Rate of Recurrence of Lentigo Maligna Treated With Off-Label Neoadjuvant Topical Imiquimod, 5%, Cream Prior to Conservatively Staged Excision.

Importance: Staged excision of lentigo maligna (LM) often requires multiple stages and can result in significant cosmetic morbidity. Imiquimod cream has been used off-label as monotherapy in the treatment of LM and may be used in the neoadjuvant setting prior to staged excision as a strategy to reduce the size of the surgical margins required to confirm negative histologic margins. Objective: To examine the rate of recurrence of LM in patients treated with neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions. Design, Setting, and Participants: This was a retrospective medical record review of 334 patients with 345 biopsy-confirmed LM tumors from June 2004 to January 2012 who were treated with imiquimod prior to undergoing staged excisions at the University of Utah Medical Center and Huntsman Cancer Institute, large academic hospitals in Salt Lake City. Interventions: Patients were treated with off-label imiquimod, 5%, cream 5 nights per week for 2 to 3 months. Those deemed to have an inadequate inflammatory response were also treated with tazarotene, 0.1%, gel twice weekly. Conservatively staged excisions, beginning with 2-mm margins, were then performed. Main Outcomes and Measures: The rate of recurrence of LM after long-term follow-up. Results: Patients included 235 men (70%) and 99 women (30%) with a mean (SD) age of 67 (13) years. Patients were treated with imiquimod cream for a mean of 2.5 months prior to undergoing conservatively staged excisions. There were 12 local recurrences (a rate of 3.9%) with a mean time to recurrence of 4.3 years and a mean length of follow-up of 5.5 years. Conclusions and Relevance: Neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions for LM allowed for negative histologic margins with a median final margin of 2 mm and a rate of recurrence similar to reported recurrence rates with standard staged excisions by either Mohs surgery or en face permanent sections.

Cutaneous carcinosarcoma: a series of six cases and a review of the literature.

BACKGROUND: Cutaneous carcinosarcoma is a rare tumor with distinct malignant epithelial and mesenchymal cell populations. The histologic subtypes of epithelial and mesenchymal components in cutaneous carcinosarcoma are variable, as an assortment of carcinomatous and sarcomatous patterns have been described in the literature. METHODS: Clinical information was obtained from patient charts and archival slides were retrieved and reviewed. RESULTS: We present a novel series of six distinct cases of cutaneous carcinosarcoma and review the literature. Our cases consisted of basal cell, pilomatrical, squamous cell, and trichoblastic variants. These cases occurred in elderly men on sun exposed skin with treatment and follow up was available for 4 of 6 cases. The four cases were treated with Mohs micrographic surgery with mean follow up of nine months. CONCLUSION: We report six cases of cutaneous carcinosarcoma with distinctive clinical and histologic characterization not previously described in a single series.

Mohs appropriate use criteria: retrospectively applied to nonmelanoma skin cancers at a single academic center.

BACKGROUND: In September 2012, appropriate use criteria (AUC) for Mohs micrographic surgery (MMS) were released by a collaboration of dermatology organizations including the American College of Mohs Surgery. OBJECTIVE: The group sought to determine adherence to the Mohs AUC at the academic institution. MATERIALS AND METHODS: The authors performed a retrospective chart review of all nonmelanoma skin cancers (NMSCs) treated within the University of Utah, Department of Dermatology, from January through March of 2012. They applied the Mohs AUC to analyze these cases. RESULTS: In total, the authors identified 724 patients and 1,026 cases of NMSCs, including 557 (54.3%) basal cell carcinomas and 469 (45.7%) squamous cell carcinomas. Of the 1,026 NMSCs, 350 (34.1%) were treated with MMS. Of these cases treated with MMS, there were 339 cases (96.9%) deemed appropriate, 4 (1.1%) uncertain, and 7 (2.0%) inappropriate per AUC. Also examined were 611 cases treated with modalities other than MMS, of which 60.7% would have met AUC for MMS. CONCLUSION: In a 3-month review of all NMSC cases at the academic center, there is a low percentage of cases performed that are inappropriate for MMS by AUC. At the institution, there is a large percentage of NMSC that meet AUC but are treated by other modalities. The use is highly appropriate for MMS, and these data suggest possible underutilization of MMS for certain NMSCs. Further studies are required to determine the effectiveness of other treatment modalities for NMSC that meet Mohs AUC.

A randomized trial of the off-label use of imiquimod, 5%, cream with vs without tazarotene, 0.1%, gel for the treatment of lentigo maligna, followed by conservative staged excisions.

OBJECTIVE: To determine if the complete response rates of lentigo maligna (LM) to imiquimod, 5%, cream can be improved by the addition of a topical retinoid. DESIGN: Prospective randomized study of patients treated with imiquimod alone vs imiquimod plus a topical retinoid, followed by conservative staged excisions. SETTING: Mohs surgical clinic in an academic institution. PATIENTS: Ninety patients with biopsy-confirmed LM. INTERVENTIONS: Ninety patients with 91 LMs were randomized into 2 groups. One group received imiquimod, 5%, cream 5 d/wk for 3 months, while the other group also received tazarotene, 0.1%, gel 2 d/wk for 3 months. Following topical therapy, all patients underwent staged excisions and frozen section analysis with Melan-A immunostaining to confirm negative margins. MAIN OUTCOME MEASURE: The presence or absence of residual LM at the time of staged excision. RESULTS: Forty-six patients with 47 LMs were randomized to receive monotherapy: 42 of 47 LMs reached the intended treatment duration, with 27 complete responses (64%). Forty-four patients with 44 LMs were randomized to receive combined therapy: 37 of 44 LMs reached the intended treatment duration, with 29 complete responses (78%). This difference did not reach statistical significance (P=.17). There have been no recurrences to date, with a mean follow-up period of 42 months. CONCLUSIONS: Among patients who received topical imiquimod with vs without tazarotene, 22% (8 of 37) of lesions vs 36% (15 of 42) of lesions showed residual LM on staged excisions. Pretreating LM with imiquimod, 5%, cream may decrease surgical defect sizes; however, total reliance on topical imiquimod as an alternative to surgery may put the patient at increased risk of a local recurrence.

Use of physician assistants in Mohs micrographic surgery: a survey of fellowship-trained Mohs micrographic surgeons.

BACKGROUND: An increasing number of dermatologists are using physician assistants (PAs) in their practices. A lack of information regarding the use of PAs in Mohs micrographic surgery (MMS) served as the driving force for this research. OBJECTIVES: To quantify the extent to which Mohs surgeons are using PAs in MMS. METHODS: Five hundred seventy-six fellows of the American College of Mohs Surgery were sent surveys in the mail in January 2009. The survey was focused on what percentage of Mohs surgeons are using PAs and how those PAs are being used. RESULTS: One hundred forty-three of the 576 surgeons surveyed (24.8%) responded; 43 of those (30.1%) currently employed one or more PAs; and of those 43, 15 (34.9%) reported that PAs in their practice perform preoperative consults, 25 (58.1%) reported that PAs perform postoperative follow-up, 18 (41.9%) reported that PAs were participating in some aspect of repairs, and 35 (81.4%) reported that PAs were seeing general dermatology patients. CONCLUSION: Mohs surgeons are using PAs for perioperative care, as well as seeing general dermatology patients. A smaller percentage of Mohs surgeons are using PAs to perform portions of MMS or the consequent repairs.

Nonmelanoma skin cancers of the ear: correlation between subanatomic location and post-Mohs micrographic surgery defect size.

BACKGROUND: Nonmelanoma skin cancer (NMSC) of the ear can result in large defects with significant morbidity. OBJECTIVE: To determine whether subanatomic location of NMSCs, based on ease of visualization of the ear, correlated with post-Mohs micrographic surgery (MMS) defect size. METHODS: A retrospective chart review of 142 post-MMS ear lesions was performed and categorized according to subanatomic location: the helix, antihelix, and tragus (Location 1); retroauricular (Location 2); and conchal bowl, scapha, and triangular fossa (Location 3). RESULTS: The average defect sizes were 2.50 cm(2) (Location 1), 5.76 cm(2) (Location 2), and 4.03 cm(2) (Location 3). Tumors in Location 1 were significantly smaller than those occurring in Location 2 (P<.001) and Location 3 (P<.01), but a significant difference in size was not seen between Locations 2 and 3 (P=.16). As a control group, we randomly selected 50 NMSC cases from the nose and found the average defect size of nose NMSCs to be 1.58 cm(2). CONCLUSIONS: MMS defects of the ear are larger in nonvisible parts of the ear. As a group, MMS defects on the ear were larger than those on the nose.

Androgen receptor expression patterns in Becker's nevi: an immunohistochemical study.

BACKGROUND: Becker's nevus (BN) is a hyperpigmented patch that traditionally presents on the upper torso in adolescent males. Previous studies have reported an association with increased androgen receptors (ARs) in lesional skin in men and women who have associated physical abnormalities. OBJECTIVE: This study was conducted to assess the presence of ARs immunohistochemically in female patients with BN but no other physical abnormalities and compare this finding with BN in males and in normal skin. METHODS: Biopsy specimens from Becker's nevi in 3 women and 3 men as well as normal skin in the 3 female subjects were stained with AR antibody, and the level of expression in various cutaneous structures was measured. RESULTS: ARs were increased in dermal fibroblasts in Becker's nevi compared to that found in normal skin. LIMITATIONS: The major limitation of the study was the small sample size. CONCLUSION: In BN there is increased AR expression in dermal fibroblasts; immunohistochemical staining may aid in making the biopsy diagnosis.

A cosmetic approach to cutaneous defects.

The options available to cosmetic surgeons for the treatment of the aging face are expanding at a rapid pace. Although any one modality may help, often a combination of approaches provides the most dramatic results. Whereas some of these techniques represent refinements of old tools, others represent entirely new modalities (Box 1). To tailor the most effective treatment plan appropriately, the limitations and strengths of these various tools must be understood by the patient and physician. During the preoperative consultation, assessment of a patient's expectations is critical when suggesting a treatment plan. By performing an assessment, the physician and patient can experience increased satisfaction because more optimal results are achieved.