method to image head and neck malignancies, … it cannot be used to evaluate for the presence or absence of neurotropic tumor. In that case or with that suspicion, you would want to get an MRI; this is by far the preferred imaging modality."

Five of the patients underwent treatment for their recurrence with various combinations of surgery, radiation therapy, and chemotherapy.

"As you can imagine, the surgery in these patients is salvage surgery and is amazingly extensive. These patients have to be counseled preoperatively, they have to be adequately staged, and they need multidisciplinary consultations," Dr. Cook said.

"But surgery is the only chance these patients have to survive," he added.

Three of the patients eventually died, with evidence of metastases. The other three, however, all of whom had undergone surgery, were still alive without evidence of disease 2.5–6 years after their operations.

Dr. Cook concluded that any time a patient is found to have a cranial neuropathy and that patient has previously undergone resection of a high-risk skin cancer, "you need to be very skeptical of an alternative diagnosis other than neurotropic recurrence."

He reported no disclosures in association with the study.

VANCOUVER, B.C. — A new study finds that the local anesthesia used for Mohs surgery appears to be safe, with serum levels of lidocaine remaining well below the threshold for toxicity and an absence of any drug-related adverse events.

Although Mohs procedures are routinely performed using lidocaine anesthesia without any complications, few studies have looked at lidocaine levels specifically in this context, said study author Dr. Murad Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago.

Research on tumescent anesthesia suggests that a greater vascular supply above the clavicle promotes faster systemic absorption of lidocaine (Plast. Reconstr. Surg. 2005;115:1744–51). The concentration of lidocaine in the anesthesia used for Mohs surgery is 5–10 times that of tumescent anesthesia.

The prospective cohort study, reported at the annual meeting of the American College of Mohs Surgery, took place among 20 consecutive adults undergoing Mohs surgery with local anesthesia for nonmelanoma skin cancer. The anesthesia consisted of a lidocaine solution (concentration, 1:100) also containing epinephrine (1:100,000) and 8.4% sodium bicarbonate (1:10); it was injected at the start of each stage of Mohs surgery. Blood was drawn from the patient's arm before and after each of three stages (or two stages plus closure), for a total of six sampling time points over roughly 5 hours.

Serum lidocaine levels were measured by gas chromatography, and both patients and physicians assessed the occurrence of adverse events.

Dr. Alam explained that mild symptoms of lidocaine toxicity occur when the serum level of the drug reaches 3 mcg/mL; moderate symptoms when the level exceeds 5 mcg/mL; and severe and potentially life threatening symptoms when the level exceeds 10 mcg/mL.

Study results indicated that across all time points, lidocaine levels were detectable (greater than 0.1 mcg/mL) in just five (25%) of the patients.

"Even in the worst-case scenario—the sixth and final time point, where you would expect the serum lidocaine level to be the highest because of the cumulated dosage to that point—only 5 of the 20 patients had a detectable serum lidocaine level," Dr. Alam remarked.

Furthermore, the median level for the cohort was undetectable at all time points.

"Assuming the vast majority of patients did absolutely fine, were there some patients who had very high levels and got into trouble? Again, the answer is no," Dr. Alam asserted.

Of all patients, the highest peak serum lidocaine level observed was 0.3 mcg/mL noted during the last three time points. "That is still one-tenth of the amount for even mild symptoms to occur," he pointed out.

When patients who did and did not have detectable serum lidocaine levels were compared, those with detectable levels had been injected with a significantly greater mean volume of lidocaine solution (30 vs. 9.5 mL). They were also significantly older (68.6 vs. 50.7 years) and somewhat more likely to be male, although Dr. Alam cautioned "this might just mean that older men have larger tumors."

A final analysis showed that peak serum lidocaine levels were well correlated with the total volume of solution injected.

Adverse events were reported by two patients—a 56-year-old man who reported a mild headache and a 42-year-old woman who reported feeling shaky. "Both were after the first Mohs stage, and so they were much more likely to be epinephrine effects than lidocaine effects, which would be expected to happen after a lot of lidocaine was injected," Dr. Alam observed. No adverse events related to the drug were noted.

"There was no case in which serious adverse events or even mild adverse events associated with lidocaine toxicity were seen, which suggests what we already knew to be true based on experience—that local anesthesia given during Mohs surgery appears to be safe," Dr. Alam concluded.

He reported having no conflicts of interest in association with the study.

No patient in the study experienced adverse events associated with lidocaine toxicity. DR. ALAM

VANCOUVER, B.C. — A new study finds that the local anesthesia used for Mohs surgery appears to be safe, with serum levels of lidocaine remaining well below the threshold for toxicity and an absence of any drug-related adverse events.

Although Mohs procedures are routinely performed using lidocaine anesthesia without any complications, few studies have looked at lidocaine levels specifically in this context, said study author Dr. Murad Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago.

Research on tumescent anesthesia suggests that a greater vascular supply above the clavicle promotes faster systemic absorption of lidocaine (Plast. Reconstr. Surg. 2005;115:1744–51). The concentration of lidocaine in the anesthesia used for Mohs surgery is 5–10 times that of tumescent anesthesia.

The prospective cohort study, reported at the annual meeting of the American College of Mohs Surgery, took place among 20 consecutive adults undergoing Mohs surgery with local anesthesia for nonmelanoma skin cancer. The anesthesia consisted of a lidocaine solution (concentration, 1:100) also containing epinephrine (1:100,000) and 8.4% sodium bicarbonate (1:10); it was injected at the start of each stage of Mohs surgery. Blood was drawn from the patient's arm before and after each of three stages (or two stages plus closure), for a total of six sampling time points over roughly 5 hours.

Serum lidocaine levels were measured by gas chromatography, and both patients and physicians assessed the occurrence of adverse events.

Dr. Alam explained that mild symptoms of lidocaine toxicity occur when the serum level of the drug reaches 3 mcg/mL; moderate symptoms when the level exceeds 5 mcg/mL; and severe and potentially life threatening symptoms when the level exceeds 10 mcg/mL.

Study results indicated that across all time points, lidocaine levels were detectable (greater than 0.1 mcg/mL) in just five (25%) of the patients.

"Even in the worst-case scenario—the sixth and final time point, where you would expect the serum lidocaine level to be the highest because of the cumulated dosage to that point—only 5 of the 20 patients had a detectable serum lidocaine level," Dr. Alam remarked.

Furthermore, the median level for the cohort was undetectable at all time points.

"Assuming the vast majority of patients did absolutely fine, were there some patients who had very high levels and got into trouble? Again, the answer is no," Dr. Alam asserted.

Of all patients, the highest peak serum lidocaine level observed was 0.3 mcg/mL noted during the last three time points. "That is still one-tenth of the amount for even mild symptoms to occur," he pointed out.

When patients who did and did not have detectable serum lidocaine levels were compared, those with detectable levels had been injected with a significantly greater mean volume of lidocaine solution (30 vs. 9.5 mL). They were also significantly older (68.6 vs. 50.7 years) and somewhat more likely to be male, although Dr. Alam cautioned "this might just mean that older men have larger tumors."

A final analysis showed that peak serum lidocaine levels were well correlated with the total volume of solution injected.

Adverse events were reported by two patients—a 56-year-old man who reported a mild headache and a 42-year-old woman who reported feeling shaky. "Both were after the first Mohs stage, and so they were much more likely to be epinephrine effects than lidocaine effects, which would be expected to happen after a lot of lidocaine was injected," Dr. Alam observed. No adverse events related to the drug were noted.

"There was no case in which serious adverse events or even mild adverse events associated with lidocaine toxicity were seen, which suggests what we already knew to be true based on experience—that local anesthesia given during Mohs surgery appears to be safe," Dr. Alam concluded.

He reported having no conflicts of interest in association with the study.

No patient in the study experienced adverse events associated with lidocaine toxicity. DR. ALAM

VANCOUVER, B.C. — A new study finds that the local anesthesia used for Mohs surgery appears to be safe, with serum levels of lidocaine remaining well below the threshold for toxicity and an absence of any drug-related adverse events.

Although Mohs procedures are routinely performed using lidocaine anesthesia without any complications, few studies have looked at lidocaine levels specifically in this context, said study author Dr. Murad Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago.

Research on tumescent anesthesia suggests that a greater vascular supply above the clavicle promotes faster systemic absorption of lidocaine (Plast. Reconstr. Surg. 2005;115:1744–51). The concentration of lidocaine in the anesthesia used for Mohs surgery is 5–10 times that of tumescent anesthesia.

The prospective cohort study, reported at the annual meeting of the American College of Mohs Surgery, took place among 20 consecutive adults undergoing Mohs surgery with local anesthesia for nonmelanoma skin cancer. The anesthesia consisted of a lidocaine solution (concentration, 1:100) also containing epinephrine (1:100,000) and 8.4% sodium bicarbonate (1:10); it was injected at the start of each stage of Mohs surgery. Blood was drawn from the patient's arm before and after each of three stages (or two stages plus closure), for a total of six sampling time points over roughly 5 hours.

Serum lidocaine levels were measured by gas chromatography, and both patients and physicians assessed the occurrence of adverse events.

Dr. Alam explained that mild symptoms of lidocaine toxicity occur when the serum level of the drug reaches 3 mcg/mL; moderate symptoms when the level exceeds 5 mcg/mL; and severe and potentially life threatening symptoms when the level exceeds 10 mcg/mL.

Study results indicated that across all time points, lidocaine levels were detectable (greater than 0.1 mcg/mL) in just five (25%) of the patients.

"Even in the worst-case scenario—the sixth and final time point, where you would expect the serum lidocaine level to be the highest because of the cumulated dosage to that point—only 5 of the 20 patients had a detectable serum lidocaine level," Dr. Alam remarked.

Furthermore, the median level for the cohort was undetectable at all time points.

"Assuming the vast majority of patients did absolutely fine, were there some patients who had very high levels and got into trouble? Again, the answer is no," Dr. Alam asserted.

Of all patients, the highest peak serum lidocaine level observed was 0.3 mcg/mL noted during the last three time points. "That is still one-tenth of the amount for even mild symptoms to occur," he pointed out.

When patients who did and did not have detectable serum lidocaine levels were compared, those with detectable levels had been injected with a significantly greater mean volume of lidocaine solution (30 vs. 9.5 mL). They were also significantly older (68.6 vs. 50.7 years) and somewhat more likely to be male, although Dr. Alam cautioned "this might just mean that older men have larger tumors."

A final analysis showed that peak serum lidocaine levels were well correlated with the total volume of solution injected.

Adverse events were reported by two patients—a 56-year-old man who reported a mild headache and a 42-year-old woman who reported feeling shaky. "Both were after the first Mohs stage, and so they were much more likely to be epinephrine effects than lidocaine effects, which would be expected to happen after a lot of lidocaine was injected," Dr. Alam observed. No adverse events related to the drug were noted.

"There was no case in which serious adverse events or even mild adverse events associated with lidocaine toxicity were seen, which suggests what we already knew to be true based on experience—that local anesthesia given during Mohs surgery appears to be safe," Dr. Alam concluded.

He reported having no conflicts of interest in association with the study.

No patient in the study experienced adverse events associated with lidocaine toxicity. DR. ALAM

VANCOUVER, B.C. — Some patients undergoing Mohs micrographic surgery have undiagnosed bleeding disorders, but careful history taking, vigilance during surgery, and tailored management can prevent complications in most cases, according to results of a study of more than 2,500 patients.

Dr. Carl Vinciullo and his colleague, Dr. Ross Baker, both of Royal Perth Hospital in Australia, prospectively assessed the prevalence of bleeding disorders among 2,517 patients undergoing Mohs surgery between 2003 and 2007. The investigators obtained a detailed bleeding history from all patients and performed a hematologic workup in those who had a positive history or who had unexplained excessive bleeding during their Mohs surgery.

A total of 18 patients (0.7%) had a previously undiagnosed bleeding disorder. Eleven of them had a positive bleeding history, while seven had a negative history but bled excessively during surgery. Dr. Vinciullo noted that most of the affected patients had normal routine coagulation profiles on hematologic testing and that one patient had even undergone general surgery uneventfully 2 years earlier.

The hematologic workup further revealed that 6 of the 18 patients had von Willebrand disease (alone or with other abnormalities), three had acquired platelet abnormalities with myelodysplasia and other abnormalities, two had suspected increased capillary fragility, one had a clopidogrel-like platelet secretion defect, and one had suspected impaired vasoconstriction with hereditary hemorrhagic telangiectasia.

Another two patients—one with refractory immune thrombocytopenia and antiplatelet antibodies, and another with disseminated intravascular coagulation, thrombocytopenia, and cancer-associated fibrinogen deficiency—were treated with radiation therapy instead because their disorders were judged to be contraindications to surgery.

Finally, three of the patients had no definable hematologic abnormality. "This does not mean that they do not have a bleeding abnormality," Dr. Vinciullo said of the last group. "It is quite conceivable that there are bleeding abnormalities which are yet not possible to define with the investigations available to us."

Among the patients who were surgical candidates, those with von Willebrand disease were treated with preoperative desmopressin infusion, oral tranexamic acid, or a combination thereof. Those with platelet function abnormalities were all treated with preoperative platelet infusions; one also received desmopressin, and another also received additional platelet cross-matching, recombinant factor VIIa, and tranexamic acid. The remaining patients were given tranexamic acid or were not treated, Dr. Vinciullo reported at the annual meeting of the American College of Mohs Surgery.

With this management approach, 17 of the 18 patients did not experience initial or additional excessive bleeding and did not require further intervention, according to Dr. Vinciullo. The remaining patient, who had an acquired platelet function abnormality, antiplatelet antibodies, low factor XII levels, and myelodysplasia, was hospitalized for 3 days because of surgery-associated bleeding, despite all measures.

Summing up the study's findings, Dr. Vinciullo said that the incidence of undiagnosed bleeding disorders is low in Mohs surgical patients, but physicians nonetheless should be alert for such disorders—even when a bleeding history is negative and the results of routine coagulation studies are normal.

"Hematology assessment is essential, and specialized prophylactic treatment can prevent the vast majority of bleeding complications," he said.

However, he added, routine preoperative hematologic testing is not warranted in patients with a negative bleeding history. "The most sensitive sign is a positive history, so you must take a detailed bleeding history," he emphasized. (See box.) "The sort of questions I listed are the questions you need to ask. It's absolutely incredible how many of these patients have simply never been asked those questions, or the physician knows they bleed but has never done anything about it."

Finally, Dr. Vinciullo advised, "unexplained excessive bleeding during Mohs surgery should be investigated." He noted that a watery consistency of the blood and bleeding from suture holes can be additional telltale signs of underlying bleeding disorders.

"If you have a patient where you place a stitch and blood comes out of the suture hole, to me, that's a reason to send [that person] off for a hematology investigation," he said.

Dr. Vinciullo reported no conflicts of interest in association with the study.

'Hematology assessment is essential, and specialized prophylactic treatment can prevent' bleeding. DR. VINCIULLO

Take a Detailed Bleeding History

Ask patients if they have had excessive bleeding during any of the following:

▸ Menstrual periods or childbirth?

▸ Nosebleeds?

▸ Skin surgery?

▸ Dental work, tonsillectomy, or general surgery? And also ask:

▸ Have you had to return to a physician's office or hospital because of bleeding?

▸ Do you bruise excessively?

▸ Do you take supplements or complementary products (vitamin E, garlic, ginkgo biloba)?

▸ Do you have a family history of bleeding, hemophilia, or von Willebrand disease?

▸ Do you have any blood disorders or leukemia?

Source: Dr. Vinciullo

VANCOUVER, B.C. — Some patients undergoing Mohs micrographic surgery have undiagnosed bleeding disorders, but careful history taking, vigilance during surgery, and tailored management can prevent complications in most cases, according to results of a study of more than 2,500 patients.

Dr. Carl Vinciullo and his colleague, Dr. Ross Baker, both of Royal Perth Hospital in Australia, prospectively assessed the prevalence of bleeding disorders among 2,517 patients undergoing Mohs surgery between 2003 and 2007. The investigators obtained a detailed bleeding history from all patients and performed a hematologic workup in those who had a positive history or who had unexplained excessive bleeding during their Mohs surgery.

A total of 18 patients (0.7%) had a previously undiagnosed bleeding disorder. Eleven of them had a positive bleeding history, while seven had a negative history but bled excessively during surgery. Dr. Vinciullo noted that most of the affected patients had normal routine coagulation profiles on hematologic testing and that one patient had even undergone general surgery uneventfully 2 years earlier.

The hematologic workup further revealed that 6 of the 18 patients had von Willebrand disease (alone or with other abnormalities), three had acquired platelet abnormalities with myelodysplasia and other abnormalities, two had suspected increased capillary fragility, one had a clopidogrel-like platelet secretion defect, and one had suspected impaired vasoconstriction with hereditary hemorrhagic telangiectasia.

Another two patients—one with refractory immune thrombocytopenia and antiplatelet antibodies, and another with disseminated intravascular coagulation, thrombocytopenia, and cancer-associated fibrinogen deficiency—were treated with radiation therapy instead because their disorders were judged to be contraindications to surgery.

Finally, three of the patients had no definable hematologic abnormality. "This does not mean that they do not have a bleeding abnormality," Dr. Vinciullo said of the last group. "It is quite conceivable that there are bleeding abnormalities which are yet not possible to define with the investigations available to us."

Among the patients who were surgical candidates, those with von Willebrand disease were treated with preoperative desmopressin infusion, oral tranexamic acid, or a combination thereof. Those with platelet function abnormalities were all treated with preoperative platelet infusions; one also received desmopressin, and another also received additional platelet cross-matching, recombinant factor VIIa, and tranexamic acid. The remaining patients were given tranexamic acid or were not treated, Dr. Vinciullo reported at the annual meeting of the American College of Mohs Surgery.

With this management approach, 17 of the 18 patients did not experience initial or additional excessive bleeding and did not require further intervention, according to Dr. Vinciullo. The remaining patient, who had an acquired platelet function abnormality, antiplatelet antibodies, low factor XII levels, and myelodysplasia, was hospitalized for 3 days because of surgery-associated bleeding, despite all measures.

Summing up the study's findings, Dr. Vinciullo said that the incidence of undiagnosed bleeding disorders is low in Mohs surgical patients, but physicians nonetheless should be alert for such disorders—even when a bleeding history is negative and the results of routine coagulation studies are normal.

"Hematology assessment is essential, and specialized prophylactic treatment can prevent the vast majority of bleeding complications," he said.

However, he added, routine preoperative hematologic testing is not warranted in patients with a negative bleeding history. "The most sensitive sign is a positive history, so you must take a detailed bleeding history," he emphasized. (See box.) "The sort of questions I listed are the questions you need to ask. It's absolutely incredible how many of these patients have simply never been asked those questions, or the physician knows they bleed but has never done anything about it."

Finally, Dr. Vinciullo advised, "unexplained excessive bleeding during Mohs surgery should be investigated." He noted that a watery consistency of the blood and bleeding from suture holes can be additional telltale signs of underlying bleeding disorders.

"If you have a patient where you place a stitch and blood comes out of the suture hole, to me, that's a reason to send [that person] off for a hematology investigation," he said.

Dr. Vinciullo reported no conflicts of interest in association with the study.

'Hematology assessment is essential, and specialized prophylactic treatment can prevent' bleeding. DR. VINCIULLO

Take a Detailed Bleeding History

Ask patients if they have had excessive bleeding during any of the following:

▸ Menstrual periods or childbirth?

▸ Nosebleeds?

▸ Skin surgery?

▸ Dental work, tonsillectomy, or general surgery? And also ask:

▸ Have you had to return to a physician's office or hospital because of bleeding?

▸ Do you bruise excessively?

▸ Do you take supplements or complementary products (vitamin E, garlic, ginkgo biloba)?

▸ Do you have a family history of bleeding, hemophilia, or von Willebrand disease?

▸ Do you have any blood disorders or leukemia?

Source: Dr. Vinciullo

VANCOUVER, B.C. — Some patients undergoing Mohs micrographic surgery have undiagnosed bleeding disorders, but careful history taking, vigilance during surgery, and tailored management can prevent complications in most cases, according to results of a study of more than 2,500 patients.

Dr. Carl Vinciullo and his colleague, Dr. Ross Baker, both of Royal Perth Hospital in Australia, prospectively assessed the prevalence of bleeding disorders among 2,517 patients undergoing Mohs surgery between 2003 and 2007. The investigators obtained a detailed bleeding history from all patients and performed a hematologic workup in those who had a positive history or who had unexplained excessive bleeding during their Mohs surgery.

A total of 18 patients (0.7%) had a previously undiagnosed bleeding disorder. Eleven of them had a positive bleeding history, while seven had a negative history but bled excessively during surgery. Dr. Vinciullo noted that most of the affected patients had normal routine coagulation profiles on hematologic testing and that one patient had even undergone general surgery uneventfully 2 years earlier.

The hematologic workup further revealed that 6 of the 18 patients had von Willebrand disease (alone or with other abnormalities), three had acquired platelet abnormalities with myelodysplasia and other abnormalities, two had suspected increased capillary fragility, one had a clopidogrel-like platelet secretion defect, and one had suspected impaired vasoconstriction with hereditary hemorrhagic telangiectasia.

Another two patients—one with refractory immune thrombocytopenia and antiplatelet antibodies, and another with disseminated intravascular coagulation, thrombocytopenia, and cancer-associated fibrinogen deficiency—were treated with radiation therapy instead because their disorders were judged to be contraindications to surgery.

Finally, three of the patients had no definable hematologic abnormality. "This does not mean that they do not have a bleeding abnormality," Dr. Vinciullo said of the last group. "It is quite conceivable that there are bleeding abnormalities which are yet not possible to define with the investigations available to us."

Among the patients who were surgical candidates, those with von Willebrand disease were treated with preoperative desmopressin infusion, oral tranexamic acid, or a combination thereof. Those with platelet function abnormalities were all treated with preoperative platelet infusions; one also received desmopressin, and another also received additional platelet cross-matching, recombinant factor VIIa, and tranexamic acid. The remaining patients were given tranexamic acid or were not treated, Dr. Vinciullo reported at the annual meeting of the American College of Mohs Surgery.

With this management approach, 17 of the 18 patients did not experience initial or additional excessive bleeding and did not require further intervention, according to Dr. Vinciullo. The remaining patient, who had an acquired platelet function abnormality, antiplatelet antibodies, low factor XII levels, and myelodysplasia, was hospitalized for 3 days because of surgery-associated bleeding, despite all measures.

Summing up the study's findings, Dr. Vinciullo said that the incidence of undiagnosed bleeding disorders is low in Mohs surgical patients, but physicians nonetheless should be alert for such disorders—even when a bleeding history is negative and the results of routine coagulation studies are normal.

"Hematology assessment is essential, and specialized prophylactic treatment can prevent the vast majority of bleeding complications," he said.

However, he added, routine preoperative hematologic testing is not warranted in patients with a negative bleeding history. "The most sensitive sign is a positive history, so you must take a detailed bleeding history," he emphasized. (See box.) "The sort of questions I listed are the questions you need to ask. It's absolutely incredible how many of these patients have simply never been asked those questions, or the physician knows they bleed but has never done anything about it."

Finally, Dr. Vinciullo advised, "unexplained excessive bleeding during Mohs surgery should be investigated." He noted that a watery consistency of the blood and bleeding from suture holes can be additional telltale signs of underlying bleeding disorders.

"If you have a patient where you place a stitch and blood comes out of the suture hole, to me, that's a reason to send [that person] off for a hematology investigation," he said.

Dr. Vinciullo reported no conflicts of interest in association with the study.

'Hematology assessment is essential, and specialized prophylactic treatment can prevent' bleeding. DR. VINCIULLO

Take a Detailed Bleeding History

Ask patients if they have had excessive bleeding during any of the following:

▸ Menstrual periods or childbirth?

▸ Nosebleeds?

▸ Skin surgery?

▸ Dental work, tonsillectomy, or general surgery? And also ask:

▸ Have you had to return to a physician's office or hospital because of bleeding?

▸ Do you bruise excessively?

▸ Do you take supplements or complementary products (vitamin E, garlic, ginkgo biloba)?

▸ Do you have a family history of bleeding, hemophilia, or von Willebrand disease?

▸ Do you have any blood disorders or leukemia?

Source: Dr. Vinciullo