Background: The risk of squamous cell carcinoma (SCC) is increased in solid organ transplant recipients (OTRs), and preferential treatment modalities vary among clinicians.
Objectives: The purpose of this study was to survey dermatologists regarding practice patterns for electrodesiccation and curettage (EDC) of SCC in OTRs and nontransplant patients.
Methods: An 18-question survey was sent to dermatologist members of the International Transplant Skin Cancer Collaborative, Association of Professors of Dermatology, and American College of Mohs Surgery. Differences in EDC practice patterns for treatment of SCC in OTRs and nontransplant patients were evaluated.
Results: Dermatologists in this study (
Conclusions: In OTRs with SCC, 48% of clinicians would consider EDC. The main factors that affect the decision to perform EDC include tumor location and patient comorbidities

Bauman, Tyler M

Hurst, Eva A

Laurin Council, M

Nemer, Kathleen M

English

Digital Commons@Becker

Washington University School of Medicine Digital Commons@Becker Open Access Publications 3-1-2020 Surveyed dermatologists are less likely to curette invasive squamous cell carcinoma in solid organ transplant recipients Kathleen M Nemer Tyler M Bauman M Laurin Council Eva A Hurst Follow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubs Original ResearchSurveyed dermatologists are less likely to curette invasive squamous cellcarcinoma in solid organ transplant recipientsqKathleen M. Nemer, MD, Tyler M. Bauman, MD, M. Laurin Council, MD, Eva A. Hurst, MD ⇑Division of Dermatology, Washington University School of Medicine, St. Louis, MO, United Statesa r t i c l e i n f oArticle history:Received 25 August 2019Received in revised form 7 October 2019Accepted 16 October 2019Keywords:Squamous cell carcinomaSolid organ transplant recipientElectrodesiccation and curettageSurveyPractice patternsa b s t r a c tBackground: The risk of squamous cell carcinoma (SCC) is increased in solid organ transplant recipients(OTRs), and preferential treatment modalities vary among clinicians.Objectives: The purpose of this study was to survey dermatologists regarding practice patterns for elec-trodesiccation and curettage (EDC) of SCC in OTRs and nontransplant patients.Methods: An 18-question survey was sent to dermatologist members of the International Transplant SkinCancer Collaborative, Association of Professors of Dermatology, and American College of Mohs Surgery.Differences in EDC practice patterns for treatment of SCC in OTRs and nontransplant patients were eval-uated.Results: Dermatologists in this study (N = 227) were more likely to treat SCC with EDC in nontransplantpatients (67.4%) than in OTRs (48.0%; P = .0003).Dermatologists who perform EDC in both groups (n = 108) were unlikely to use EDC on the H-zone ofthe face; they were more likely to EDC tumors on non-H-zone areas of the face and neck in nontransplantpatients compared to OTRs (P = .0007). Dermatologists were more likely to use EDC over surgery in non-transplant patients compared to OTRs with the following demographics: dementia or psychiatric disease(P = .04), multiple medical comorbidities (P = .03), or anticoagulation medications (P = .02).Conclusions: In OTRs with SCC, 48% of clinicians would consider EDC. The main factors that affect thedecision to perform EDC include tumor location and patient comorbidities. 2019 Published by Elsevier Inc. on behalf of Women’s Dermatologic Society. This is an open accessarticle under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).IntroductionThe number of solid organ transplantations continues to rise,with more than 33,000 transplantations performed in the UnitedStates in 2016 (OPTN/SRTR 205 Annual Data Report, 2017).Because of the necessary immunosuppressive regimens in solidorgan transplant recipients (OTRs), the incidence of cutaneousmalignancy is increased, with more than half of OTRs experiencingat least one type of cutaneous malignancy (Euvrard et al., 2003).Unlike the general population, where the incidence of basal cellcarcinoma is highest, the most common cutaneous malignancyamong OTRs is squamous cell carcinoma (SCC) (Garrett et al.,2017). SCC in solid organ transplant patients presents at a youngerage and with more aggressive features, including a higher risk forlocal recurrence, metastases, and mortality (Carucci et al., 2004;Chockalingam et al., 2015). These features often make manage-ment of SCC in this patient population more challenging.SCC in transplant patients is commonly treated with surgicalexcision or Mohs micrographic surgery (MMS). However, recentevidence suggests that a number of clinicians also use destructivemethods such as electrodesiccation and curettage (EDC) for lowerrisk lesions (Zwald and Brown, 2011). The purpose of this studywas to electronically survey dermatologists regarding their prac-tice patterns for treatment of SCC in OTRs versus non–organ trans-plant patients. Furthermore, we aimed to specifically delineatedifferences in dermatologist practice patterns regarding use ofEDC for SCC in OTRs versus nontransplant patients. Our hypotheseswere that dermatologists are (1) less likely to use EDC for invasiveSCC in transplant patients compared with nontransplant patientsand (2) are less likely to use EDC in high-risk areas of the bodyin transplant patients compared with nontransplant patients.https://doi.org/10.1016/j.ijwd.2019.10.0052352-6475/ 2019 Published by Elsevier Inc. on behalf of Women’s Dermatologic Society.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).q Human subjects were included in this study. No animals were used in thisstudy. All portions of this study were conducted as a part of an Institutional ReviewBoard–approved study at Washington University School of Medicine; IRB#201506014. All information presented in this study is HIPAA compliant.⇑ Corresponding author.E-mail address: hurste@wustl.edu (E.A. Hurst).International Journal of Women’s Dermatology 6 (2020) 99–101Contents lists available at ScienceDirectInternational Journal of Women’s DermatologyMethodsAn 18-question voluntary survey was electronically adminis-tered to members of the International Transplant Skin Cancer Col-laborative (ITSCC), the Association of Professors of Dermatology(APD), and the American College of Mohs Surgery (ACMS) (Supple-mental Document). The survey was approved by the WashingtonUniversity School of Medicine Institutional Review Board. Provi-ders were asked the same set of questions regarding treatment ofbiopsy-proven SCC with EDC in OTRs versus nontransplantpatients. The study population included dermatologists with mem-bership in any of the three organizations: ITSCC, APD, or ACMS. Inanalysis of intrasubject variability for EDC practice patterns forOTR and nontransplant patients, dermatologists who responded‘‘never” to EDC on transplant patients were excluded. To detect a20% difference between dermatologists who would consider EDCin (1) transplant patients and (2) nontransplant patients, assuming⍺ = 0.05 and power = 0.80, we would need 92 dermatologists pergroup. A v2 analysis was used to compare the rate of EDC for solidorgan transplant patients between private and academic dermatol-ogists. McNemar’s test was used to evaluate intrasubject variabilitybetween EDC practice patterns for solid organ transplant and non-transplant patients based on tumor and patient characteristics.ResultsA total of 227 surveys were returned, including 120 (52.9%)from dermatologists in an academic setting and 107 (47.1%) fromprivate practice. The combined approximate active membershipof the ITSCC, the APD, and the ACMS is 2200 to 2300 members.Therefore, the survey response rate approximates 10%, which isan underestimate because a significant percentage of physiciansare members of more than one of the organizations. Of the 227 der-matologists in this study, 118 (52.0%) would never use EDC forinvasive SCC in an OTR versus 74 (32.6%) who would never useEDC for invasive SCC in a nontransplant patient (Table 1). Interest-ingly, one physician would use EDC for invasive SCC in OTRs butnot in nontransplant patients. Overall, dermatologists were morelikely to treat a biopsy-proven SCC with EDC in nontransplantpatients than in OTRs (P = .0003). There was no difference in therate of EDC use for treatment of SCC in OTRs between privateand academic dermatologists (P = .67).Among dermatologists who would consider performing EDC fortreatment of SCC in both OTRs and nontransplant patients(n = 108), there was no difference in practice patterns for SCClocated on the H-zone of the face (defined as forehead, periorbitalarea and temples, nose, cutaneous lip, and ears) (P = .22), extremi-ties (P = .50), or trunk (P = .68) (Table 2). Dermatologists were morelikely to perform EDC for treatment of SCC on other areas of theface and neck in nontransplant patients (29.6%) compared withOTRs (15.7%; P = .0007). There was no difference in practice pat-terns between the two groups of patients based on histology ofSCC, including well differentiated (P = 1.00), moderately differenti-ated (P = .16), and poorly differentiated (P = 1.00) SCC.In clinical practice, some clinicians may perform a biopsy on alesion and treat with EDC on the day of biopsy. In cases wherethe final pathology report upstaged the lesion, clinicians wereasked if they would employ surgical excision or MMS based onthe final pathologic diagnosis. The decision to pursue further exci-sion or MMS after EDC did not differ between OTRs and nontrans-plant patients based on the following pathology findings: SCCin situ (P = 1.00), well-differentiated (P = .68), well-differentiated(P = .68), moderately differentiated (P = .77), and poorly differenti-ated (P = .77) SCC.Dermatologists were more likely to treat SCC with EDC oversurgical intervention in nontransplant patients compared withOTRs with the following demographic characteristics: significantdementia or psychiatric disease (P = .04), multiple medical comor-bidities (P = .03), or blood thinners in addition to or stronger than81 mg aspirin (P = .02). There was no difference in practice patternsbased on patients with a history of staphylococcal infection(P = 1.00).DiscussionMore than 33,000 patients received a solid organ transplant in2016, and the number of transplantations has steadily increasedover the last decade (OPTN/SRTR 2015 Annual Data Report,2017). Potent immunosuppressive medications are required aftersolid organ transplant to prevent transplant rejection. Likelybecause of immunosuppression, there is a noted increase in cancerTable 1Clinician practice patterns for the management of SCC in OTRs and nontransplantpatients (n = 227 clinicians).Solid organtransplantpatientsNontransplantpatientsPFrequency of EDC for SCC 0.0003Never 118 (52.0%) 74 (32.6%)Rarely (<10% of the time) 67 (29.5%) 84 (37.0%)Sometimes 39 (17.2%) 63 (27.8%)Frequently (>75% of thetime)3 (1.3%) 6 (2.6%)EDC, electrodesiccation and curettage; OTR, organ transplant recipient; SCC,squamous cell carcinoma.Table 2Practice patterns for the management of SCC in OTRs and nontransplant patients inclinicians who would consider EDC in both patient populations (n = 108 clinicians).Solid organtransplantpatientsNontransplantpatientsPConsider EDC of invasive SCCbased on tumorcharacteristicsH-zone of face 4 (3.7%) 8 (7.4%) 0.22Other face/neck 17 (15.7%) 32 (29.6%) 0.0007Extremities 97 (89.8%) 103 (95.4%) 0.50Trunk 103 (95.4%) 105 (97.2%) 0.68Well-differentiated SCC 107 (99.1%) 106 (98.1%) 1.00Moderately differentiated SCC 15 (13.9%) 20 (18.5%) 0.16Poorly differentiated SCC 0 (0.0%) 1 (0.9%) 1.00Further surgical excision afterEDC if upstaging on pathologySCC in situ 2 (1.9%) 3 (2.8%) 1.00Well-differentiated SCC 15 (13.9%) 13 (12.0%) 0.68Moderately differentiated SCC 58 (53.7%) 58 (53.7%) 0.77Poorly differentiated SCC 75 (69.4%) 82 (75.9%) 0.07Perineural SCC ordepth > 4 mm76 (70.4%) 83 (76.9%) 0.07Consider EDC over surgicalintervention based on patientdemographic characteristicsElderly (>85 years old) 86 (79.6%) 89 (82.4%) 0.75Multiple medicalcomorbidities80 (74.1%) 89 (82.4%) 0.03Dementia/psychiatric disease 82 (75.9%) 90 (83.3%) 0.04Anticoagulation 22 (20.4%) 31 (28.7%) 0.02History of staphylococcalinfections9 (8.3%) 10 (9.3%) 1.00Nursing home resident 36 (33.3%) 39 (36.1%) 0.25No effect of above factors 16 (14.8%) 13 (12.0%) 0.50EDC, electrodesiccation and curettage; OTR, organ transplant recipient; SCC, squa-mous cell carcinoma.100 K.M. Nemer et al. / International Journal of Women’s Dermatology 6 (2020) 99–101risk independent of infection (Engels et al., 2011). Among all malig-nancies, the most common cancer after solid organ transplant isSCC, with an incidence of 812 per 100,000 person-years (Garrettet al., 2017). Risk factors for post-transplant skin cancer includehistory of pretransplant skin cancer, male sex, white race, olderage at time of transplant, and a more recent transplant (Garrettet al., 2017).Important differences between SCC in transplant and nontrans-plant patients have been noted. SCC tumors in OTRs are also morelikely to metastasize than SCC tumors in nontransplant patients(Chockalingam et al., 2015). Interestingly, whereas the face andneck are high-risk zones for SCC in the general population, thereis a noted increase in the risk of metastasis of the extremitiesand trunk in immunosuppressed patients (Rowe et al., 1992). Theoften aggressive phenotype of SCC in OTRs makes management dif-ficult, and it is expected that clinicians will vary in practice pat-terns for treatment of these lesions. No studies to date haveevaluated dermatologists’ use of EDC for treatment of SCC in OTRs.Our first hypothesis was supported by our data, which statedthat clinicians were less likely to use EDC for invasive SCC in OTRscompared to nontransplant patients. Among dermatologists whowould consider EDC in both patient populations, the only tumorcharacteristic that differentially influenced management decisionsbetween the two groups was tumor location; clinicians were morelikely to treat SCC with EDC on non–H-zone areas of the face andneck in nontransplant patients compared with OTRs. However,the overall rate of EDC in this location was low in both groups,weakening support for the second hypothesis, which stated thatclinicians were less likely to use EDC in high-risk areas of the bodyin OTRs compared to nontransplant patients.For both OTRs and nontransplant patients, there was a trend ofdecreasing EDC use with increasing pathologic severity (from well-differentiated to moderately to poorly differentiated SCC). No onesurveyed would use EDC for poorly differentiated SCC in an OTR,and only one respondent would use EDC for poorly differentiatedSCC in a nontransplant patient. Because of this trend, we werelikely underpowered to detect any differences in managementbetween OTRs and non-OTRs based on pathologic severity. Patientdemographic characteristics that differentially affected manage-ment of SCC in OTRs versus nontransplant patients included mul-tiple medical comorbidities, significant dementia or psychiatricdisease, and anticoagulation.EDC is a reasonable approach for many localized skin tumors,with well-documented efficacy in the literature (Goldman, 2002;Reschly and Shenefelt, 2010). However, there are no randomizedcontrolled studies that evaluate EDC for treatment of SCC in OTRs.Based on available data, Stasko et al. (2004) have introduced a sim-ple algorithm for managing SCC in OTRs. Aggressive EDC is anoption for superficial, slowly growing SCC, whereas surgical exci-sion or MMS is preferred for larger tumors and SCC of the face orneck. The results herein are consistent with these recommenda-tions. Not surprisingly, clinicians in our study were unlikely to per-form EDC in the H-zone area of the face (forehead, periorbital areaand temples, nose, cutaneous lip, and ears) regardless of transplantstatus, because EDC is not considered the standard of care in theseareas. Although EDC is used in both transplant and nontransplantpopulations for SCC, some aggressive SCCs require more definitivesurgical treatment with margin assessment to reduce the chance ofresidual tumor and subsequent metastasis and mortality.The primary limitations of this study are inherent to studiesusing surveys, including selection and recall bias. In addition, weare unable to calculate the exact response rate to our surveybecause many physicians are members of more than one of thesurveyed organizations, but we are able to estimate a 10% responserate. This is obviously a small proportion of all practicing dermatol-ogists. Among our respondents, the proportion of dermatologists inacademic practice was larger than the general dermatology work-force, and overrepresentation of academia may have influencedour results. However, there was no difference in the rate of EDCfor treatment of SCC in OTRs in academia compared with privatepractice, making a large effect from academic overrepresentationunlikely. Additionally, we did not categorize surveyed dermatolo-gists by their primary practice pattern (e.g., general dermatology,medical dermatology, surgical/procedural dermatology), as use ofEDC may differ based on subspecialty type. Finally, although it isclear from our results that a sizable portion of clinicians wouldconsider EDC for treatment of SCC in OTRs, there are no studiesthat directly compare outcomes of EDC to excision or MMS in thispopulation. Further prospective studies would be helpful to stratifyOTRs diagnosed with SCC for optimum definitive therapy.Conflict of InterestNoneFundingThis work was supported by the Washington University Schoolof Medicine, Division of Dermatology Resident Fund and by a pri-vate donation from the Rusty Hager Family for statistical analysis.Study ApprovalThe authors confirm that any aspect of the work covered in thismanuscript that has involved human patients has been conductedwith the ethical approval of all relevant bodies.ReferencesCarucci JA, Martinez JC, Zeitouni NC, et al. In-transit metastasis from primarycutaneous squamous cell carcinoma in organ transplant recipients andnonimmunosuppressed patients: clinical characteristics, management, andoutcome in a series of 21 patients. Dermatol Surg 2004;30:651–5.Chockalingam R, Downing C, Tyring SK. Cutaneous squamous cell carcinomas inorgan transplant recipients. J Clin Med 2015;4:1229–39.Engels EA, Pfeiffer RM, Fraumeni JF, Kasiske BL, Israni AK, Snyder JJ, et al. Spectrumof cancer risk among US solid organ transplant tecipients: the TransplantCancer Match Study. JAMA 2011;306:1891–901.Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. N Engl JMed 2003;348:1681–91.Garrett GL, Blanc PD, Boscardin J, Lloyd AA, Ahmed RL, Anthony T, et al. Incidence ofand risk factors for skin cancer in organ transplant recipients in the UnitedStates. JAMA Dermatol 2017;153:296–303.Goldman G. The current status of curettage and electrodesiccation. Dermatol Clin2002;20(569–78):ix.OPTN/SRTR 2015 Annual data report: introduction. Am J Transplant 2017;17:11–20.Reschly MJ, Shenefelt PD. Controversies in skin surgery: electrodessication andcurettage versus excision for low-risk, small, well-differentiated squamous cellcarcinomas. J Drugs Dermatol 2010;9:773–6.Rowe DE, Carroll RJ, Day Jr CL. Prognostic factors for local recurrence, metastasis,and survival rates in squamous cell carcinoma of the skin, ear, and lip.Implications for treatment modality selection. J Am Acad Dermatol1992;26:976–90.Stasko T, Brown MD, Carucci JA, Euvrard S, Johnson TM, Sengelmann RD, et al.Guidelines for the management of squamous cell carcinoma in organ transplantrecipients. Dermatol Surg 2004;30:642–50.Zwald FO, Brown M. Skin cancer in solid organ transplant recipients: advances intherapy and management: part II. Management of skin cancer in solid organtransplant recipients. J Am Acad Dermatol 2011;65:263–79; quiz 280.K.M. Nemer et al. / International Journal of Women’s Dermatology 6 (2020) 99–101 101

Surveyed dermatologists are less likely to curette invasive squamous cell carcinoma in solid organ transplant recipients

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Surveyed dermatologists are less likely to curette invasive squamous cell carcinoma in solid organ transplant recipients

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