In an exhilarating review of what is new in dermatologic surgery, Brett Coldiron, MD took us through topics that he found to be noteworthy in 2023. He started by reviewing treatments for basal cell carcinoma, including a small study from Sweden demonstrating efficacy of Mohs surgery as an initial treatment and another that compared curettage and cryosurgery. Out of 228 superficial basal cells in 97 patients, those who received cryosurgery had no recurrence at 1 year while 5 of 115 that were treated with curettage demonstrated histopathologically verified recurrence. While superficial basal cells do well with a variety of treatments, squamous cell carcinoma has numerous reports of bone invasion mostly on the skull emphasizing the importance of completely clear margins. Rounding out the discussion of skin cancers with melanoma, Dr. Coldiron reviewed a large cohort study that examined the impact of time between diagnostic excision biopsy and sentinel lymph node biopsy. In short, out of over 10,000 patients, no significant association was seen in overall survival and time until SN biopsy or SN positivity. With the advent of PD-1 inhibitors, treatment algorithms for primary melanoma may be changing. One study from JAMA Dermatology on stage-specific risk of melanoma highlighted the inaccuracy of TMN staging on predicting overall survival and pushed for an increase in PET scans for thicker lesions or immunotherapy with resultant high risk gene analysis.
In the second half of this presentation, he covered a few rare cancers and distinguished pearls. Cutaneous leiomyosarcoma may have more clinical variability due to different muscular origins. More aggressive varieties are TP53 +, RB1 +, and MYOCD amplification. Recurrence should be minimized by wider margins and potentially Mohs. One study published in JAAD showed a significant risk of recurrence and disease-specific death when postoperative radiation was delayed more than 8 weeks for Merkel cell carcinoma. Dr. Coldiron also presented some odd factoids to be aware of such as a 10% increased skin cancer risk in patients taking statin medications and a lack of bleeding complications with patients on novel oral anticoagulants during Mohs micrographic surgery, especially compared to aspirin. Other insights included the environmental burden of procedures occurring in hospital operating rooms which may make an argument to move them to the office setting when appropriate and the increasing use of AI in all aspects of dermatology, specifically as a tool for detecting skin cancer.