Search PubMed⌕ Search

Biomedical subjects

Clark C Otley

Publications and source records attributed to Clark C Otley.

At least 37 records · Page 2Linked to original sources
PubMed2005

Megasession: excision of numerous skin cancers in a single session.

BACKGROUND: A large number of synchronous skin cancers in a patient may be managed with extensive removal in one session or limited removal in several sessions. OBJECTIVE: Our objective was to prospectively evaluate the experiences of patients undergoing excisional surgery for multiple nonmelanoma skin cancers in one session. METHODS: Patients scheduled for excision of five or more skin lesions in one operative session were prospectively surveyed and followed for outcomes. Patients were surveyed immediately postoperatively and 7 and 90 days postoperatively. RESULTS: Ten patients were prospectively enrolled. They had a previous history of numerous skin cancers (median 76; range 4-551). The median number of lesions excised was 8 (range 5-21). All patients received local anesthesia, 90% received sedation, and none had general anesthesia. The median duration of the procedure was 480 minutes. Nine patients tolerated the procedure well. Two patients were electively hospitalized for observation because of the extent of surgery. Nine patients were very satisfied with the megasession. CONCLUSION: Carefully selected patients with extensive skin cancer can tolerate excisional surgery of a large number of cutaneous neoplasms in one session, with few and readily managed complications. Most of our patients preferred extensive tumor removal in one session to removal of fewer tumors in several sessions.

Adult↗
PubMed2004

High recurrence rates of Basal cell carcinoma after mohs surgery in patients with chronic lymphocytic leukemia.

OBJECTIVES: To estimate and compare the recurrence rates of basal cell carcinoma (BCC) after Mohs surgery in patients with chronic lymphocytic leukemia (CLL) and controls and to evaluate differences among histologic subtypes of BCC. DESIGN: Retrospective assessment of clinical histories, postoperative notes, and surgical photographs. SETTING: Tertiary-care institution (Mayo Clinic, Rochester, Minn). PATIENTS: Twenty-four patients with CLL who underwent Mohs surgery for 33 BCCs and 66 controls matched for sex, age, and surgical year who underwent Mohs surgery for BCC of the head and neck from May 1988 through September 1998. RESULTS: Among the 24 patients with CLL who underwent Mohs surgery for 33 BCCs, there were 4 recurrences. The cumulative incidence of recurrence on a per-tumor basis was 3% at 1 year, 12% at 3 years, and 22% at 5 years. Basal cell carcinoma was 14 times more likely to recur in patients with CLL than in controls (P =.02). Overall, there were no significant differences between patients with CLL and controls in preoperative tumor size (median, 1.6 cm vs 1.4 cm; P =.18) and proportion of aggressive histologic subtypes of BCC (58% vs 41%; P =.12). CONCLUSIONS: Recurrence rates of BCC are significantly higher after Mohs surgery in patients with CLL. Overall, patients with CLL do not appear to have significantly larger BCCs or more aggressive histologic subtypes of BCC. In patients with CLL, close surveillance is warranted for recurrence of BCC and a decreased threshold is indicated for subsequent biopsies.

Aged↗
PubMed2004

Specialty clinics for the dermatologic care of solid-organ transplant recipients.

BACKGROUND: Solid-organ transplant recipients constitute a complex patient population that experiences numerous and aggressive skin cancers. Proactive, comprehensive, ongoing, and effective dermatologic care of these patients is a necessity. OBJECTIVE: The objective of this study was to emphasize the need for organized dermatologic care for transplant recipients and to collect and present various proactive paradigms established in and designed for different practice settings to manage organ transplant recipients at high risk for skin cancer. METHODS: Information about practice setting, patient demographics, and the care model used was obtained through questionnaires sent to a selection of 12 physicians known to care for transplant recipients in various practice settings. RESULTS: All 12 physicians completed the questionnaire. The organized dermatologic care of transplant recipients occurs in three basic clinic settings: multidisciplinary transplant clinics, designated dermatology transplant subspecialty clinics, and integration of transplant recipient care within existing dermatology clinics. CONCLUSIONS: Various practice settings offer both advantages and disadvantages in providing preventive and therapeutic care of organ transplant recipients at risk for skin cancer. Regardless of the clinic design used, an organized and firmly established clinic model to allow proactive and ongoing care for these patients is important for education, prevention, and early intervention.

Dermatology↗
PubMed2004

In-transit metastasis from primary cutaneous squamous cell carcinoma in organ transplant recipients and nonimmunosuppressed patients: clinical characteristics, management, and outcome in a series of 21 patients.

BACKGROUND: In-transit metastases from cutaneous squamous cell carcinoma (SCC) may occur in organ transplant recipients and may indicate aggressive disease and poor prognosis. OBJECTIVE: The objective of this study was to describe in-transit metastases from cutaneous SCC and to identify factors associated with this phenomenon in a series of 21 patients. We also attempted to evaluate outcome with respect to status as an organ transplant recipient or nonorgan transplant recipient. METHODS: A multicenter case series of patients was reviewed; factors included clinical presentation, management, and outcome. RESULTS: Twenty-one patients, 15 organ transplant recipients, and 6 nontransplant recipients with in-transit metastases were reviewed. In-transit metastases presented most commonly as discrete, dermal papules distinct from but in the vicinity of the primary tumor site. Histologic differentiation was variable. At a mean follow up of 24 months, 33% the transplant patients had no evidence of disease compared with 80% of nontransplant patients. Thirty-three percent were dead from disease and 33% were alive with nodal or distant metastases. In contrast, 80% of nonimmunosuppressed patients had no evidence of disease and none had died at mean follow-up of 24 months. CONCLUSION: In-transit metastasis from cutaneous SCC is a unique presentation of metastatic SCC, more commonly described in organ transplant recipients, and is associated with poor prognosis in that group. This description represents the largest experience with in-transit metastases from cutaneous SCC in the literature.

Adult↗
PubMed2004

Complications of systemic retinoid therapy in organ transplant recipients with squamous cell carcinoma.

BACKGROUND: Organ transplant recipients receiving immunosuppressive medications are at increased risk of cutaneous malignancies. OBJECTIVE: We sought to determine the complications associated with systemic retinoid therapy in severely affected organ transplant recipients receiving treatment before or during the course of metastatic squamous cell carcinoma. METHODS: This was a collaborative retrospective study of solid organ transplant recipients treated with systemic retinoids for severe squamous cell carcinoma, with subjective analysis of complications associated with treatment. RESULTS: Complications and intolerance of systemic retinoid therapy were common, necessitating discontinuation of therapy in six of eight cases. CONCLUSION: This subset of transplant patients, severely affected by skin cancer, appeared to be less able to tolerate systemic retinoid therapy than patients in formal clinical trials. Intolerance of adverse effects in this context suggests the need for novel approaches with these challenging patients.

Administration, Oral↗
PubMed2004

Chemotherapy in the management of advanced cutaneous squamous cell carcinoma in organ transplant recipients: theoretical and practical considerations.

BACKGROUND: The use of chemotherapy in organ transplant recipients (OTRs) with advanced and metastatic cutaneous squamous cell carcinoma (SCC) remains relatively unexplored in dermatology. Advances in the use of chemotherapy in metastatic head and neck squamous cell carcinoma (HNSCC) may be applicable to this increasingly common disease. OBJECTIVE: The objective of this study was to determine whether recent advances in the role of chemotherapy in the management of HNSCC and cutaneous SCC offer insights into treatment strategies for metastatic cutaneous SCC. METHODS: We reviewed the literature pertaining to treatment of advanced and metastatic HNSCC and cutaneous SCC, with particular attention to the role of chemotherapy. In addition, specialists in the fields of cutaneous oncology and dermatologic surgery, head and neck surgery, medical oncology, and radiation oncology were consulted for expert multidisciplinary advice. RESULTS: Specific roles for chemotherapy in the management of advanced and cutaneous HNSCC are discussed and summarized. In addition, we propose theoretical analogies in the treatment of advanced and metastatic cutaneous SCC in OTRs. CONCLUSIONS: The head and neck surgery and oncology literature is rich with experience in locoregionally advanced and metastatic HNSCC, and adaptation of management concepts may prove feasible in the management of OTRs with advanced and metastatic cutaneous SCC.

Antineoplastic Agents↗
PubMed2003

Defining the clinical course of metastatic skin cancer in organ transplant recipients: a multicenter collaborative study.

OBJECTIVE: To evaluate the demographic characteristics, clinical course, and outcome in organ transplant recipients with metastatic skin cancer. DESIGN AND SETTING: An international, multicenter, Internet-coordinated collaborative group retrospectively analyzed data from 68 organ transplant recipients with 73 distinct metastatic skin cancers. MAIN OUTCOME MEASUREMENTS: The Kaplan-Meier method was used to estimate the cumulative incidence of relapse, overall survival, and disease-specific survival after metastatic skin cancer. Univariate Cox proportional hazards models were fit to evaluate factors for an association with survival. RESULTS: Metastasis from skin cancer in organ transplant recipients most commonly consisted of squamous cell carcinoma in regional nodal basins. It was predominantly treated with a combination of surgery and irradiation. By 1 year after metastasis, the cumulative incidence of relapse was 29%, and the 3-year disease-specific survival was 56%. Patients whose initial metastases were distant or systemic had a significantly poorer disease-specific survival than those whose initial metastases were in-transit or regional (risk ratio, 6.5; P<.001). CONCLUSIONS: Metastatic skin cancer in organ transplant recipients has a poor prognosis. Preventive, early, and aggressive therapeutic interventions are required to minimize this serious complication of transplant-associated immunosuppression.

Adult↗
PubMed2003

Lymphocytic infiltrates and subclinical epithelial tumor extension in patients with chronic leukemia and solid-organ transplantation.

BACKGROUND: Dense infiltrates in association with squamous cell carcinoma (SCC) or basal cell carcinoma (BCC) in patients with underlying chronic lymphocytic leukemia (CLL) may complicate pathologic interpretation of histologic margins. OBJECTIVE: The study was conducted to determine the frequency of identifying dense inflammatory infiltrates in frozen histologic sections during Mohs operation for BCC or SCC in patients with CLL and organ-transplant recipients, to characterize the infiltrate (reactive versus leukemic) in CLL, and to estimate the subclinical tumor extension in patients with CLL, transplant recipients, and control subjects undergoing Mohs procedure. METHODS: Frozen sections of head and neck BCC and SCC obtained during Mohs procedures in patients with CLL, organ transplant recipients, and a control group were reviewed retrospectively. Biopsy specimens of CLL with dense infiltrates were assessed with immunohistochemical stains. Subclinical tumor extension (postoperative defect size minus preoperative tumor size) was evaluated in each group. RESULTS: Dense infiltrates were found in tumors of 20 of 55 patients with CLL (36%), 1 of 8 transplant recipients (13%), and 1 of 105 controls (1%). In patients with CLL, 75% of the dense infiltrates were B-cell leukemic. Compared with controls, the mean subclinical tumor extension was larger in patients with CLL (P=0.029) and in transplant recipients (P=0.55). CONCLUSION: Dense leukemic infiltrates associated with BCC or SCC in CLL may complicate pathologic interpretation of Mohs surgical histologic margins and may be associated with larger postoperative defects relative to preoperative clinical tumor appearance. In patients with CLL, as in transplant recipients, SCC seems more likely to develop than BCC.

Basal Cell Carcinoma↗
PubMed2003

Comparison of mohs micrographic surgery and wide excision for extramammary Paget's disease.

BACKGROUND: Extramammary Paget's disease is a rare cutaneous adenocarcinoma that occurs in an apocrine gland distribution mainly in the anogenital region. OBJECTIVE: To formulate treatment recommendations for this rare disease, we examined clinical and follow-up data of patients with it. METHODS: A retrospective review is given about the treatment and outcome for 95 patients at Mayo Clinic, Rochester, Minnesota, and Scottsdale, Arizona, between 1976 and 2001. The literature regarding diagnosis and treatment of this disease is also reviewed. RESULTS: Of the 95 patients, 86 had primary disease and 9 had recurrent disease. At mean follow-up (wide excision, 65 months; Mohs surgery, 24 months), disease had recurred in 18 of 83 (22%) who underwent standard wide excision, compared with recurrence in 1 of 12 (8%) who had the Mohs micrographic excision. CONCLUSION: Mohs micrographic surgery compares favorably with wide excision. Intraoperative immunostaining with cytokeratin 7 is helpful in delineating disease, as are preoperative scouting biopsies and photodynamic diagnosis.

Aged↗
PubMed2003

Thrombotic complications related to discontinuation of warfarin and aspirin therapy perioperatively for cutaneous operation.

BACKGROUND: Aside from anecdotal reports, there are few data on the risk of thrombotic complications in patients in whom use of warfarin and aspirin is discontinued perioperatively for cutaneous operation. OBJECTIVE: Our aim was to present a large case series of thrombotic complications resulting from this practice and to estimate the incidence of these events. METHODS: A total of 504 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology were surveyed regarding thrombotic complications when blood thinners were withheld perioperatively to ascertain the frequency of these complications and to describe associated morbidity and mortality. RESULTS: A total of 168 responding physicians reported 46 patients who experienced thrombotic events. Of these patients, 54% (25 of 46) experienced the event when warfarin was withheld and 39% (18 of 46) when aspirin use was discontinued. Thrombotic events included 24 strokes, 3 cerebral emboli, 5 myocardial infarctions, 8 transient ischemic attacks, 3 deep venous thromboses, 2 pulmonary emboli, and 1 retinal artery occlusion leading to blindness. Three deaths were reported. Calculation of incidence yielded an estimated thrombotic risk of 1 event per 12,816 operations, 1 in 6219 operations when use of warfarin was discontinued and 1 in 21,448 when aspirin was withheld. CONCLUSIONS: With no documented increase in severe hemorrhagic complications during continued use perioperatively of blood thinners, these data provide a compelling argument to maintain patients on medically necessary blood thinners during cutaneous operation. All relevant clinical facts must be weighed when making this decision.

Aged↗
PubMed2003

Continuation of medically necessary aspirin and warfarin during cutaneous surgery.

Excisional cutaneous surgery is performed commonly in patients who take medically necessary aspirin or warfarin. Although controversy has existed regarding the appropriate perioperative management of anticoagulant therapy during cutaneous surgery, recent data suggest that the risk of severe hemorrhagic complications is not increased if these medications are continued. Brief perioperative discontinuation does not lower this already minimal hemorrhagic risk. Furthermore, life-threatening thromboembolic complications have been related temporally to perioperative discontinuation of both aspirin and warfarin. In light of the absence of benefit and the presence of risks associated with discontinuation of warfarin and aspirin perioperatively during excisional cutaneous surgery, continuation of these medications is recommended in most situations. In all cases, the individual patient's medical history and risk factors should be taken into account when making this clinical decision, and deviation from the guidelines should be considered if clinical imperatives warrant.

Anticoagulants↗
PubMed2002

A meta-analysis of the prognostic significance of sentinel lymph node status in Merkel cell carcinoma.

BACKGROUND: Merkel cell carcinoma is an aggressive cutaneous neoplasm with a high propensity to metastasize to lymph nodes. OBJECTIVE: The objective of this study was to determine the prognostic significance of sentinel lymph node status in patients with Merkel cell carcinoma. METHODS: A meta-analysis of case series of patients with Merkel cell carcinoma managed with sentinel lymph node biopsy was performed. RESULTS: Forty of 60 patients (67%) had a biopsy-negative sentinel lymph node; 97% of this group had no recurrence at 7.3 months median follow-up. Twenty patients (33%) had a biopsy-positive sentinel lymph node; 33% of this group experienced local, regional, or systemic recurrence at 12 months median follow-up. Risk of recurrence or metastasis was 19-fold greater in biopsy-positive patients (odds ratio, 18.9; p = 0.005). None of 15 biopsy-positive patients who underwent therapeutic lymph node dissection experienced a regional recurrence; 3 of 4 who did not receive therapeutic lymphadenectomy experienced regional recurrence. CONCLUSION: Sentinel lymph node positivity is strongly predictive of a high short-term risk of recurrence or metastasis in patients with Merkel cell carcinoma. Therapeutic lymph node dissection appears effective in preventing short-term regional nodal recurrence. Aggressive adjuvant treatment should be considered for patients with positive sentinel lymph nodes.

Carcinoma, Merkel Cell↗
PubMed2002

Perioperative management of anticoagulants and platelet inhibitors for cutaneous surgery: a survey of current practice.

BACKGROUND: Perioperative management of therapy with anticoagulants or platelet inhibitors for patients having cutaneous surgery presents dilemmas for dermatologic surgeons. OBJECTIVE: To outline the current spectrum of practice for perioperative management. METHODS: Questionnaires were mailed to 504 dermatologic surgeons. Data included use of warfarin, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) perioperatively and involvement of other physicians in making management decisions. RESULTS: Of the responding physicians, 83% routinely ask primary physicians or cardiologists for recommendations about perioperative management, 80% discontinue warfarin therapy perioperatively at least some of the time, 26% always discontinue aspirin therapy, 38% manage aspirin and NSAIDs in the same manner, and 53% withhold therapy with NSAIDs for less time than with aspirin. CONCLUSION: Dermatologic surgeons use various perioperative management strategies. Despite no published evidence of increased hemorrhagic risk with anticoagulant or platelet inhibitor therapy during cutaneous surgery, many physicians discontinue therapy perioperatively.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2002

Prognostic factors for life expectancy in nonagenarians with nonmelanoma skin cancer: implications for selecting surgical candidates.

BACKGROUND: Controversy exists over surgical intervention for nonmelanoma skin cancer in the very elderly. OBJECTIVE: We sought to define variables that are prognostic for survival in the elderly after surgery for skin cancer. METHODS: We reviewed 99 charts of nonagenarians who had Mohs micrographic surgery for nonmelanoma skin cancer and recorded data on comorbid conditions and date of death. Comorbid conditions were quantified by the Charlson index. RESULTS: Patients with Charlson scores of zero (no comorbidities) had a statistically significant longer survival than patients with Charlson scores of >/=3 (multiple comorbidities). Women survived longer than men at both 1 and 5 years. No patient died within 30 days of operation. CONCLUSION: Charlson scores of >/=3 in nonagenarians predict shorter survival. Although this parameter may predict shorter survival when skin cancer surgery is considered in a cohort of elderly patients, it remains difficult to predict accurately the survival of individual patients with scores >/=3.

Age Factors↗
PubMed2002

Skin cancer in organ transplant recipients: Epidemiology, pathogenesis, and management.

In the United States more than 100,000 people are living with solid organ transplants. The intense immunosuppressive regimens necessary for prolonged survival of allografts significantly increase the rates of both internal and cutaneous malignancies in recipients of solid organ transplants. Skin cancer is the most common cancer in patients after transplantation. Because of the early onset and high tumor burden in transplant recipients, dermatologists have significant challenges in managing the treatment of these patients. This article describes the epidemiology and clinical presentation of skin cancer during posttransplantation immunosuppression, discusses pathogenic cofactors, and reviews the optimal management for mild and severe skin cancer in transplant recipients.

Basal Cell Carcinoma↗