The Hunt for Baby Melanomas: A Prospective Study of the Dermoscopy Features on 100 Small Melanoma Cases with in Vivo Surface Diameters up to a Maximum of 6 mm.

Introduction: Early diagnosis can improve melanoma prognosis. Dermoscopy can enhance early melanoma recognition. Objectives: Examine the dermoscopy features of early melanoma up to a maximum surface diameter of 6 mm. Methods: Consecutive melanoma cases were collected from two medical practices in Sydney, Australia 2019-2021. Dermoscopy features were recorded for melanomas by maximum surface diameter, to the nearest 0.1 mm, to a limit of 6 mm. Results: Total cases numbered 100; with males (N = 48) and females (N = 52), melanoma in situ (MIS, N = 96) and invasive (N = 4). The most frequent anatomic sites on both males and females were back (males N = 20, females N = 16) then knee or leg (males N = 8, females N = 12). Minimum respective MIS diameters for males/females was 1.2/2.0 mm and for invasive cases 2.0/3.4 mm. Highest frequency dermoscopy features were: light brown, dark brown, gray and asymmetric melanoma shape. Brown pigment in hair follicles were more frequent on legs compared to other anatomic sites (odds ratio [OR] 14.6; 95% CI 1.29-165.17, P 0.03). Pseudopods were substantially increased in frequency comparing diameters less than 4 mm with 4 up to 6 mm (OR 8.81; 95% CI 1.05-73.9, P 0.004). Structureless area cases recorded increased gray (OR 7.08; 95% CI 1.61-31.11, P=0.01). Melanomas with edge angulation were noted in 20%-50% of cases across diameters 1-6 mm, less frequent were pigmented circles and polygons. Conclusions: Watch out! MIS presented with a surface diameter of just 1.2 mm and invasive melanoma 2.5 mm. Pseudopods were a strong clue to melanomas with a surface diameter less than 5mm. We found melanomas on leg sites displayed more frequent pigmented hair follicles.

Early Squamous Cell Carcinoma With Perineural Invasion: A Prospective Study Examining Anatomic Site, Tumor Surface Diameter, Invasion Depth, and Grade of Differentiation in 1,772 Consecutive Cases.

BACKGROUND: Squamous cell carcinoma (SCC) may present with perineural invasion (PNI). OBJECTIVE: To investigate the characteristics of early invasive SCC with or without PNI. METHODS: Consecutive SCC excisions were prospectively reviewed from a single Australian community-based practice for 2016-2018. Tumor characteristics recorded were anatomic site, maximum microscopic tumor surface diameter, invasion depth, grade of differentiation, and diameter of nerves with PNI. RESULTS: In total, 1,772 cases were collected. No PNI cases were found on female patients. Seven of the total 10 PNI cases were on facial sites. Maximum average microscopic tumor surface diameters ranged from 10.1 mm (well differentiated) up to 11.0 mm (moderately differentiated). Maximum average invasion depths by differentiation ranged from 1.7 (well differentiated) up to 2.6 mm (poorly differentiated). The PNI cases were as follows: well differentiated (n = 0), moderately differentiated (n = 4), or poorly differentiated (n = 6). Minimum average histopathological margins for well, moderately, and poorly differentiated SCC, respectively, were 1.4, 1.1, and 1.3 mm. Minimum microscopic tumor surface diameters for PNI cases were 7 mm for moderately and 5 mm for poorly differentiated SCC. Minimum microscopic invasion depths for PNI cases were 2.2 mm for moderate and 0.9 mm for poor differentiation. CONCLUSIONS: We found early SCC with PNI displayed nerve diameters of 0.1 mm or less and were exclusively on male patients aged 60 or older, on chronically sun-exposed sites of the head and upper midline anterior chest. Histopathological features associated with PNI were moderate and poor differentiation, tumor invasion beyond 0.9 mm, and adjacent lymphocytosis.

Basal cell carcinoma with perineural invasion: A prospective study examining subtype, tumor surface diameter, invasion depth, and anatomic site in 3005 consecutive cases.

BACKGROUND: Basal cell carcinoma (BCC) may present with or without perineural invasion (PNI). We reviewed BCC for PNI by subtype, microscopic tumor surface diameter, invasion depth, and anatomic site. METHOD: Consecutive excisions were prospectively collected in an Australian center 2016-2018. RESULTS: Total cases were 3005 including 40 with PNI: 28 in males, 12 in females. Superficial and nodular subtypes had no PNI. As the percentage tumor mass of infiltrative BCC increased beyond 90% the presence of PNI substantially escalated (OR7.0). Comparing PNI absent or present the respective maximum mean tumor microscopic surface diameters ranged from (95%CI [9.6-10.0] P < .001) to 11.2 mm (95%CI [9.4-13.0] P = .59). Respective maximum mean invasion depths were from 1.0 mm (95%CI [0.98-1.05] P < .001) to 2.3 mm (95%CI [1.8-2.7] P < .001). Respective maximum mean invasion depths were from 1.0 mm (95%CI [0.98-1.05] P < .001) to 2.3 mm (95%CI [1.8-2.7] P < .001) to 2.3 mm (95%CI[1.8-2.7] P < .001). Males recorded most PNI on the scalp, followed by cheek and chin. Patients with more than two BCC cases had a greater proportional PNI risk (OR3.7). Mean PNI nerve diameters were 0.06 mm2 (males) and 0.03 mm2 (females). CONCLUSION: Increases in percentage infiltrative subtype within the tumor mass, microscopic tumor diameter, tumor invasion depth, and BCC cases per patient all recorded more PNI. Minimum invasion depths with PNI were 1.0 mm on males (nose) and 1.0 mm females (forehead).

Do prophylactic steroids prevent chemical meningitis in surgery for epidermoid cysts? Case report and literature review.

BACKGROUND: Cranial and spinal epidermoid cysts (ECs) are rare and surgical resection can be complicated by chemical meningitis. Here, we treated a patient undergoing surgical resection of an intramedullary spinal EC with prophylactic steroids to help prevent postoperative chemical meningitis. Notably, we found a paucity of evidence regarding the efficacy of steroids used for this purpose. CASE DESCRIPTION: A 44-year-old male presented with a rare intramedullary thoracic EC. He was given oral dexamethasone postoperatively and did not subsequently develop chemical meningitis. Here, we reviewed the current literature regarding the efficacy of steroid use for this purpose, utilizing multiple electronic databases (Ovid MEDLINE, Ovid EMBASE, and Scopus). We found only three studies (one case report, one case series, and a randomized controlled trial), that involved patients who received steroids. Of the 24 patients given prophylactic steroids, none developed fever or meningismus. One patient received 8 days of oral dexamethasone. Eleven patients received intraoperative hydrocortisone irrigation alone, while final 12 patients received intraoperative hydrocortisone irrigation plus a 3 week postoperative tapering course of oral steroids. Notably, all of the nine patients who did not receive any steroids developed postoperative fever, with 78% demonstrating meningismus. CONCLUSION: Here is level II evidence that establishes the efficacy of prophylactic steroids utilized in patients undergoing surgery for ECs to prevent postoperative chemical meningitis. Nevertheless, there is still no current consensus regarding either the type of steroid utilized, or the route of administration.

Poorly differentiated cutaneous squamous cell carcinoma with osteoclast-like giant cell: A rare, aggressive variant.

Squamous Cell Carcinoma (SCC) with Osteoclast-like giant cell (OLGC) is a rare SCC variant; only 10 cases have been reported. Our case suggests OLGC are resultant of a reactive process, driven by the fusion of adjacent macrophages. Knowledge regarding SCC with OLGC is of great importance as this entity has greater prometastatic potential compared to conventional SCC.

Early invasive squamous cell carcinoma recurrence rates: A study examining surgical margins, tumor surface diameter, invasion depth, and grade of differentiation in 1296 cases over 9 years.

BACKGROUND: Invasive squamous cell carcinoma (SCC) is typically treated by surgical excision. METHODS: Consecutive SCC excisions were reviewed prospectively in a single Australian center from 2009 to 2017. Cases were examined for recurrence by histopathologic margins, microscopic tumor surface diameter, invasion depth, grade of differentiation, and anatomic site. RESULTS: Over 9 years, 1296 cases were collected. By grade of differentiation maximum average microscopic surface diameters ranged from 8.0 to 9.6 mm and maximum average depths from 1.3 to 2.5 mm. Minimum average histopathologic margins for well, moderate, and poorly differentiated SCC, respectively, were 1.4, 1.1, and 1.3 mm. Recurrence occurred in 1.7% of well (n = 18/1084), 1.8% moderate (n = 3/165) and 6.4% in poorly differentiated (n = 3/47) SCC. No recurrence occurred beyond a histopathologic margin of 3.5 mm for well and 2.5 mm for moderately differentiated SCC. Highest recurrence for well-differentiated SCC by anatomic site was the lip (7.0%) then ear (4.6%). CONCLUSION: We found a recurrence rate of 1.0% for histopathologic margins of 1.5 mm with early well-differentiated SCC. The grade of differentiation and anatomic site had a larger influence on recurrence rates compared to the histopathologic margins. Poorly differentiated SCC and ear or lip sites require wider surgical margins.

Basal cell carcinoma: variation in invasion depth by subtype, sex, and anatomic site in 4,565 cases.

BACKGROUND: The depth of invasion by basal cell carcinoma (BCC) subtypes varies. OBJECTIVE: To investigate BCC invasion depth variation by subtype and anatomic site. METHOD: A prospective consecutive case series of excised BCC from 2009 to 2014 in a single Australian clinic. RESULTS: Descending mean depths for a total of 4,565 BCC cases by subtype were as follows: nodulocystic, 1.9 mm (n = 84, 95% CI: 1.70-2.03, P = 0.66); nodular, 1.6 mm (n = 947, 95% CI: 1.53-1.63, P < 0.0001); aggressive, 1.5 mm (n = 925, 95% CI: 1.44-1.59, P < 0.0001); superficial combined with nodular, 0.9 mm (n = 1,081, 95% CI: 0.83-0.90, P < 0.0001); and superficial, 0.3 mm (n = 1,528, 95% CI: 0.32-0.36, P < 0.0001). Deeper invasion was associated with increased chronic sunlight exposed sites. The deepest aggressive BCCs occurred on the neck with a mean depth of 1.8 mm (n = 46, 95% CI: 1.47-2.21). CONCLUSION: We found significant differences in the depth of invasion for BCCs by sex, subtype, and anatomic site. For BCC with characteristics matching this study, overall adequate microscopic excision depths are proposed: superficial, 1.0 mm; superficial combined with nodular, 2.0 mm; nodular, 3.0 mm; and aggressive, 3.0 mm.

Superficial basal cell carcinoma: A comparison of superficial only subtype with superficial combined with other subtypes by age, sex and anatomic site in 3150 cases.

BACKGROUND: Basal cell carcinoma (BCC) may present as superficial subtype alone (sBCC) or superficial combined with other subtypes. The objective of this study was to compare sBCC without or with other BCC subtypes by age, sex and anatomic site. METHODS: We retrospectively collected superficial BCC with the above characteristics from an Australian center during 2009 to 2014. RESULTS: We recorded 1528 sBCC and 1622 superficial BCC combined with other BCC subtype cases. Males numbered 2007 and females 1140. On males, head sites (forehead, cheek, nose and ear combined) compared to limb plus trunk sites displayed a higher incidence of superficial BCC combined with either nodular and or aggressive BCC subtypes (OR 13.15 CI 95% 8.9-19.5 P < .0001). On females a similar comparison also found a higher incidence of superficial BCC combined with solid subtype BCC on head sites compared to trunk and limb sites (OR 9.66 CI 95% 5.8-16.1 P < .0001). CONCLUSION: Superficial BCC alone is more likely on younger females on trunk and limb sites. Small partial biopsies reported as sBCC may miss other BCC subtypes present with higher risk on facial sites for males and females. Males had smaller proportions of superficial only subtype BCC on facial and ear sites compared to females.

Invasive Squamous Cell Carcinoma: A Comparison of Tumors With or Without Horn Presentation Based on Age, Sex, Anatomic Site, Tumor Diameter, Depth of Invasion, and Grade of Differentiation in 1,666 Cases.

INTRODUCTION: Invasive squamous cell carcinoma (SCC) may present clinically with or without a horn. OBJECTIVE: To compare invasive SCC with or without horn presentation by anatomic site, tumor diameter, depth, and grade of differentiation. MATERIALS AND METHODS: The above characteristics of invasive SCC with or without horns were compared using a logistic regression model adjusted for potential confounders. RESULTS: There were 7.0% horns (n = 116) and 93.0% nonhorns (n = 1,550) in 1,666 cases. The median tumor diameter was 6 mm for horns, and 8 mm for nonhorn cases, p < .001. The median depth of invasion was 0.8 mm for horn cases and 1.3 mm for nonhorns, p < .001. Most cases were well-differentiated SCC for both horns (n = 102, 87.9%) and nonhorns (n = 1,265, 81.6%) p = .07. Horn cases had a borderline significant shift to well differentiation with moderate differentiation in 11.2% of cases (n = 13) and poor differentiation in 0.9% (n = 1). CONCLUSION: Horns presented on invasive SCC with reduced tumor diameters and reduced invasion depths compared to nonhorns. Horns presenting on invasive SCC were usually well differentiated. However, moderate and even poor differentiation can occur within a horn base.

Changes in Epithelium, Stroma, and Lumen Space Correlate More Strongly with Gleason Pattern and Are Stronger Predictors of Prostate ADC Changes than Cellularity Metrics.

PURPOSE: To investigate the hypothesis that the clinically observed decrease in apparent diffusion coefficient (ADC) at diffusion-weighted magnetic resonance imaging with increasing prostate cancer Gleason grade can be attributed to an increasing volume of low-diffusivity epithelial cells and corresponding decreasing volumes of higher-diffusivity stroma and lumen space rather than to increased cell density. MATERIALS AND METHODS: Tissue samples were acquired after institutional ethics review committee approval and informed consent from patients were obtained. Nuclear count, nuclear area, and gland component volumes (epithelium, stroma, lumen space) were measured in tissue from 14 patients. Gland component volumes and cellularity metrics were correlated with Gleason pattern (Spearman rank correlation coefficient) and measured ADC (Pearson correlation coefficient) in six prostates ex vivo. Differences between metrics for cancerous tissue and those for normal tissue were assessed by using a two-tailed two-sample t test. Linear mixed models with a post hoc Fisher least significant difference test were used to assess differences between gland component volumes and cellularity metrics for multiple groups. To adjust for a clustering effect due to repeated measures, the organ mean value of the measured metric for each tissue type was used in the analysis. RESULTS: There were significant differences between Gleason patterns for gland component volumes (P < .05) but not nuclear count (P = .100) or area (P = .141). There was a stronger correlation of Gleason pattern with gland component volumes (n = 553) of epithelium (Spearman ρ = 0.898, P < .001), stroma (ρ = -0.651, P < .001), and lumen space (ρ = -0.912, P = .007) than with the cellularity metrics (n = 288) nuclear area (ρ = 0.422, P = .133) or nuclear count (ρ = 0.082, P = .780). There was a stronger correlation between measured ADC and lumen volume (r = 0.688, P < .001) and epithelium volume (r = -0.647, P < .001) than between ADC and nuclear count (r = -0.598, P < .001) or nuclear area (r = -0.569, P < .001) (n = 57). CONCLUSION: Differences in the gland compartment volumes of prostate tissue having distinct diffusivities, rather than changes in the conventionally cited "cellularity" metrics, are likely to be the major contributor to clinically observed variations of ADC in prostate tissue.

Fulminant Clostridium Septicum myonecrosis in well controlled diabetes: a case report.

Diabetic myonecrosis with Clostridium Septicum is uncommon but carries a high mortality rate. This commensal organism is part of the gastrointestinal tract flora and can become extremely virulent, often in the setting of immuno-suppression such as neutropenia, occult malignancy (commonly caecal) and poorly controlled diabetes. The case report is unusual in that there are few risk factors other than very mild neutropenia. This highlights the opportunistic character of the organism and recommends that a high index of suspicion and vigilance be carried out in the presence of fevers and sepsis, even in the well-controlled diabetic population.