Merkel cell carcinoma of the skin and mucosa: report of 12 cutaneous cases with 2 cases arising from the nasal mucosa.

BACKGROUND: Merkel cell carcinoma (MCC) is an uncommon skin tumor that most frequently arises on sun-exposed facial sites. It rarely occurs on mucous membranes of the head region. The primary MCC is usually treated by wide excision followed by radiation to the primary site and regional lymph nodes. Using traditional surgery the local recurrence rate ranges from 20 to 50%. In our clinic, Mohs surgery is used to excise the primary MCC completely, followed by radiation. Here we present our treatment experiences and outcomes. OBJECTIVE: To document our experience of MCC treated by Mohs surgery. We present our series of 12 cases of MCC, 2 cases of which arose from mucosal sites of the nasal cavity. METHODS: We reviewed 12 cases of MCC from the Mohs clinic database. We also reviewed the literature for cutaneous and mucosal MCC. RESULTS: There were 12 cases of MCC: 10 cutaneous and 2 mucous. The site distribution of cutaneous MCC was eight on the head, one on the neck, and one on the groin. Of these, nine were treated by Mohs excision. Two patients developed local recurrence following Mohs treatment. The local recurrence rate was 22% (2 of 9). The sites of mucosal MCC were the nasal septum and nasopharynx. One case had a history of previous radiation and developed an MCC 40 years later. This case also demonstrated epidermotropic spread of Merkel cells to the overlying mucous epithelium. This patient required extensive intranasal and cranial surgery to remove the tumor. Both patients with mucosal MCCs died of their disease. The overall mucocutaneous survival of MCC at 1 year was 80% and at 2 years was 50%. CONCLUSION: In our series, local control of the primary MCC was achieved in 70% of patients (7 of 10) using combined Mohs excision and radiation. Two recurrences had primary tumors larger than 3.5 cm in diameter, while the other case was nonresectable by Mohs surgery. Tumor size appeared to determine the degree of local control. When the postoperative Mohs defect was less than 3.0 cm in diameter, local and regional control appeared to be more favorable. When the primary facial MCC is relatively small, removal by Mohs surgery followed by radiation was effective, therapeutic, and less disfiguring. Mucosal MCC is rare and may occur as a long-term sequelae after radiation therapy to the skin.

Basal cell carcinoma of the vermilion zone of the lower lip: a report of 3 cases.

Three cases of basal cell carcinomas (BCCs) of the vermilion zone of the lower lip are reported. The possible histopathogenesis of these BCCs is discussed. All lesions were treated by Mohs micrographic surgery.

Angiosarcoma of the head and neck managed by a combination of multiple biopsies to determine tumor margin and radiation therapy. Report of three cases and review of the literature.

BACKGROUND: Cutaneous angiosarcoma (AS) is a rare, often multicentric vascular tumor of the head and neck region with a rather poor prognosis. The original clinical size of the tumor rarely correlates to the degree of microscopic tissue invasion. Treatment by surgical excision sometimes requires very wide excision. Treatment by radiation or electron beam appears less mutilating but its efficacy is not well documented. OBJECTIVE: To present our experience with a combined surgical delineation of tumor margins followed by radiation treatment. METHODS: We treated three patients with extensive AS of the scalp and face. Prior to radiation, in two cases the tumor margins were determined by grid-pattern punch biopsies. In the third patient, the tumor margins were determined by Mohs mapping system. All three patients then received radiation either by rotational arc electron beam (n = 2) and standard radiation. RESULTS: One patient developed two local recurrences in nonirradiated areas plus a metastatic cervical node, all of which responded to additional electron beam. The patient has no evidence of disease (NED) after 30 months of observation. The other two patients were treated by electron beam and radiation have NED at 5 and 1 years follow-up, respectively. CONCLUSIONS: Local control of AS of the scalp may be achieved by assessment of the tumor margin by peripheral biopsies or Mohs technique followed by electron beam and radiation.

Oral malignant melanoma treated with Mohs micrographic surgery by fixed-tissue technique.

We describe a 77-year-old man with stage III oral malignant melanoma (Breslow thickness, 4.0 mm) treated with Mohs micrographic surgery by fixed-tissue technique, elective lymph node dissection, and postoperative radiation therapy. This treatment plan permitted complete excision of the melanomatous field, sparing the need for radical resection. Although the patient later died of widespread metastases, there was no evidence of local or regional recurrence and his quality of life was preserved. We believe that Mohs micrographic surgery by fixed-tissue technique followed by radiation therapy offers a safe and alternative treatment option for deep melanomas in the oral cavity.

Tumors of the nasal columella treated by Mohs micrographic surgery.

Primary nasal columellar tumors are rare but can exhibit aggressive clinical behavior, often leading to devastating outcomes if these tumors are not completely removed. Eleven patients with nonmelanoma nasal columellar lesions were evaluated. All lesions were excised by obtaining tumor-free margins with Mohs micrographic surgery. Seven of eight cases with basal cell carcinoma have been tumor free for more than 5 years, the eighth case remains tumor free at 4 years. The primary squamous cell carcinoma lesions treated in this study have fared well; one patient has been tumor free for the past 4.3 years. No local recurrence or distant metastasis has occurred to date for all cases. We conclude that intervention with Mohs micrographic surgery for the treatment of early nasal columellar tumors may lead to improved outcomes.

Cutaneous malignant melanoma treated by Mohs surgery. Review of the treatment results of 179 cases from the Mohs Melanoma Registry.

BACKGROUND: There has been much debate regarding the efficacy of the Mohs chemosurgery fixed-tissue technique vs the fresh-tissue technique in the treatment of cutaneous melanoma. OBJECTIVE: To review the treatment results of the 179 cases of melanoma registered with the Mohs melanoma tumor registry from 1981 to 1991, accumulated from nine referring Mohs surgeons. METHODS: Review of the two treatment techniques using a case presentation format. There were 113 cases treated by the hybrid fixed-tissue technique and 61 cases treated by the fresh-tissue technique. The data compared technique of treatment vs degree of invasion by both Clark level and Breslow thickness determinations. Analysis of the data using Kaplan-Meier graph. RESULTS: Five-year survival data for melanomas treated by either the fresh-tissue or fixed-tissue method appear concordant. CONCLUSION: For thin and intermediate melanoma thicknesses treatment by either method appears to be equally efficacious. For deep melanomas, the number of cases were insufficient to evaluate. Further study of this high-risk category is warranted.

Rotation flaps to reconstruct nasal tip defects following Mohs surgery.

BACKGROUND: Skin cancer involving the nasal tip is fairly common. The repair of these nasal tip defects is often a challenging opportunity. The current range of reconstructive techniques include partial closure and second intention healing to skin grafts and midline forehead flaps. OBJECTIVE: Here we present an interesting method of nasal tip repair harvesting a rotation flap that uses adjacent skin from lateral and upper bridge of nose. METHODS: Using three case studies examples of the rotation flap are demonstrated to reconstruct the nasal tip defects following Mohs surgery for skin cancer. RESULTS: For medium size defects of up to 1 cm in diameter, rotation flaps offer an alternative surgical one-stage method of reconstruction of the nasal tip in selected cases. CONCLUSION: Satisfactory results can often be achieved with a modest amount of planning, intra-, and postoperative care. Rotation flaps possess a circular configuration that allow recapitulation of the natural creases and contours of nasal tip anatomy resulting in aesthetic repairs.

Basal-cell carcinoma of the finger: a case report and review of the literature.

Basal-cell carcinoma (BCC) of the digit is a very uncommon entity. Various modalities have been used to treat it, including amputation, radiotherapy, excision, and Mohs micrographic surgery. This article presents the fourteenth reported case of BCC of the finger, which involved treatment by Mohs micrographic surgery. A review of the literature is also provided.

Multiple agminated Spitz nevi: report of two cases and review of the literature.

Spitz nevus is most commonly a benign solitary lesion. Multiple lesions arranged in clusters (agminated) are very rare. Malignant degeneration has not been reported. Although spontaneous involution may occur, the nevi are frequently treated by surgical excision. We describe two preschool girls with multiple agminated Spitz nevi, and review the current world literature on multiple Spitz nevi.

Freehand technique to harvest partial-thickness skin to repair superficial facial defects.

BACKGROUND: The freehand-scalpel technique to harvest skin for grafting is a forgotten surgical art. Modern facial surgeons prefer to use local skin flaps or Wolfe-type full grafts to repair facial defects. OBJECTIVE: To determine the relative merits and cosmetic results of freehand skin grafts to cover facial defects following Mohs surgery. METHODS: We used the freehand-scalpel technique to harvest skin from the periauricular region of the neck and cheek, and other sites. After a local anesthetic is injected the number 15 or 10 blade is used to harvest skin by sequential tangential incisions. The average dermal thickness was about 1.0 mm. To improve cosmetic appearance, the overall shape and thickness of the graft was contoured during harvesting to fit cosmetic unit or facial line. RESULTS: For more than 5 years we have used the freehand technique to repair superficial facial defects of the nose, ear, scalp, temple, forehead, and other nonhead sites. A total of 65 freehand procedures were performed to repair facial defects. The distribution of the anatomic sites and sizes are presented. The size ranged from less than 1 cm to greater than 5 cm in diameter. Three typical cases are presented to illustrate the gratifying results that can be obtained with this technique. CONCLUSIONS: In selected sites and patients, the freehand graft is a rapid and convenient method of harvesting skin. When harvested from the preauricular cheek and subauricular neck, the graft is a good match to cover sun-exposed defects of the nose and ear. The major advantages of the freehand technique are that: 1) it expands the number of potential donor sites from which to select the most compatible skin to cover facial defects; 2) it allows the surgeon to efficiently configure the graft to the desired shape and depth to conform to the cosmetic unit or defect that is being reconstructed; 3) it does not require a dermatome or other specialized instrument to perform; and 4) it achieves wound repair with good appearance and function. The freehand partial-thickness skin graft has become our preferred method of grafting superficial facial defects.

Second-intention healing of exposed facial-scalp bone after Mohs surgery for skin cancer: review of ninety-one cases.

BACKGROUND: Second-intention healing over exposed bone is considered by some to be subject to the complications of pain, infection, and nonhealing. OBJECTIVE: Our purpose was to determine would healing by second intention over exposed scalp or facial bone after Mohs micrographic surgery for skin cancer. METHODS: The chart records of all patients treated between 1981 and 1992 for skin cancer that resulted in exposed bone were identified. RESULTS: There were 115 wounds in 91 patients that were managed by second-intention healing, or partial closure, or both. Three cases of soft tissue infection occurred adjacent to nasal and sinus areas. The overall complication rate was 5.4% (6 of 112 cases) and consisted of localized soft tissue infections (2.7%) and poor wound healing (2.7%). There were no cases of osteomyelitis. Second-intention wound healing was successful in 95% of the wounds. CONCLUSION: The outpatient management of exposed bone after Mohs surgery is relatively safe. Relative risk factors for development of complications include (1) a history of previous x-radiation treatment for skin cancer, (2) manipulation of the operative site, and (3) an open defect located near the nose or exposed sinus cavity.

Giant basal cell carcinoma. Report of two cases and review of the literature.

Only 10% of all basal cell carcinomas are located on the trunk. Giant basal cell carcinomas are rare and are preferentially located on the trunk. We report two giant basal cell carcinomas of the trunk, one of which was fatal. Our review also includes a summary of previously reported cases of giant basal cell carcinoma. An analysis of these cases discloses an interesting feature of large basal cell carcinoma: Once giant basal cell carcinomas reach a critical mass, they demonstrate extremely aggressive behavior.

Scalpel sculpturing techniques for graft revision and dermatologic surgery.

BACKGROUND: Postoperative scars can be revised by a variety of techniques, including dermabrasion, laser, curettage, razor blade, and scalpel surgery. Most modern methods of scar revision provide good results but at the expense of time and economy. OBJECTIVE: We present our scalpel sculpting technique that uses the #15 scalpel blade to microshave and feather the skin edges to equalize differences in skin elevations caused by uneven healing. The superficial wounds then heal by second intention. METHODS: Sculpting techniques were used to revise side-to-side closures (grafts and flaps), trap-door elevations, standing tricones and hypertrophic scars. In addition, we used the sculpting technique to remove superficial blemishes such as actinic and seborrheic keratoses, skin tags, and other benign lesions. RESULTS: We have used scalpel sculpting techniques to revise scars and remove blemishes for more than 5 years. We have removed thousands of skin imperfections with very gratifying results. CONCLUSION: Scalpel sculpting techniques provide a simple, efficient method of scar revision and removal of superficial skin lesions. The technique reduces operative time and streamlines instrument reprocessing. Because of its simplicity, there is a high degree of patient, nursing, and physician satisfaction.

Metastatic basal cell carcinoma. Report of five cases.

BACKGROUND: Metastatic basal cell carcinoma (MBCC) is rare. Risk factors for the development of MBCC include a history of persistent basal cell carcinoma (BCC) for many years, refractory to conventional methods of treatment and previous radiation treatment either in early adulthood or for localized cancer. Most MBCC originate from large tumors. METHODS: The authors report five patients with basal cell carcinomas (BCC) of the ear (two patients), scalp, inner canthus, and nasolabial fold that metastasized to the regional lymph nodes, skin, and submandibular gland. In addition, the authors reviewed more than 40 reports of MBCC (n = 65) from 1981 to 1991 and tabulated the primary tumors by size and depth of invasion according to TNM classification, a classification that previously has not been used for BCC. RESULTS: The authors tabulated the size distribution of tumors of 45 patients with MBCC. The overall mean and median diameters of the primary BCC were 8.7 and 7.0 cm, respectively. The mean area of the primary MBCC lesion that originated on the face and trunk was 62 and 217 cm2, respectively. Using the TNM classification, approximately 9% of MBCC originate from tumors smaller than 10 cm2. In addition, the authors found that large (T2 and T3) and deep (T4) BCC account for approximately 75% of the metastatic tumors. Metastatic BCC from primary tumors smaller than 1 cm in diameter are exceptionally rare. CONCLUSIONS: Approximately 67% of MBCC (n = 238) originate from facial sites. Using the data base of the Mohs Surgery Clinic, the authors found that BCC greater than 3 cm in diameter have approximately a 1.9% incidence of metastasis, and the overall rate of metastases for morpheaform BCC is less than 1%. Patients with tumors classified as T3 and T4 lesions ideally should be followed up for 10 or more years for the remote possibility of the development of MBCC.

Linear basal cell carcinoma.

Linear basal cell carcinoma is a rare morphologic variant of basal cell carcinoma. We present two cases of linear basal cell carcinoma. Both cases, treated by Mohs' micrographic surgery, demonstrated that there was lateral spread of the tumor that was not clinically present.