Significance of Basal Cell Carcinomas Exhibiting Intravascular Invasion.

ABSTRACT: Intravascular invasion of tumor cells can be associated with metastasis in many cancers. Basal cell carcinomas (BCCs), however, rarely metastasize; therefore, the clinical impact of intravascularly invasive BCC (IVBCC) is currently unclear. Because of these facts and the rarity of IVBCC, questions have arisen on whether IVBCC truly exists. We present 4 cases of IVBCC: one case with obvious tumor islands within immunolabeled blood vessels in the context of advanced disease and 3 cases found incidentally during Mohs micrographic surgery. We discuss the difficulty in studying IVBCC, the idea that it could be due to artifact, and the lack of direct clinical-pathological correlation. Given these challenges, we propose diagnostic criteria for IVBCC to decrease ambiguity for pathological diagnosis. Such criteria may facilitate further studies on the clinical significance of IVBCC.

Eccrine Porocarcinoma Treated by Mohs Micrographic Surgery: Over 6-Year Follow-up of 12 Cases and Literature Review.

BACKGROUND: Eccrine porocarcinoma (EPC) has a poor prognosis after standard wide local excision (WLE), with 20% local recurrence, 20% regional and 12% distant metastatic rates. Mohs micrographic surgery (MMS) has been used as a promising treatment. OBJECTIVE: To review the use of MMS for EPC and assess treatment outcomes. MATERIALS AND METHODS: This was a retrospective case series of 12 EPC patients treated by MMS between 1984 and 2013 in the institution. Furthermore, a literature review revealed an additional 17 cases of EPC managed by MMS. RESULTS: Of 29 cases of EPC treated by MMS, outcome was established in 27 cases. The patients had a significantly longer mean follow-up period of 6 years (range, 4-206 months), as compared with 19 months (range, 2-48 months) in reported cases. Two patients had regional lymph node metastasis after MMS. The regional metastatic rates to lymph nodes were 7% (2/27). There was no local recurrence, distant metastasis, or disease-specific death in the 27 cases studied. CONCLUSION: To the best of the authors' knowledge, this is the single largest case series of EPCs treated by MMS and the authors' data demonstrated that MMS may be superior to the standard WLE.

Desmoplastic trichoepithelioma, infiltrative/morpheaform BCC, and microcystic adnexal carcinoma: differentiation by immunohistochemistry and determining the need for Mohs micrographic surgery.

Several important cutaneous neoplasms present with basaloid cells in the dermis. Desmoplastic trichoepithelioma (DTE), infiltrative/morpheaform basal cell carcinoma (BCC), and microcystic adnexal carcinoma (MAC) are tumors in this category that may be difficult to differentiate, especially when evaluating thin biopsy specimens. An accurate diagnosis has important clinical implications. While DTE is a benign neoplasm with indolent behavior, infiltrative/morpheaform BCC and MAC can be highly aggressive, leading to substantial local destruction and potential metastasis. We present a patient with an unusual tumor demonstrating basaloid cells in the dermis and discuss the diagnostic approach for these lesions, emphasizing the potential role of cytokeratin 20 (CK20) in determining the need for Mohs micrographic surgery.

Sebaceous cell carcinoma of the eyelid: a rapidly enlarging lesion with massive xanthogranulomatous inflammation.

A 76-year-old man presented atypically with a 4-week history of a rapidly enlarging ulcerated nodular lesion of the left upper eyelid that was found to be sebaceous cell carcinoma. Further investigation showed no metastatic disease, and Mohs surgery was performed to resect the tumor. Histopathologic analysis showed features diagnostic of sebaceous cell carcinoma. However, most of the mass consisted of xanthomatous granulomatous inflammatory reaction vastly out of proportion with the tumor burden. The patient was spared from orbital exenteration, and no evidence of recurrence was present 6 months after resection.

Cutaneous adenoid cystic carcinoma with perineural invasion treated by mohs micrographic surgery-a case report with literature review.

We report a 58-year-old woman with cutaneous adenoid cystic carcinoma arising on the chest treated with Mohs micrographic surgery. The patient remained tumor-free at 24-month follow-up. To date, only six other cases of cutaneous adenoid cystic carcinoma were reportedly managed by Mohs surgery. Cutaneous adenoid cystic carcinoma has low potential for distant metastasis but is notorious for its aggressive infiltrative growth pattern, frequent perineural invasion, and high risk of local recurrence after excision. We propose that Mohs surgery is an ideal method to achieve margin-free removal of cutaneous adenoid cystic carcinoma. A brief literature review is provided.

Pilomatrix carcinoma of the back treated by mohs micrographic surgery.

BACKGROUND: Pilomatrix carcinoma (synonyms, matrical carcinoma or malignant pilomatrixoma) is a rare malignant neoplasm derived from the hair matrix first described in 1980. This neoplasm can exhibit local aggressive behavior and distant metastasis. Most pilomatrix carcinomas occur on the head and neck of elderly individuals with a predilection for males (M:F 5:1). Pilomatrix carcinoma is often clinically misdiagnosed as a sebaceous cyst and histologic difficulty can occur in differentiating this entity from the benign entity pilomatrixoma. OBJECTIVE: The objective was to describe a case of pilomatrix carcinoma encountered in a Mohs micrographic surgery practice. We present the first case of this lesion treated by Mohs surgery. METHODS: A case report and literature review are presented. CONCLUSION: Pilomatrix carcinoma is a rare malignant variant of pilomatrixoma. Given the rarity of this lesion there are no well-defined standards for surgical management. Wide local excision has been recommended given the high rate of reoccurrence. Mohs micrographic surgery may provide optimal treatment of this neoplasm given the ability to have 100% margin control.

Dermatofibrosarcoma protuberans: a report on 29 patients treated by Mohs micrographic surgery with long-term follow-up and review of the literature.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is an uncommon tumor of the skin. Clinically, it often masquerades as a benign, indolent tumor on the trunk and extremities. Microscopically, it extends far beyond assessed clinical margins, spreading locally in the dermis, subcutaneous tissue, and muscle. The local recurrence rate in patients with DFSP who undergo wide local excision ranges from 0% to 21%. Recent preliminary reports indicate more consistently favorable cure rates with Mohs micrographic surgery (MMS). However, to date only a few scattered reports have documented long-term 5-year follow-up. The authors present data on 29 patients with DFSP who underwent MMS. In addition, they reviewed the medical literature to summarize the accumulated experience of MMS treatment in the management of DFSP. METHODS: The authors conducted a retrospective review of a series of 40 consecutive patients with DFSP who underwent MMS over the last 20 years. Of these, there were 29 patients with > 5 years of follow-up who formed the basis of the current review. The literature also was searched for patients with DFSP who underwent MMS with > 5 years of follow-up RESULTS: At the University of Wisconsin Mohs Surgery Clinic, 29 patients with > 5 years of follow-up were treated. There were 16 women and 13 men. Eight patients developed recurrent disease after previous non-Mohs treatment. Site distribution was 45% head and neck and 55% trunk and extremities. In the current series, there were no local recurrences, with a local 5-year cure rate of 100%. In the literature review, which included the current series, there were 136 patients with DFSP who underwent Mohs surgery with > 5 years of follow-up. Nine patients in the current series developed local recurrences, including five patients who underwent a second Mohs procedure. The local cure rates after the first and second Mohs surgeries were 93.4% and 98.5%, respectively. The rate (percent) and time to local recurrence was 50% at 3 years and 75% at 5 years. However, 25% of local recurrences appeared late, after the usual 5-year recommendation. CONCLUSIONS: In a series of 29 patients with of DFSP and in an accompanying update of the medical literature, 136 patients with DFSP underwent MMS with > 5 years of follow-up. There were no regional and/or distant metastases. However, late recurrences beyond the usual recommended 5-year follow-up may occur. Therefore, all patients with DFSP, especially those with recurrent tumors, should be followed for an extended period. The accumulated data continue to confirm that, when DFSP is discovered early and is accessible readily to excision by MMS, a favorable outcome can be expected with minimal trauma or sacrifice of adjacent normal structures and with a low recurrence rate.

Sebaceous carcinoma of the eyelids treated by mohs micrographic surgery: report of nine cases with review of the literature.

BACKGROUND: Ocular sebaceous carcinoma (SC) is a rare tumor of the eyelids. Clinically it frequently involves the upper lid in older women. Microscopically it tends to extend far beyond its assessed clinical margins. SC is characterized by a variety of tissue invasion mechanisms. It may spread by direct extension, be multifocal in advanced cases, and develop "skip areas" after trauma. Despite its ability to develop discontinuity, over the past two decades there have been several favorable case reports of SC treated by Mohs micrographic surgery (MMS). OBJECTIVE: To illustrate by case report the clinical presentation and management of patients with SC and to document our series of SC patients treated by MMS over the last 14 years. METHODS: A retrospective study was conducted of all cases of sebaceous carcinoma involving the ocular adnexa treated at the University of Wisconsin Mohs Surgery Clinic from 1987 to 2001. We also reviewed the accumulated medical literature of SC treated by MMS. RESULTS: In our series, there were nine cases of periocular SC. Five cases originated on the upper lid and four on the lower lid. Five of nine patients (55%) showed epithelial invasion. One patient developed a local recurrence 1.5 years later and was treated by orbital exenteration. This patient has had no evidence of disease for 5 years. Eight of nine patients (88%) had no evidence of local recurrence with a follow-up of 1-14 years. In our literature review we found 40 additional cases of orbital SC treated by MMS. Intraepithelial spread of SC was found in 50% of patients (24 of 48). Six patients developed local recurrence. The overall local cure rate following MMS is 87.8% (43 of 49), with a mean follow-up of 3.1 years. The regional metastatic rate was 8% (4 of 49). There were no deaths reported. CONCLUSION: We present nine new cases of SC. The age, sex, and site distribution are compatible with other SC cases reported in the literature. We reviewed the medical literature and compiled 49 cases of SC treated by Mohs surgery. Intraepithelial spread was discovered in 50% of the cases. Multifocal disease or discontinuity was present in 6% (3 of 49). Mohs surgery appears to be an effective method for excising the microscopic ramifications of primary SC. When feasible, we recommend in SC cases where intraepithelial pagetoid spread has been observed, that removal of another Mohs layer should be considered in order to provide an additional assurance layer against local tumor recurrence.